Chapter 13: Off-the-Field Injury Evaluation

1. Chapter 13: Off-the-Field Injury Evaluation 2009 McGraw-Hill Higher Education. All rights reserved.

2. Evaluation of Injuries • Essential skill for athletic trainers • 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 2009 McGraw-Hill Higher Education. All rights reserved.

3. Clinical Evaluation & Diagnosis • Diagnosis • Use of clinical or scientific methods to establish cause and nature of patient’s illness or injury and subsequent functional impairment due to pathology • Forms basis for patient care • Physicians make medical diagnosis • Ultimate determination of patient’s physical condition 2009 McGraw-Hill Higher Education. All rights reserved.

4. Athletic trainers and other health care professionals use evaluation skills to make clinical diagnoses • Clinical diagnosis identifies pathology and limitations/disabilities associated with pathology • Athletic trainers have academically-based credential and in many states some form of regulation which recognizes ability and empowers clinician to make accurate clinical diagnosis 2009 McGraw-Hill Higher Education. All rights reserved.

5. Basic Knowledge Requirements • Athletic trainer 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) 2009 McGraw-Hill Higher Education. All rights reserved.

6. 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 2009 McGraw-Hill Higher Education. All rights reserved.

7. 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) 2009 McGraw-Hill Higher Education. All rights reserved.

8. Understanding the Activity • More knowledge of activity allows for more inherent knowledge of injuries associated with activity resulting in more accurate clinical diagnosis and rehab design with appropriate functional aspects incorporated for return to activity • Must be aware of proper biomechanical and kinesiological principles to be applied in activity • Violation of principles can lead to repetitive overuse trauma • Increased understanding = better assessment and care 2009 McGraw-Hill Higher Education. All rights reserved.

9. Descriptive Assessment Terms • Etiology - cause of injury or disease • Mechanism – mechanical description of cause • Pathology - structural and functional changes associated with injury process • Symptoms- perceptible changes in body or function that indicate injury or illness (subjective) • Sign - objective, definitive and obvious indicator for specific condition • Degree- grading for injury/condition • Diagnosis- denotes name of specific condition 2009 McGraw-Hill Higher Education. All rights reserved.

10. Prognosis- prediction of the course of 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 • Differential diagnosis – systematic method of diagnosing a disorder • Refers to a list of possible causes • Prioritizing of possibilities • Also referred to as hypothesis or working diagnosis • Utilize skills to make decision regarding condition 2009 McGraw-Hill Higher Education. All rights reserved.

11. 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 2009 McGraw-Hill Higher Education. All rights reserved.

12. History • Obtain subjective information relative to how injury occurred, extent of injury, MOI • 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 2009 McGraw-Hill Higher Education. All rights reserved.

13. Observations • Asymmetries, postural mal-alignments or deformities? • How does the athlete move? Is there a limp? • Are movements abnormal? • What is the body position? • Facial expressions? • Abnormal sounds? • Swelling, heat, redness, inflammation, swelling or discoloration? 2009 McGraw-Hill Higher Education. All rights reserved.

14. Palpation • Bony & soft tissue • Special Tests • Used to detect specific pathologies • Compare inert and contractile tissues and their integrity • Assessment should be made bilaterally • Range of Motion Assessment • Active • Passive • Normal vs. Abnormal end points • Manual muscle tests • Goniometric measures vs. Digital inclinometers 2009 McGraw-Hill Higher Education. All rights reserved.

15. Figure 13-4 A & B 2009 McGraw-Hill Higher Education. All rights reserved.

16. Neurologic and circulation assessments • Brain • Cerebral, cranial nerve function, cerebellar function • Sensory & motor function • Dermatome • Area of skin innervated by a single nerve • Myotome • Muscle or group of muscles innervated by a specific motor nerve • Reflex testing • Involuntary response to a stimulus • Deep tendon – caused by stimulation of stretch reflex • Superficial – stimulation of skin which causes reflexive muscle contraction • Pathological – superficial reflex indicative of upper motor neuron lesion • Babinski’s sign, Chaddock’s, Oppenheim’s Gordon’s • Referred pain 2009 McGraw-Hill Higher Education. All rights reserved.

17. Figure 13-5 2009 McGraw-Hill Higher Education. All rights reserved.

18. Motor Testing • Testing Joint Stability • Testing Accessory Motions • Testing Functional Performance • Used to determine athletes readiness to participate or continue participation • Other tests • Postural • Anthropometric • Volumetric Figure 13-6 2009 McGraw-Hill Higher Education. All rights reserved.

19. 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 2009 McGraw-Hill Higher Education. All rights reserved.

20. 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 patient - primarily history information and patient’s perceptions including severity, pain, MOI 2009 McGraw-Hill Higher Education. All rights reserved.

21. O (Objective) • Findings based on athletic trainer’s evaluation • A (Assessment) • Athletic trainer'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 2009 McGraw-Hill Higher Education. All rights reserved.

