Chapter 13: Off-the Field Injury Evaluation

1. Chapter 13: Off-the Field Injury Evaluation

2. Evaluation of Sports Injuries • Essential skill • Four distinct evaluations • Pre-participation (prior to start of season) • On-the-field assessment • Off-the-field evaluation (performed in the clinic/training room…etc) • Progress evaluation

3. Injury Evaluation vs. Diagnosis • While ATC can recognize injury, by law they cannot diagnose --only a doctor can • Doctors of specific regions are allowed to diagnose conditions in those regions (dentist) • Fine line between evaluation and diagnosis • Athletic trainer must act within limits of his/her ability and training and act in accord with professional ethics

4. Basic Knowledge Requirements • ATC must have general knowledge of anatomy and biomechanics as well as hazards associated with particular sport • Anatomy • Surface anatomy • Topographical anatomy is essential • Key surface landmarks provide examiner with indications of normal or injured structures • Body planes and anatomical directions • Points of reference (midsagital, transverse, and frontal (coronal) planes)

5. Abdominopelvic Quadrants • Four corresponding regions of the abdomen • Divided for evaluative and diagnostic purposes • A second division system involves the abdomen being divided into 9 regions

6. Musculoskeletal Anatomy • Structural and functional anatomy • Encompasses bony and skeletal musculature • Neural anatomy useful relative to motion, sensation, and pain • Standard Terminology • Used to describe precise location of structures and orientation • Biomechanics (foundation for assessment) • Application of mechanical forces which may stem from within or outside the body to living organisms • Pathomechanics - mechanical forces applied to the body due to structural deviation - leading to faulty alignment (resulting in overuse injuries)

7. Understanding the Sport • More knowledge of sport allows for more inherent knowledge of injuries associated with sport and better injury assessment • Must be aware of proper biomechanical and kinesiological principles to be applied in activity • Violation of principles can lead to repetitive overuse trauma • Descriptive Assessment Terms • Etiology - cause of injury or disease • Pathology - structural and functional changes associated with injury process • Symptoms- perceptible changes in body or function that indicate injury or illness (subjective)

8. Sign - objective, definitive and obvious indicator for specific condition • Degree- grading for injury/condition • Diagnosis- denotes name of specific condition • Prognosis- prediction of the course of the the condition • Sequela - condition following and resulting from disease or injury (pneumonia resulting from flu) • Syndrome - group of symptoms and signs that together indicate a particular injury or disease

9. Off-the-field Injury Evaluation • Detailed evaluation on sideline or in clinic setting • May be the evaluation of an acute injury or one several days later following acute injury • Divided into 4 components • History, observation, palpation and special tests • HOPS

10. History • Obtain subjective information relative to how injury occurred, extent of injury, MOI • While obtaining history, remain calm, present simple questions, listen carefully to complaint, take good records • Inquire about previous injuries/illnesses that may be involved as well as past treatments • Ask the following questions • What is the problem? • How and when did it occur? • Did you hear or feel something? • Which direction did the joint move? • Characterize the pain

11. Be sure to identify the location of the pain and injury • Pain characteristics • What type of pain? • Where is the pain? • Does it change at different times? • Are there any other types of sensations? • Joint response • Is there instability? • Does it feel loose or like it will give way? • Does the joint lock? • Determine chronic vs. acute • Time frame

12. Observations • How does the athlete move? Is there a limp? • Are movement abnormal? • What is the body position? • Facial expressions? • Asymmetries postural mal-alignments or deformities? • Abnormal sounds? • Swelling, heat, redness, inflammation, swelling or discoloration?

13. Palpation • Used at the start or further into the evaluation • Bony and soft tissue palpation • Perform systematically - begin away from the injured site • Start with light pressure followed gradually by deeper pressure • Bony • Compare bilaterally • Look for abnormal gapping, swelling, abnormal protuberances associated with bone or joint

14. Soft tissue • Must remain relaxed • Look for lumps, swelling, gaps, tension, temperature • Variations of shape and structure, tightness, textures • Skin dryness, moistness, skin dysesthesia or anesthesia or hyperesthesia • Perform bilaterally • Special Tests • Used to detect specific pathologies • Compare inert and contractile tissues and their integrity • Lesion in contractile tissue will result in pain with motion (pain with active motion in one direction and with passive motion in opposite direction) • Lesion in inert tissue will elicit pain on active and passive motion in the same direction

15. Active Range of Motion (AROM) • Should be first movement assessment • Assess quality of movement through different ranges and planes at varying speeds and strengths • Pain free throughout full range should be tested while applying force or resistance • Passive Range of Motion (PROM) • Athlete must remain relaxed to remove influence of contractile tissue • Try to classify feel of endpoints • Normal • soft tissue approximation- soft, spongy - painless stop • capsular feel-abrupt, hard and firm • bone to bone- distinct abrupt stop • muscular - springy

