Chapter 13: Off-the Field Injury Evaluation

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Chapter 13 Off-the Field Injury Evaluation
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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 roometc)
• Progress evaluation

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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

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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)

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• 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

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• 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)

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• 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)

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• 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

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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

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• 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

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• 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

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• 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?

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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
• Babinskis sign, Chaddocks, Oppenheims, Gordons

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• 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

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• 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

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• 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

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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

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• 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 athletes affect? Attitude and mood?
• Palpation
• What is consistency of swelling and has it
  changed?
• Is it still tender to touch?
• Deformity compared to yesterday

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• 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?

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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

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• 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

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• O(Objective)
• Findings based on ATCs evaluation
• A (Assessment)
• ATCs 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
  examiners plan for treatment

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• 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, athletes and
  injurys response to treatment, progress and
  goals
• Should also discuss future treatment plans if
  necessary

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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

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• 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

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X-Ray
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• 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)

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CT Scan
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Bone Scan
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• 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

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Magnetic Resonance Imaging
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• 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

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• 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)

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• 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

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• Urinalysis using dip and read test strips provide
  fast accurate results for a number of things
  including, specific gravity, WBCs, 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.