1. Off-the Field Injury Evaluation

2. 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

3. 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

4. Basic Knowledge Requirements
ATC must have general knowledge of anatomy and biomechanics as well as hazards associated with particular sport
Anatomy
Surface anatomy
Key surface landmarks provide examiner with indications of normal or injured structures
Body planes and anatomical directions
Points of reference

5. Abdominopelvic Quadrants
Four corresponding regions of the abdomen
Divided for evaluative and diagnostic purposes

6. 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)

7. Understanding the Sport
More knowledge of sport allows for more inherent knowledge of injuries associated with sport and better injury assessment
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)

8. 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 condition
Syndrome - group of symptoms and signs that together indicate a particular injury or disease

9. Off-the-field Injury Evaluation
Detailed evaluation on sideline or in clinic/training room setting
May be the evaluation of an acute injury or one several days later following acute injury
Divided into 4 components
HOPS

10. History
Obtain subjective information relative to how injury occurred, extent of injury, MOI
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

11. Observations How does the athlete move? Is there a limp?
Are movements abnormal?
What is the body position?
Facial expressions?
Asymmetries postural mal-alignments or deformities?
Abnormal sounds?
Swelling, heat, redness, inflammation, swelling or discoloration?

12. 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

13. Special Tests Used to detect specific pathologies
Compare inert and contractile tissues and their integrity
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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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?

26. Manual Muscle Testing
An evaluation system for diagnosis of disease or dysfunction of the musculo-skeletal and nervous systems

27. Purpose
Measures the capability of muscles or groups to provide support and movement
Diagnostic tool
Postural balance
Gait impairment
Range of motion
Uses little equipment
Obtains information not defined by other procedures

28. Precautions Do No Harm (use gentleness) Know ROM limits
Follow procedure
Record
Promptly
Accurately

29. To Get Standardized Results
Proper training and education
Knowledge base of anatomy, physiology and neurology of muscle function
Follow precise testing protocol
Practice, Practice, Practice
A skill developed and maintained with number of cases

30. Validity and Accuracy
Coordinate the muscle testing findings with other standard diagnostic procedures
The amount of pressure used to test may vary between persons performing the test.
The amount of strength loss must be greater than approximately 20 to 30% to be dependably measurable
Comparison of both sides is a better indicator of loss
Manual muscle tests evaluate the ability of the nervous system to adapt the muscle to meet the changing pressure of the examiner’s test. This requires that the examiner be trained in the anatomy, physiology, and neurology of muscle function. The action of the muscle being tested, as well as the role of synergistic muscles, must be understood. Manual muscle testing is both a science and an art. To achieve accurate results, muscle tests must be performed according to a precise testing protocol. The following factors must be carefully considered when testing muscles in clinical and research settings.
Proper positioning so the test muscle is the prime mover
Adequate stabilization of regional anatomy
Observation of the manner in which the patient or subject assumes and maintains the test position
Observation of the manner in which the patient or subject performs the test
Consistent timing, pressure, and position
Avoidance of preconceived impressions regarding the test outcome by the tester
Utilizing nonpainful contacts  ensuring a nonpainful execution of the test
Contraindications due to age, debilitative disease, acute pain and local pathology or inflammation

31. Muscles 3 Types: Skeletal, Smooth, Cardiac Composed of fibers
Skeletal around 40% of muscle composition
Generally voluntarily controlled
Composed of fibers
Work in groups
Movement depends on how the muscles are attached

32. Structure of Muscle Movement depends on how the muscles are attached
Structure of a muscle
A single muscle is fat in the middle and tapers towards the ends. The middle part, which gets fatter when the muscle contracts, is called the belly of the muscle. If you contract your biceps muscle in your upper you may feel it getting fatter in the middle. You may also notice that the biceps is attached at its top end to bones in your shoulder while at the bottom it is attached to bones in your lower arm. Notice that the bones at only one end move when you contract the biceps. This end of the muscle is called the insertion. The other end of the muscle, the origin, is attached to the bone that moves the least (see diagram 35).
Picture:
Movement depends on how the muscles are attached

33. How Do Muscles Cause Movement
Origin- where the muscle is attached to the bone; this bone will move very little
Insertion- muscle attachment to bone with most motion
Belly of muscle- part of muscle that enlarges on contraction

34. Muscle Groups Quadriceps Hamstrings Calf Low back Abdominals
Pectoralis major
Rhomboids
Trapezius
Latisimus dorsi
Deltoids
Biceps
Triceps

35. Conduct Strength Testing
Correct positioning is essential (Start in extended anatomical position)
Exert uniform force directly on the line opposing movement
Such tests are very physio specific and do not have good inter rater reliability, although intra rater reliability is fine. In this case, it goes down to the individual experience of a physio. What you should more look to is a comparison to the 'normal' side, or if there are no 'normal' sides, then it's more whether the patient can constantly push as hard as they can throughout range, which is considered a grade 5. Otherwise, manual muscle tests are largely irrelevant I find, and I preferably use 'functional' measures myself, such as the number of squats, heel raises, bicep curls, shoulder raises etc to fatigue, where what you look for is the point where quality of movement becomes distorted/shaky/compensated etc.

36. Testing of Bicep & Tricep
Support humerus where gravity is against the bicep and tricep, client in anatomical position
Move elbow through full ROM (Passive ROM)
Flexion
Extension
Internal rotation
External rotation
Passive ROM means movement is performed by the caregiver

37. Maneuver to Assess Muscle Strength
With arm in full extension, pull downward on forearm while client attempts to flex.
With arm flexed, apply pressure against forearm, ask client to straighten arm.
When performing muscle tests, be sure to evaluate for asymmetry of the muscle groups (i.e. atrophy on one side and not the other) and landmarks prior to testing.

38. Use the following scale to rate strength:
0-No movement, no contraction of the muscle
1- Trace, evidence of muscle contraction but no joint movement
2- Poor, complete range of motion with gravity eliminated
3-Fair, complete range of motion against gravity
4- Good, complete range of motion against gravity with moderate resistance
5-Normal, complete range of motion against gravity with maximal resistance without evidence of fatigue

39. Other Test Results
Weakness – defined as a strength below fair in non weight bearing muscles; below fair + in weight bearing muscles
Contracture – degree of shortness in muscle, so it cannot move through ROM
Substitution – weak muscles are supported by other muscles to move

40. Strength Test Examples
Gastrocnemius
Rectus Femoris
Brachioradialis