16. Abnormal • Empty - movement beyond anatomical limits with pain • Spasm - involuntary muscle guarding • Loose - occurs in extreme hypermobility • Springy block - rebound at endpoint • Throughout PROM ATC looking for limitation in movement and presence of pain • Report of pain before end range indicates acute inflammation (stretching and manipulation would be contraindicated) • Pain synchronous with end range indicates subacute and involves inert tissue fibrosis • If no pain at end range, injury is chronic and contractures have replaced inflammation

17. Resisted Motions (RROM) • Evaluate status of contractile tissue • Isometric contraction at mid range • Different from manual muscle test which occurs throughout ROM • Different grading systems used to identify severity and degrees of strength (Cyriax) • Goniometric Measurements • Measure joint ROM (degrees) • Full ROM is major factor in determining return to activity • To perform measurement goniometer is placed on lateral aspect of extremity, with 0 or starting position in anatomical positions

18. Athlete will move either active or passively through available range to endpoint • Stationary arm should be placed parallel to long axis of fixed reference part while moveable arm is placed along axis of moveable segment • Accuracy and consistency requires practice and repetition • Manual Muscle Testing • Used to determine vary extent of injury to contractile tissue • Limitation in muscular strength is generally caused by pain • Generally performed so muscle or group of muscles can be isolated and tested through a full range while applying manual resistance

19. Ability to move through range or offer resistance is subjectively graded by ATC according to various classification systems • Neurological Examination • Test 5 major areas (cerebral, cranial nerve, cerebellar, sensory functioning, reflex testing and referred pain) • Most musculoskeletal injuries do not require cranial, cerebral or cerebellar assessment and exam can focus on peripheral neurological functioning • Cerebral functioning • Questions assess general affect, consciousness, intellectual performance, emotional status, sensory interpretation, thought content, and language skills • Cranial Nerve function • Quality assessed through assessments of smell, eye tracking, facial expressions, biting down, balance, swallowing, tongue protrusion, and shoulder shrug

20. Cerebellar Function • Control of purposeful coordinated movement • Touch finger to nose, finger to finger, heel-toe walking • Sensory Testing • Determine distribution of dermatomes and peripheral nerves • Assess • Superficial sensation • Superficial pain • Deep pressure pain • Sensitivity to temperature • Sensitivity to vibration • Position sense

21. Reflex testing • Reflex refers to involuntary response to a stimulus • Three types - deep tendon, superficial and pathological • Deep tendon reflex (somatic) • Caused by stimulation of stretch reflex • Biceps (C5) brachioradialis (C6) triceps (C7) patella (L4) Achilles (S1) • Superficial reflexes • Elicited by stimulation of skin at specific sites producing muscle contraction • Upper abdominal (T7,8,9), lower abdominal (T11, 12) cremasteric (S1, 2), gluteal (L4, S3) • Absence of reflex = lesion of cerebral cortex • Pathological • Also superficial reflexes • Indicative of lesion in cerebral cortex • Babinski’s sign, Chaddock’s, Oppenheim’s, Gordon’s

22. Determining Projected or Referred Pain • Deep burning pain, or ache that is diffuse or in area of no sign of malfunction or disorder is most likely referred • Cyriax considers common sites of pain in order of importance - joint, tendon, muscle, ligament, and bursa • Pressure on dura mater or nerve sheath can also produce referred pain or sensory response • Myofascial trigger points are not related to deep, referred pain (tense tissue bands) • Testing Joint Stability • A number of specific tests are used to test ligamentous stability for each specific joint • Allows clinician to grade severity of injury and determine extent of dysfunction

23. Testing Accessory Motions • The manner in which one articular surface moves relative to another • Normal accessory motion must occur to allow for full and un-compromised range of motion • Can be impacted by capsular tightness or tightness of musculotendinous units • Testing Functional Performance • Used to determine athletes readiness to participate or continue participation • Used for progress evaluation during rehab • Should proceed gradually from relatively easy task to more challenging --mimicking actual sport participation • Questions whether athlete has regained full ROM, strength, speed, endurance, and neuromuscular control and is pain free

24. Postural Examination • Many conditions can be attributed to body malalignment • Used to look at asymmetries by comparing body relative to grid or plumb line • Anthropometric Measurements • Science of measuring the body • Includes osteometry, craniometry, skin-fold measurements, height and weight. • Also involves measurements of limb girth • Volumetric Measurements • Used to determine changes in limb volume caused by swelling which can be attributed to hemorrhaging, edema or inflammation • Measure water that is displaced from a tank in which limb is immersed

25. Progress Evaluations • When rehab is occurring, follow-up evaluations must be performed to monitor progress • Seeing the athlete daily allows for daily modification • Progress evals should be based on healing process at any given time - providing a framework for the rehabilitation and sometime constraints on progress • Progress evaluations are generally more limited in scope - focus on specific injury and progress relative to previous day • Should still follow similar outline to evaluation

26. History • Pain comparison (today vs. yesterday) • Movement, better or worse relative to pain? • Treatment - effective or not? • Observations • Degree of swelling • Degree of movement relative to yesterday • Is athlete still guarding? • What is athlete’s affect? Attitude and mood? • Palpation • What is consistency of swelling and has it changed? • Is it still tender to touch? • Deformity compared to yesterday

27. Special Tests • Do ligamentous tests result in pain and what is the grade? • How do ROM, accessory motion and manual muscle tests compare today to yesterday? • How does the athlete perform in functional tests?

