Injury evaluation ATTN: Sophomore Athletic Training Students

1. Systematic Process Injury evaluationATTN: Sophomore Athletic Training Students By: Corey Caterina

2. The systematic evaluation is seven-step process, where each step is designed to obtain specific information. The individual steps, as well as the components of each step, are presented sequentially, with one task completed before another is begun. After the examiner is familiar with the evaluation process, tasks can be combined and the sequence altered. Systematic Evaluation

3. On-Field Evaluation: • Evaluations performed during game/practice competition and the athletic trainer must assist the athlete onto the field. • Off-Field Evaluation: • Clinical evaluations are performed in a relatively controlled environment compared with on-field evaluations. Types of Evaluations

4. On-field injuries are divided into ambulatory and athlete-down types. Ambulatory conditions are marked by the athlete’s coming to the clinician to be evaluated, little difference is evident between ambulatory and clinical evaluations. However, the amount of time available to perform the evaluation may be decreased during game competition. On-field Evaluations

5. Athlete-down conditions are signified by the athletic trainer’s responding to the athlete and the situation. On-field evaluations are best performed with two responders. On-field Evaluations

6. In order of their importance, the on-field evaluation must rule out: • Inhibition of the cardiovascular and respiratory systems • Life-threatening trauma to the head or spinal column • Profuse bleeding • Fractures • Joint dislocation • Peripheral nerve damage • Other soft tissue injury On-field Evaluations

7. Based on the findings of this triage, the immediate disposition of the condition must be determined. This includes the on-field management of the injury, the safest method of removing the athlete from the field, and the urgency of referring the athlete for further medical care. On-field Evaluations

8. Seven Steps: • History • Inspection • Palpation • Range of Motion • Ligamentous Tests • Special Tests • Neurological Tests Off-field Evaluations

9. The most important portion of an examination! Provides information about the structures involved and the extent of the tissue damage. Taking a medical history relies on the ability to communicate with the patient. The quality of information gained from the patient’s response will be equal to your ability to communicate. Avoidyes or no questions! Stick with open-ended questions… History

10. Remember! The history continues throughout the evaluation based on subsequent findings. • At the conclusion of the history-taking process, a clear picture is formed of the events causing the injury: • Predisposing conditions that may have led to its occurrence • Activities, motion, and postures that increase the symptoms. history

11. Examples of Questions: • What happened? • Pain Scale? • Did you hear any sounds? • Were you able to continue to play? • Any previous injuries? • Where is the pain? • What type of pain? • Does anything make the pain better or worse? • Any general medical questions Now I understand why my professors stressed the importance of history!?!?!?! history

12. Begins when the patient enters the facility: • At this time, gait, posture, and functional movement patterns are observed. • Notice the patient’s posture, and if guarding or carrying occurs in a protective manner. • Visually inspect the area for signs of gross deformity or other obvious injury: • Signs of joint displacement or bony fracture warrant the termination of the evaluation and the immediate referral to a physician. • Careful bilateral inspection may reveal subtle differences in otherwise healthy-looking body parts. Inspection

13. Inspect the injured body part and compare the results with the opposite structure for: • Gross deformity • Swelling • Bilateral symmetry • Skin • Infection Inspection I have not a clue what I’m looking for! But I’m looking!

14. The process of touching and feeling the tissues: • Allows the examiner to detect tissue damage that cannot be visually observed by comparing the findings of one body part with those of the opposite one. • Performed in a specific sequence, beginning with structures away from the pain site and progressively moving toward the damaged tissues. palpation

15. Two methods of sequencing: • 1st Method: • Bones and Ligaments • Muscle and Tendons • Other areas, such as pulses • 2nd Method: • Palpate all structures (listed above) farthest from the suspected injury and then progress toward the injury site. palpation

16. During palpation, make note of the following potential findings: • Point tenderness • Trigger points • Change in tissue density • Crepitus • Symmetry • Increased tissue temperature • Check out this video for help! palpation

17. Assessment of the patient’s ability to move the limb through the range of motion actively, passively, and against resistance helps to quantify the person’s current functional status. Complete tests for a particular body part must include all the motions allowed by the joint. Additionally, the joints proximal and distal to the affected joint may also need to be evaluated. Range of Motion

18. When the clinician has the patient move the injured joint and or area. Looking for the patient’s willingness to move the injured body part. Also, noticing for the patient’s ability to move the body part through the range of motion. Active Range of Motion (AROM)

19. When the clinician moves the injured joint and or area through the full range of motion. • Attempting to feel the end-feels of the joint: • Abnormal vs. Normal • As well as noting the patient’s quantity of movement: • Use a goniometer to determine specific amounts of the joint’s range of motion. Passive Range of Motion (PROM)

