Chapter 3: The Evaluation Process

1. Chapter 3: The Evaluation Process

2. Evaluation is the foundation of rehabilitation • Must be able to perform systematic evaluation to determine athlete’s needs Provoked tissue – Normal tissue = Pathologic tissue Pathologic tissue – Contraindications = Treatment • When determining rehabilitation plan severity, irritability, nature and stage of injury must be considered • Re-evaluation is critical – monitor progress

3. Athletic trainer may conduct multiple evaluations for varying reasons • On-site evaluation at time of injury • On-site evaluation just following injury • Off-site evaluation, involving injury assessment and rehabilitation plan • Follow-up evaluation during rehabilitation process • Pre-participation physical evaluation

4. Systematic Differential Evaluation Process • Key to successful evaluation – sequential and systematic approach • Sequence = thorough • Systematic flexible approach • Systematic approach • Subjective • Objective • Assessment

5. Subjective Evaluation • Sequential dialogue allowing for establishment of comfort and trust • History of injury • Athlete’s impression • Description of how injury occurred • Location of the injury • Level of discomfort being experienced • Site of injury • Determine location of pain and injury • Consider normal, provoked, and pathologic tissue in order to develop appropriate plan

6. History of Injury (continued) • Mechanism of Injury • Injury results from forces acting on the anatomical structures causing tissue failure • Identify nature of forces acting on body and how they relate to anatomical function • Macrotrauma – single traumatic force • Microtrauma – accumulation of repeated forces • Identify body position, direction of applied force, magnitude of force and point of application • Sounds and sensations (pop, click, lock, giving way) • Previous Injury • Current vs. previous injury • Anatomical structures involved and managed • Previous treatment • Recurrent • Excessive scarring, reduced soft tissue elasticity, muscle contracture/inhibition, muscle weakness, altered posture…etc

7. Behavior of Symptoms • Details of symptoms • Provocation • Quality • Sharp, dull, aching, burning pain • Nerve, bone, vascular, muscular pain • Region of Symptoms • Deep vs. superficial • Location of tissue vs. referred region • Localized vs. diffuse • Severity of Symptoms • Used to track progress of rehabilitation • Quantify pain (rating scale) • Timing of Symptoms • May help to determine nature of injury • Time course – Micro- vs. Macrotrauma

8. Response of symptoms to activity (classifications) • Joint adhesions – pain during activity that decreases with rest • Chronic inflammation and edema – morning stiffness that reduces with activity • Joint congestion – pain or aching that progressively worsens with activity • Acute inflammation – pain at rest and worsens at the beginning of activity in comparison to the end of activity • Bone pain or systemic disorder – pain is not influenced by rest or activity • Peripheral nerve entrapment – pain that worsens at night • Intervertebral disc involvement – pain that increases with trunk motion

9. Objective Evaluation • Observation and Inspection • Visual inspection • Gait, carrying position, movement/compensatory patterns • Muscle guarding, antalgic movements, facial expressions • Bilateral comparison • Postural alignment • Especially important with chronic overuse patients • Compensatory mechanisms and tissue stress • Be mindful of muscle tightness, weakness, imbalance • View standing, and from multiple vantage points • Looking for neutral alignment, symmetry, balanced muscle tone, specific postural alignments

10. Postural Assessment

11. Signs of Trauma • Gross deformity • Visible swelling • Rapid vs. gradual = Acute vs. Chronic • Quantification of swelling • Signs of infection • Bleeding • Atrophy – may be present with chronic injuries • Skin color and texture

12. Palpation • Should be performed immediately in instances of acute injury (injury may warrant physician referral) • Manual probing may elicit pain, detracting from later evaluation stages • Purpose is to localize pathologic tissue involved • Sequential fashion including bones, joints and soft tissue • Bilateral comparison • Assess point tenderness, trigger points, tissue quality, crepitus, temperature and symmetry

13. Range of Motion • Determines patients ability to move the limbs through a specific pattern of motion • Perform passively, actively and against resistance • Compare bilaterally • Useful tool in assessing patient progress • Assess inert and contractile tissue components of the joint complex

14. Active Range of Motion • Patient actively contracts muscles as they take a limb through a particular movement pattern • Evaluate quality of motion, total range, location of pain and painful arcs • Limited range may be caused by swelling, joint capsule tightness, agonist muscle weakness/inhibition or contracture • Passive Range of Motion • Contractile tissues are relaxed • Assess end point feels • Deficiencies may be the result of spasm, contracture, weakness, muscle pain or neurologic deficits • Crepitus may also be present