22. SOAP Note vs. Progress Note or Evaluation 2009 McGraw-Hill Higher Education. All rights reserved.

23. 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 2009 McGraw-Hill Higher Education. All rights reserved.

24. 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 2009 McGraw-Hill Higher Education. All rights reserved.

25. X-Ray 2009 McGraw-Hill Higher Education. All rights reserved.

26. 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) in which there is inflammation 2009 McGraw-Hill Higher Education. All rights reserved.

27. CT Scan 2009 McGraw-Hill Higher Education. All rights reserved.

28. Bone Scan and DEXA Scan Figure 13-8 F & G 2009 McGraw-Hill Higher Education. All rights reserved.

29. DEXA Scan • Dual energy X-ray absorptiometry • Used to measure bone mineral density • Greater mineral density = greater signal picked up • Documents small changes in bone mass • Used on both spine and extremities • Less expensive, less radiation exposure • More sensitive and accurate for measuring subtle bone density changes over time 2009 McGraw-Hill Higher Education. All rights reserved.

30. 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 • MRI Arthrography • Imaging study involving injection of contrast agent into joint prior to MRI • Allows for more detailed assessment of joint vs. traditional MRI • Contrast agent allows for highlighting of certain areas 2009 McGraw-Hill Higher Education. All rights reserved.

31. Magnetic Resonance Imaging 2009 McGraw-Hill Higher Education. All rights reserved.

32. Ultrasonography • Diagnostic ultrasound of sonography • Allows clinician 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 • Advancements in technology are allowing for 3-D imaging as well • Musculoskeletal Ultrasound • Allows for imaging and evaluation of soft tissue structures • Complimentary technique to MRI or CT • Non-painful, non-invasive, cost effective 2009 McGraw-Hill Higher Education. All rights reserved.

33. Doppler Ultrasound • Used to examine blood flow in arms and legs • Alternative to arteriography and venography • Detects blood clots, venous insufficiency, vessel closing, or altered blood flow • Arteriogram • Catheter inserted into blood vessel and contrast medium is injected • Using x-ray, images are taken to determine path of fluid flow in vessels • Venogram • Radiographic procedure used to image veins filled with contrast medium • Used for detecting thrombophlebitis and for tracing of venous pulse 2009 McGraw-Hill Higher Education. All rights reserved.

34. 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 2009 McGraw-Hill Higher Education. All rights reserved.

35. Electrocardiography • Recording of electrical activity of heart at various stages in contraction cycle • Assesses impulse formation, conduction, depolarization and re-polarization of atria and ventricles Figure 13-9 2009 McGraw-Hill Higher Education. All rights reserved.

36. 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) 2009 McGraw-Hill Higher Education. All rights reserved.

37. 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 2009 McGraw-Hill Higher Education. All rights reserved.

38. 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. 2009 McGraw-Hill Higher Education. All rights reserved.

39. Ergonomic Risk Assessment (ERA) • If working in a clinic or industrial setting an athletic trainer may be called upon to perform this assessment • Involves evaluation of factors within a job that increase risk of someone suffering a workplace-related ergonomic injury • Assess aspects and movements that could be modified to reduce risk • Injury prevention and intervention through ergonomic control measures and injury statistics 2009 McGraw-Hill Higher Education. All rights reserved.

40. Using ergonomics • Improve efficiency (time and resources) • Reduce time lost due to injury • Reduce decreases in productivity • Consider how changes could impact physical requirements and demands • Investigate worker complaints and concerns • Proactive step towards reducing work-related injuries, workers compensation and time lost • If workers are experiencing pain and discomfort, there may be a safer and more effective way of doing the job 2009 McGraw-Hill Higher Education. All rights reserved.

41. If an employee suffers an injury it is likely due to ergonomic stress • Must be addressed to prevent further and future injuries • Steps and tools of risk assessment • Identify and prioritize jobs • Maximizes impact of intervention • Workers must be briefed • Review injury statistics, worker concerns, physical demand analysis • Direct supervisor must be notified • Why the modification and what new expectations will be 2009 McGraw-Hill Higher Education. All rights reserved.

42. Steps and tools of risk assessment (continued) • Management must be informed • Aware of costs associated with injuries, benefits of ERA • Company support professionals (nurse, engineer, safety personnel) • Use of videotape • Allows more access for people to assessment process • Utilize for training purposes as well 2009 McGraw-Hill Higher Education. All rights reserved.

43. After risks have been identified • Athletic trainer should identify those that should be controlled in an effort to reduce injury rates • Consult workers, supervisors and management • May involve • Physical changes to job (sitting vs. standing, altering work surfaces) • Administrative changes (job rotations, lifting policy) • Personal protective equipment • Proposed changes should have an ERA performed on them to ensure that original risks have been reduced without introduction of new risks 2009 McGraw-Hill Higher Education. All rights reserved.