The Injury Examination Process ATHT 305 Fall 2015

Objectives:  Describe systematic examination technique  List appropriate history questions  List steps of a clinical examination in logical order

 Human body parts work together to produce normal movement known as biomechanics  Pathomechanics occurs after injury Example: Limping  Examination process connects the findings of dysfunctional anatomy, physiology, biomechanics.

Diagnosing  Initial diagnosis success determines rehabilitative outcomes Need to reexamine  Final determination is differential diagnosis Pathologies with similar signs and symptoms are excluded based on examination findings  Clinical diagnosis achieved via lab tests

Uninjured Pair Structure  The uninjured equivalent, the bilateral structure, should always be compared  Which do you test first: injured or non-injured?  When do you not test the uninjured? Acute situations such as dislocation

Clinical assessment  Have informed consent Under 18 Cross gender Unconscious?

Step 1: History  Most informative portion- info about structures involved, extent of tissue damage  Communication barriers Use jargon-free language Use pictures or models Speak slower, not louder Ask about one symptom at a time  Use open-ended questions Will get more information During catastrophic injury use “yes or no” questions Example:

Questions to ask- Previous history  Is there a history of injury to the area? Or “have you hurt this before”? Follow up questions:  Is this similar?  Does it feel the same as before?  When did it happen?  How was it treated?  Did that help?

Questions to ask- General Medical Health  Looking for comorbidities- presence of multiple unrelated disorders in the person at the same time  Chronic illness?  Medications?  Smoking?

Questions to ask  Mechanism of Injury How did this happen? Acute onset or insidious?  Relevant sounds Did you (or bystanders) hear a “pop” or “crack”?  Location Point with one finger to the spot it hurts most

OPQRST of Pain  Onset- When did it start?  Provoke- What makes it worse/better? Identifies tissues stretched/compressed  Quality- Nerve- sharp, burning Bone- localized & piercing Vascular- poorly localized, aching, reffered from another area Muscle- dull, aching, referred from another area  Radiating or referred- Radiating is result of nerve root or peripheral nerve compressed or contused Referred pain at site other than trauma  Severity-scale of 1-10  Time- when does it hurt? Morning vs night (muscle fatigue) After sitting for long periods of time Goes away during activity= chronic

Other  Weakness?  Does it “give out”?  Cold? – arterial involvment  Heavy? Venous or lymphatic involvement

Step 2- Inspection & Functional Assessment  Starts as soon as patient walks in- gait, guarding  Looking for: Deformity Swelling- measured by girth or volume Skin- ecchymosis, open wounds, surgical scars Infection- red, swelling, pus, red streaks, temperature

Functional Assessment  Perform tasks identified as problematic  What tests would we do for this guy?

Step 3: Palpation  Performed bilateral  Start away from pain and move towards- can rule out sources of pain and identify involved secondary structures Start with bones and ligaments, then muscles and tendons OR all structures away from then progress towards

Palpation- what to look for  Point tenderness- begin gentle then increase pressure  Trigger points  Change in tissue density Muscle spasm, hemorrage, edema, scarring, myositis ossificans  Crepitus- fx or inflammation  Tissue temperature Increased= inflammation Decreased= vascular insufficiency

Step 4- Joint and Muscle Function Assessment: AROM, PROM, RROM, & MMT  Active Range of Motion- joint motion produced by patient contracting muscles Assesses physiological and accessory motion Contraindication: fx or recently repaired soft tissue  Evaluates: Willingness and ability to move Unwilling is extreme pain, neurological deficit, or malingering “Painful arc”- part of ROM causing pain due to compression, impingement or abrasion

Passive Range of Motion  Clinician moves joint through ROM  Apply over pressure to identify end feels to indicate what type of structure stressed at terminal ROM  PROM should be more than AROM  When they fall short, capsular adhesions  When AROM less= muscle weakness

Normal End-feels End-feelsStructureExample SoftSoft tissue approximationKnee flexion FirmMuscle Stretch Capsular stretch Ligamentous stretch Hip flex with knee ext Ext of MCP joints Forearm supination HardBone contacting boneElbow ext

Resistive Range of Motion & MMT  Gross strength of muscle group through cardinal plane of motion  Manual Muscle Tests- Isometric test in mid-range of ROM (also called break test) Differentiates between muscle and ligament Ligaments not taut in joints midrange Compensation may be seen

MMT Grades VerbalNumericalClinical Finding Normal5/5 Can resist against max pressure. Examiner unable to break patient’s resistance. Good4/5 Patient can resist against moderate pressure. Fair3/5 Patient can move the body part against gravity through full ROM Poor2/5 Patient can move body part in gravity-eliminated position through full ROM Trace1/5 Patient cannot produce movement, but contraction is palpable Zero0/5 No contraction felt.

Other things to consider  Hyper vs hypomobility Can be congenital laxity  Joint play Accessory motion: roll, spin, glide  Assessed with Pt. relaxed, loose-packed position. Distract joint.  Hyper vs hypomobility Can be congenital laxity  Joint play Accessory motion: roll, spin, glide  Assessed with Pt. relaxed, loose-packed position. Distract joint.

 Step 5: Special Tests  Step 6: Neurological screening Dermatomes = sensory Myotomes = motor Reflex= integrity of CNS via GTO  Step 7: Vascular Screen

Homework questions  1. What is the difference between a “sign” and a “symptom”?  2. When asking about medications, what are 2 possible negative effects that could influence the injury. Example: prolonged bleeding time  3. Describe where and what you would start palpating if an athlete told you the lateral side of their ankle hurt.  4. If I say “MMT of knee flexion is 3/5” describe the patient position and results of the test.