28. Documenting Injury Evaluation Information • Complete and accurate documentation is critical • Clear, concise, accurate records is necessary for third party billing • While cumbersome and time consuming, athletic trainer must be proficient and be able to generate accurate records based on the evaluation performed

29. SOAP Notes • Record keeping can be performed systematically which outlines subjective & objective findings as well as immediate and future plans • SOAP notes allow for subjective & objective information, the assessment and a plan to be implemented • S(subjective) • Statements made by athlete - primarily history information and athletes perceptions including severity, pain, MOI

30. O(Objective) • Findings based on ATC’s evaluation • A (Assessment) • ATC’s professional opinion regarding impression of injury • May include suspected site of injury and structures involved along with rating of severity • P (Plan) • Includes first aid treatment, referral information, goals (short and long term) and examiner’s plan for treatment

31. Progress Notes • Need to be routinely written after each progress evaluation • Perform throughout rehab of an injury • Can follow SOAP format, generated daily, or be weekly summaries • Should focus on treatments, athlete’s and injury’s response to treatment, progress and goals • Should also discuss future treatment plans if necessary

32. Additional Diagnostic Tests • Due to the need to diagnose and design specific treatment plans, physicians have access to additional tools to acquire additional information relative to an injury • There are a series of diagnostic tools that can be utilized in order to more clearly define and determine the problem that exists

33. Plain Film Radiographs (X-ray) • Used to determine presence of fractures bone abnormalities and dislocations • Can be used to rule out disease (neoplasm) • Occasionally used to assess soft tissue • Arthrography • Visual study of joint via X-ray after injection of dye, air, or a combination of both • Shows disruption of soft tissue and loose bodies • Arthroscopy • Invasive technique, using fiber-optic arthroscope, used to assess joint integrity and damage • Can also be used to perform surgical procedures

34. X-Ray

35. Myelography • Opaque dye injected into epidural space of spinal canal (through lumbar puncture) • Used to detect tumors, nerve root compression and disk disease and other diseases associated with the spinal cord • Computed Tomography (CT scan) • Penetrates body with thin, fan-shape X-ray beam • Produces cross sectional view of tissues • Allows multiple viewing angles • Bone Scan • Involves intravenous introduction of radioactive tracer • Used to image bony lesions (i.e. stress fractures)

36. CT Scan

37. Bone Scan

38. Ultrasonography • Use of ultrasound to view location, measurement or delineation of organ or tissue by measuring reflection or transmission of high frequency ultrasound waves • Computer is able to generate 2-D image • Magnetic Resonance Imaging (MRI) • Using powerful electromagnet, magnetic current focuses hydrogen atoms in water and aligns them • After current shut off, atoms continue to spin emitting different levels of energy depending on tissue type, creating different images • While expensive, it is clearer than CT scan and the test of choice for detecting soft tissue lesions

39. Magnetic Resonance Imaging

40. Echocardiography • Uses ultrasound to produce graphic record of cardiac structures (valves and dimensions of left atrium and ventricles) • Electroencephalography (EEG) • Records electrical potentials produced in the brain to detect changes or abnormal brain wave patterns • Electromyography (EMG) • Graphic recording of muscle electrical activity using surface or needle electrodes • Observed with oscilloscope screen or graphic recordings called electromyograms • Used to evaluate muscular conditions

41. Nerve Conduction Velocity • Used to determine conduction velocity of nerves and can provide key information relative to neurological conditions • After applying stimulus to nerve, speed at which the muscle reaction occurs is monitored • Delays may indicate nerve compression or muscular/nerve disease • Synovial Fluid Analysis • Detect presence of infection in the joint • Used to confirm diagnosis of gout and differentiates between inflammatory and non-inflammatory conditions (degenerative vs. rheumatoid arthritis)

42. Blood Test • Complete blood count (CBC) used to screen for anemia, infection and many other reasons • Assesses red blood cell count, hemoglobin levels, hematocrit levels (RBC per volume), white blood cell count, platelet deficiency, & serum cholesterol • Urinalysis • Used to assess specific gravity, pH, presence of ketones, hemoglobin, proteins, nitrates, red & white blood cells, bacteria, electrolytes, hormones and drug levels

43. Urinalysis using dip and read test strips provide fast accurate results for a number of things including, specific gravity, WBC’s, nitrate, pH, protein, glucose, ketones, bilirubin and blood. • Large area on strip is impregnated with reagents which change color when dipped in urine that are then compared to color comparison charts.