Chapter 13: Off-the Field Injury Evaluation

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 room…etc) Progress evaluation

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

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)

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

Biomechanics (foundation for assessment) 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)

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)

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

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

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

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

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?

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

Special Tests Soft tissue Used to detect specific pathologies 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

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

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

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

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

Neurological Examination 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

Cerebellar Function Sensory Testing 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

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 Babinski’s sign, Chaddock’s, Oppenheim’s, Gordon’s

Testing Joint Stability 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

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

Anthropometric Measurements 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

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

History Observations Palpation 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

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?

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

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

O(Objective) A (Assessment) P (Plan) Findings based on ATC’s evaluation 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

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

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

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

X-Ray

Computed Tomography (CT scan) 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)

CT Scan

Bone Scan

Magnetic Resonance Imaging (MRI) 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

Magnetic Resonance Imaging

Electroencephalography (EEG) 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

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)

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

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.