15. Capsular Patterns of Motion • Joint capsule irritation may cause a progressive loss of available motion in different cardinal planes • Each joint has specific patterns of progressive motion loss • Total joint reaction that may involve spasm, capsular tightening, or osteophyte formation • Non-capsular Patterns of Motion • Result from irritation of structures located outside the capsule and do not follow same progressive loss • Cyriax classifications • Ligamentous adhesion • Internal derangement • Extra-articular lesion

16. Accessory Motion & Joint Play (Arthrokinematic Motion) • Motion occurring between joint surfaces • Required for full active and passive range of motion • Arthrokinematic motion • Roll • Glide • Spin • Assessed techniques same as those used for joint mobilization • Hypomobility vs. Hypermobility • Resistive Strength Testing • Used to assess status of contractile tissue • Assessed using isometric or “break” tests • Mid-range motion testing and specific muscle testing

17. Mid-Range of Motion Muscle Testing • Allows for isolation of contractile tissue • Look for compensatory motion • Focuses on groups of muscles • Guides clinician examination of specific muscles • Assess motion (strong, weak, painful, painless) • Specific Muscle Testing • Assess strength and integrity of specific muscles • Muscle isolation • Compared bilaterally and graded numerically • Consider source of muscle deficiency not simply the grading scheme

18. Muscle Imbalances • Relationship between agonists and functional antagonists • Disrupted normal force couples relationships • Assess patterns of kinetic dysfunction • Muscle tightness or hyperactivity • Tightness or hyperactivity in agonist may result in antagonist inhibition (reciprocal inhibition) • Impact on postural alignment • Tight muscles will alter joint position, allowing for increased shortening and ultimately stretching of the antagonist • Alteration of length-tension relationships resulting in altered force production and potentially additional disruption of force couples and postural alignment • Compensation for weak antagonists • Synergistic dominance • Susceptibility to injury

20. Movement Group Muscles • Prone to developing tightness • More active during functional movements • More active during fatigue or new movements • Tend to be hyperactive • Stabilization Group • Prone to developing inhibition and weakness • Less active during functional movement • Easily fatigued during dynamic movement • Reduced force capacity • Re-establishment of muscle balance • Stretch tight/shortened muscles and strengthen weak antagonist

21. Special Tests • Used to further distinguish between pathologic and normal tissue • Designed to assess integrity of specific body tissues • Types of special tests • Joint stability tests • Joint compression tests • Passive tendon stretch tests • Anthropometric assessments

22. Neurologic Testing • Some people question when neurologic testing should be performed • History • Mechanism of injury • Signs and symptoms being experienced by athlete • Five major areas (cerebral, cranial nerve, cerebellar, sensory functioning, myotomes, and reflex testing) • Generally assessing spinal nerve roots and associated peripheral nerves • Nerve roots = abnormal motor and sensory in large area • Peripheral nerve = confined to more localized area

23. Dermatome (Sensory) Testing • Determine distribution of dermatomes and peripheral nerves • Bilateral assessment • Assess • Superficial sensation • Superficial pain • Deep pressure pain • Sensitivity to temperature • Sensitivity to vibration • Position sense

24. Myotome Testing • Represents a group of muscles that are innervated from specific nerve root • Motor equivalent of dermatomes • Tested via isometric contractions of specific muscles • 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)

25. 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 • Pathologic Reflexes • Not normally present • Also superficial reflexes • Indicative of lesion in cerebral cortex • Babinski’s sign, Chaddock’s, Oppenheim’s, Gordon’s

26. Functional Testing • Tool used to assess patient function and progress • Functional movement patterns • Should reflect types of stresses that patient will experience during normal activities • Assess pain or discomfort and compensatory motion • Ideally tests lend themselves to a grading system • Total score based on performance and errors committed • Use to establish a baseline of function and continued follow-up

27. Injury Prevention Screening • Should be performed during pre-participation examination • Inspect for potential tissue stresses and strains that may result in injury • Develop prevention plan as a result of findings • Slow controlled movement patterns • Assess movement efficiency and success • Able to identify pre-existing muscle imbalances, altered force couple relationships, postural malalignment, joint kinematics and neuromuscular control

28. Screening Tools

29. 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

30. SOAP Notes • Record keeping can be performed systematically which outlines subjective & objective findings as well as immediate and future plans • S (subjective) • Statements made by athlete - primarily history information and athletes perceptions including severity, pain, MOI • O (Objective) • Findings based on ATC’s evaluation

31. 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

32. Setting Rehabilitation Goals • Based on evaluation and address signs and symptoms recorded in SOAP note • For every significant sign and symptom a corresponding goal should be set • Both short and long term goals should be set • Duration of short term goals should typically be ~2 weeks • Decrease pain – 50% in 4 days • Swelling reduction – 30% in 4 days • Increase ROM – 50% in 8 days • Long term goals represent final goals that need to be achieved in order to return to play

33. 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 • Provides 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

34. 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

35. 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?

36. 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