WILLIAM E. PRENTICE THE EVALUATION PROCESS IN REHABILITATION

INTRODUCTION Injury evaluation is the foundation of the rehabilitation process The athletic trainer determines the appropriate rehab goals and plan based on info gathered from the evaluation. Must consider the severity, irritability, nature and stage of the injury A.T. must continuously re-evaluate the status of pathological tissue throughout rehab to make appropriate adjustments

INTRODUCTION On-site evaluation: Quickly, but thoroughly evaluate the patient to determine the injury severity, whether immobilization is needed, medical referral need, manner of transportation from field Off-site evaluation: More detailed Used to gain info to effectively design rehab plan

SYSTEMATIC DIFFERENTIAL EVALUATION Subjective evaluation: History and symptoms experienced by the patient Relate info gathered to objective findings Objective evaluation: Observation and inspection Acute injury palpation Range of Motion (ROM) Assessment (Active and Passive) Muscle strength Special test Neurological assessment Functional testing Pg. 48 and 49 (Figure 3-1)

SYSTEMATIC DIFFERENTIAL EVALUATION History Patients impression of the injury Site of injury (pain) Mechanism of injury Previous injuries General health Open-ended, non leading questions Use of simple terminology

SYSTEMATIC DIFFERENTIAL EVALUATION Mechanism of Injury Identify nature of forces acting on body Single traumatic force (macrotrauma) vs. accumulation or repeated forces (microtrauma) Identify body position at time of injury Direction, point of application and magnitude of applied force Changes in training, routine, equipment use and posture Sound or sensation Pop=joint subluxation or ligament tear Clicking=cartilage or meniscus tear Locking=cartilage or meniscal tear (loose body) Giving way=reflex inhibition of muscles in an attempt to minimize muscle or joint loading

SYSTEMATIC DIFFERENTIAL EVALUATION Objective Evaluation Observation and Inspection Swelling, deformity, and discoloration Overall appearance of athlete Observe posture : especially in chronic overuse type injuries Postural malalignment creates repeated stress on specific tissue Cause muscle imbalances: tight vs. weak tissue Figure 3-2 (pg Compensatory patterns, muscle guarding, facial expressions Lower extremity: Observe athletes gait (walking pattern) Upper extremity: observe carrying pattern of injured extremity

SYSTEMATIC DIFFERENTIAL EVALUATION Palpation Identify damaged tissue Point tenderness, trigger points (small nodule or muscle spasm), tissue quality, crepitus, temperature, symmetry Use pain scale of 0(no pain) to 10 (worst pain imaginable) Start with gentle superficial touch progress to deeper tissue palpation Palpate unaffected side to identify normal tissue Helpful to develop specific sequencing of tissue palpated Bones then ligaments then muscle &tendon

SYSTEMATIC DIFFERENTIAL EVALUATION ROM: Ability to move limb through specific pattern of motion Compare bilaterally: unaffected side first to determine athletes individual range AROM, PROM, RROM in that order Differentiate between contractile tissue (muscle & tendon) and inert tissue (bone, ligament, capsule, bursae, periosteum, cartilage, fascia) Pain with AROM in one direction and PROM in the opposite direction=contractile tissue Pain with both =inert tissue Pain at end range =inert tissue injury because of compression of tissue between bony structures Crepitus or clicking during PROM may indicate damage to articular surface or loose body or in muscle tissue adhesions or tendon subluxation

SYSTEMATIC DIFFERENTIAL EVALUATION End feels (figure 3-1, pg. 57) Normal End feel Soft tissue approximation=soft and spongy, a gradual painless stop (elbow flexion) Capsular=an abrupt, hard, firm end point with only a little give (shoulder rotation) Bone to bone=a distinct and abrupt en point where 2 hard surfaces come in contact with another (elbow extension)

SYSTEMATIC DIFFERENTIAL EVALUATION End feels (figure 3-1, pg. 57) Abnormal End Feels Empty=movement definitely beyond the anatomical limit, or pain prevents body part from moving through normal ROM (ligament rupture) Spasm=involuntary muscle contraction that prevents normal ROM due to pain (muscle spasm) Loose=extreme hypermobility (chronic ankle sprain) Springy Block= a rebound at the end of motion (meniscal tear or loose body formation )

SYSTEMATIC DIFFERENTIAL EVALUATION Strength testing Used to asses state of contractile tissue (muscle, tendon, nerve) Mid-range muscle testing (isometric or “break test”) Table 3-2 pg 59 Specific muscle testing (Table 3-3 pg 59) Assess pain and strength Used at eval and throughout rehab progression May identify muscle strain, pain/reflex inhibition, peripheral nerve injury, nerve root lesion, tendon strain, or psychological overlay

MUSCLE IMBALANCES Imbalances between agonist muscle and functional antagonist Disrupt normal force-couple relationship Action of 2 forces in opposing directions about same axis of rotation Muscle tightness or hyperactivity often the initial cause of muscle imbalance. Shortened agonist muscle vs. lengthened antagonist muscle Reciprocal inhibition causes decreased neural drive which facilitates functional weakness of antagonist To compensate for weakness patient relies on synergist or secondary muscles to specific movements Synergistic dominance Increases risk of injury to the synergist muscles Janda Classification of functional muscle grouping Table 3-4 pg. 61

SYSTEMATIC DIFFERENTIAL EVALUATION Special Test Joint stability or stress test Joint compression test Neurological test Dermatome testing Sensory distribution is innervated by specific nerve root Myotome testing Muscles innervated from specific nerve root Reflex testing Deep tendon, superficial, and pathological reflexes

INJURY PREVENTION Functional Movement Screening NASM Video Overhead Squat Test Figure 3-5 (Pg. 65) In-Line Forward Lunge Test Figure 3-6 (Pg. 66)

DOCUMENTING FINDINGS SOAP Notes Subjective Objective Assessment Plan Progress Reports Athletes treatment, goals reached, performance, symptoms, pain, etc Subjective Objective Assessment Plan

DOCUMENTING FINDINGS Setting Rehab Goals

DOCUMENTING FINDINGS Progress Evaluations