20. Tends to assess the strength of muscle groups throughout the full range of motion. However, the use of isometric break tests isolate individual muscles within their functional planes of motion. Should not be performed when the patient is unable to voluntarily contract the injured muscle or perform AROM. Resisted Range of Motion (RROM)

21. Scale: • Normal: (5/5): • Resistance with maximal pressure • Good: (4/5): • Resistance with moderate pressure • Fair: (3/5): • Moves the body part through a full range of motion against gravity • Poor: (2/5): • Moves the part through a full range of motion in a gravity-eliminated position • Trace: (1/5): • Patient cannot produce movement, but a muscle contraction is palpable • Gone: (0/5): • No contraction is felt RROM Grading system

22. Evaluate the structural integrity of the non-contractile tissues surrounding a joint. • Testing involves the application of a specific stress to a tissue to assess its laxity. • However, a distinction must be made between laxity and instability: • Laxity: describes the amount of “give” within a joint’s supportive tissue. • Instability: a joint’s inability to function under the stresses encountered during functional activities. Ligamentous Test

23. Scale: • Grade I: Firm: • Pain is present, but the degree of laxity roughly compares with that of the opposite extremity. • Grade II: Soft: • There is increased glide of the joint surfaces upon one another or the joint line “opens- up”. • Grade III: Empty: • The motion is excessive and becomes restricted by other joint structures. Ligamentous Laxity Grading

24. Involve specific procedures applied to the joint to determine the presence of pathomechanics. • Therefore, these tests are unique to each structure, joint, or body part. • Take special care to perform the test precisely as described to properly stress the involved tissue. • Examples: • Impingement Test (Shoulder) • McMurray’s Test (Meniscal Tear) Special Tests

25. Used to identify nerve root impingement, peripheral nerve damage, central nervous system trauma, or disease. Involves: Neurological Tests Sensory Tests Motor Tests Reflex Tests

26. Involves a bilateral comparison of light touch discrimination, using a light stroke within the central portion of the dermatome to avoid overlap of multiple nerve roots. The stroke should be felt to an equal extent on both sides. Used to perform a peripheral nerve injury assessment. Sensory Testing

27. Lower Extremity: • L1- Upper Thigh • L2- Mid Thigh • L3- Just below mid thigh • L4- Patella, medial leg, and big toe • L5- Lateral leg, and dorsum of foot • S1- Most lateral leg, lateral foot • S2- Posterior Thigh Dermatomes

28. Upper Extremity: • C1- Top of the head • C2- Temple • C3- Angle of the mandible • C4- Base of the neck into the top of the trapezius • C5- Lateral shoulder (Deltoid region) • C6- Lateral forearm down into the thumb • C7- Middle forearm down into the 3rd finger • C8- Medial forearm down into the 5th finger • T1- Medial Humerus Dermatomes

29. Manual muscle tests are used to test the motor neurons that are innervating the upper and lower extremities. Although innervation of all muscles tend to overlap, some muscles are more commonly tested for each nerve root. Motor Testing

30. Lower Extremity: • L1/L2- Hip Flexion • L3- Knee Extension • L4- Ankle Dorsiflexion • L5- Toe Extension • S1- Ankle Plantarflexion, and Eversion • S2- Knee Flexion Myotomes

31. Upper Extremity: • C1 & C2- Neck flexion • C3- Lateral Flexion • C4- Shoulder Shrug • C5- Shoulder Abduction • C6- Elbow Flexion & Wrist Extension • C7- Elbow Extension & Wrist Flexion • C8- Thumb Extension • T1- Finger Abduction & Adduction Myotomes Maybe not the best way to learn, but use whatever works!

32. Deep tendon reflexes (DTR’s) provide further information about the integrity of the cervical and lumbar nerve roots. However, reflex testing is limited because not all nerve roots have a DTR. In an active population, DTR’s may be graded using a four-point scale. WACK!!! Reflex Testing

33. Lower Extremity: • L4- Patella Tendon • S1- Achilles Tendon • Upper Extremity: • C5- Biceps Brachii Tendon • C6- Brachioradialis Tendon • C7- Triceps Brachii Tendon Deep Tendon Reflexes

34. Scale: • Grade 0: No reflex elicited • Grade 1: Reflex elicited with reinforcement • Grade 2: Normal response • Grade 3: Hyper-responsive reflex Grading Deep tendon reflexes

35. Should indicate a person’s ability to perform the tasks required for sports, work, or the basic activities of daily living. Functional tests are typically designed to assess how multiple components of the body work together to produce functional activity.. These assessments are then expanded to replicate the activity to be performed by the patient under the precise demands faced during real-life situations. Activity-Specific Functional Testing

36. Systematic evaluation may seem quite confusing at first, but believe me it works!! • Always be sure to use common sense in collaboration with “book smarts” to determine the correct diagnosis and appropriate treatment for your patient! • Any questions?!?! • Just ask your physician or athletic trainer how they do it! • Get some info for what your getting into! Wrap-up!