Lecture 3 Assessment Protocols

History, Observation, ROM/Resisted, Special tests and Palpations

History Provides valuable information about the athletes condition -Listening to the patient / athlete -Questions – try not to lead the athlete -Repetition – taken in an orderly sequence -Try to keep patient focused on relevant information -Relevant past history and or treatments received -Surgeries, allergies, major illnesses -Relevant family history -X-rays, or any other test results -Medications

-Age, occupation (student/ sport), life style (recreational pursuits) -Chief complaint- what is the major problem -What was the trauma – Mechanism of injury (MOI) -Direction, magnitude, force applied -Predisposing factors ( old injuries, braces, field conditions) -Onset – sudden (acute) or slow (insidious)

-Pain – during day or night - when is it better ( what makes it feel better) or when is it worse -Symptoms – what bothers the athlete- can they point to one area – specific / general -Pain – has it changed since it first started -Trigger points ( points that are hyperirritable) tender to compression -Referred pain – is the pain felt somewhere other that the injured site ( referred pain is usually referred segmentally – does not cross midline) -What causes the pain

Functionally pain is seen in seven levels pain after specific activity pain after specific activity resolving after a warm up pain during and after specific activity which does not effect performance pain during and after specific activity which does effect performance pain with all activity of daily living constant dull aching pain at rest which does not disturb sleep constant dull aching pain at rest which does disturb sleep

-How long has problem existed – duration /frequency -Have they had this problem before – did it get better – how – how long -Type of pain -Nerve – sharp, bright, burning -Bone – deep, boring, very localized -Vascular – diffuse, aching poorly localized -Muscle – hard to localize, dull and achy

-Sensations - pins and needles - numbness -Locking – joint can not be fully extended -Giving way – joint buckles -Other problems – fainting, bladder, neurological problems etc.. -Stress levels of athlete

Red Flags

Cancer -persistent night pain -unexplained weight loss ( 10 – 15 lbs in 2 weeks or less) -loss of appetite -lumps or growths Cardiovascular -shortness of breath -dizziness -pain / heaviness in chest -pulsating pain in body

Gastrointestinal -frequent and sever abdominal pain -heartburn and or indigestion -nausea and vomiting -bladder problems Neurological -changes in hearing /speech or vision -frequent and or severe headaches -problems with balance -fainting spells -weakness

Miscellaneous -fever or night sweats -emotional disturbances – depression -swelling with no apparent history -severe unremitting pain -severe pain with no obvious history -severe spasms All Red Flags Refer to Doctor immediately

Observations -observations start right away when athlete walks into clinic – limping.. etc -looking and or inspecting an area -gain information on visible defects or abnormalities -posture -gait

Dominant Eye

Normal alignment Obvious deformities Obvious deviations Muscle wasting Limb position – equal / symmetrical Skin colour and temperature Scars Crepitus, snapping or abnormal sounds Swelling / redness Willingness to move

Active Movement Test joint range, muscle control and willingness of athlete to move.

Things to note -When and where during each movement the onset of pain occurs -Does it increase intensity and quality of pain -Observe restrictions -Observe pattern of movements -Observe rhythm and quality of movement -Willingness to move what are their limitations

Passive Movements -Athlete is relaxed, movement is through the full ROM of the joint as possible. -Normal movement is relative – ie. gymnasts as compared to football. (Hyper/hypo)

End Feels Normal Bone to bone – hard and unyielding – elbow extension Soft tissue approximation – yielding compression stops further movement – knee flexion Tissue stretch – hard or firm (springy) type of movement with slight give – ankle dorsiflexion – shoulder lateral rotation

Abnormal Muscular spasm - sudden and hard – quad contusion Capsular – similar to tissue stretch – but occurs when not expected – frozen shoulder Bone to bone – ends meet before normal – osteophyte formation Empty – considerable pain – no end feel - MCL rupture – bursea Springy block – similar to tissue stretch but again where not suspected – meniscus

Resisted Movement -Tested last -Strong static (isometric)contraction -Voluntary muscle contraction -Amount of pain and weakness is related to degree of injury -Athlete resists applied pressure -Keep movement to a minimal

Muscle Grading 5 – Normal – Complete max resistance 4 – Good – Moderate resistance 3 – Fair – ROM with gravity 2 – Poor – Rom with gravity eliminated 1 – Trace – Minimal contraction 0 – None – No contraction

Examination Principles test normal side first Active before passive Passive before resisted Most painful test done last Resisted – joint is in neutral and isometric – stress on inert tissue is minimal Passive ROM – not only degree of movement but end feel Ligament stress – gentle / repeat and increase stress but not beyond point of pain

Special Tests Are available for all joints and most muscles to determine injury Uses of special tests -To confirm tentative diagnosis -Make a differential diagnosis -Differentiate between structure

Reflexes BicepsC5-C6 TricepsC7-C8 PatellaL3-L4 AchillesS1-S2

Palpations To palpate the area should be as relaxed as possible discriminate the difference in tissue tension, ie rigidity and or flaccidity discriminate the difference in tissue texture – fibrous band

detect abnormalities or deformities (myositis ossificans) determine tissue thickness -obvious swelling, intra or extra articular -blood swelling - rapid (2-4 hours) – hard thick gel like -fluid swelling – slow (8- 24 hours) – softer more mobile Joint tenderness

Temperature Abnormal sensations –hyperesthesia – increased sensations –dysesthesia – diminishing sensations –anethesia – absence of sensations –crepitus etc.