1. Principles of Examination
Core Concepts in Athletic Training and Therapy
Susan Kay Hillman

2. Objectives
Explain the difference between the primary survey and the secondary survey in the evaluation of an injured person.
List the main steps in performing a complete on-site examina­tion.
List the main steps in performing a complete acute injury examination.
Explain the term “SINS” as used in acute and clinical examinations.
Explain the difference between the subjective and the objective segments of the examination.
List the elements one should include in the objective component of the clinical examination.
Explain the importance of documenting an examination.

3. Introduction Examination Components
Before making a diagnosis must thoroughly examine the injury
Sequentially performing tasks involved in specific examination components
Dictated by location and timing of examination
Three different environments
On field (onsite
On sideline (acute)
Athletic training facility (clinical)
Each demands different examination, but all should begin with evaluation to eliminate any critical or life threatening concerns

4. Examination Components
Primary Survey
Determine status of life threatening or limb threatening conditions
Life threatening conditions (ABC’s or CAB’s)
Other vital signs and severe bleeding
Treat emergency conditions or move on to secondary survey depending on your findings
Secondary Survey
Occurs when primary survey is concluded or deemed unnecessary
No life threatening conditions, patient is breathing and any bleeding is under control
Examination to determine presence of other injuries
Rapid examination to determine seriousness of injury and if and how patient should be moved
Determine nature of injury or illness and identify positive findings for referral to medical professional

5. Examination Components
SIDEBAR: When to Refer for Further Evaluation (Emergency Room or Physician)
Patient fails to regain consciousness within few minutes
Cannot determine cause of unconsciousness, even if consciousness is regained
Observe abnormal vital signs
Note any signs of serious or limb threatening or life threatening injury or illness

8. On-Site Examination Goals and Purposes
Rule out life threatening and serious injuries
Determine severity of injury
Determine most appropriate method of transporting patient
Perform a quick accurate examination and treat injury to minimize effects
Initial decisions among most critical
Incorrect decision can have dire or even deadly consequences

9. Goals and Purposes Determine conscious vs. unconscious
Unconscious serious situation
Trauma or general medical condition
Rapid decision making
Stay calm
Take your time
Be focused and efficient
Good examination skills, knowledge and experience are essential
Err on the side of caution
Stay within the scope of your practice and training
Make all decisions with persons safety in mind

10. Obtain a History Determine mechanism, location and severity of injury
On site history: investigate chief complaint and problems that are readily apparent and in need of attention
Always watch to observe for mechanism but also ask patient what happened
Also ask bystanders if patient unconscious or mechanism is unclear
Ask questions regarding exact location of pain and severity of pain and other symptoms
Pain scale 1 to 10
More detailed history can be obtained during acute and clinical examination

11. Observe and screen Observe patient movement ability and patterns
Check for abnormal positioning of head, neck or extremities
Observe discoloration, deformity, swelling, patients reaction, movement
If suspect spinal injury, stabilize patients head and neck and examine peripheral nerves for sensory and motor function
Head injury: Alert and Oriented x 4

12. Observe and screen Observe for bony injury
Deformity
Palpation (feel) for fracture or dislocation
Observe for muscular and or ligament injury
Palpation for defect
ROM test
Strength test
Stress Test
Special Test

13. Monitor for Shock
Patients with severe pain, first time injury of any severity, or poor tolerance for any injury observe for signs and symptoms of shock
Pale, cool, clammy skin
Rapid, shallow breathing
Weak, rapid pulse
Nausea, falling blood pressure
Treat immediately and transport to emergency medical facility

14. Implement Immediate Action Plan
If determine life threatening or serious injury refer patient for further examination and treatment
Follow your emergency operating plan (EOP)
If immediate transport not necessary determine transport method off playing surface
More detailed examination can occur on sideline or in AT Room
Rehearse and practice methods of transport and implementation of emergency operating plan

15. Communicate in Site Examination Results
Communicate findings with staff, coaches, officials and other healthcare professionals
Provide detailed information to allow for appropriate care for athlete

16. Acute Examination Follows the on-site examination
SINS: severity, irritability, nature, and stage of an injury
Determine more precisely the nature and severity so you can administer appropriate treatment, provide referral, or return athlete to participation

17. Acute Examination History Observation Palpation Special Test ROM Test
Strength Test
Stress Test
Neurological and circulatory tests
Functional tests
Other Special Tests

18. Acute Examination Subjective Segment How does the patient feel
Patients opportunity to describe injury or illness
More detailed history from on site examination
Questions should not be leading
Athlete may be able to recall information they could not during on site eval.
Athlete has calmed down and is less agitated
All pertinent medical information
Past and present injuries

19. Acute Examination Objective Segment What you can see or evaluate
Swelling, discoloration, deformity
Be careful not to perform test that may cause more injury or pain
Use common sense and information gathered during subjective testing
Best time to evaluate is immediately after injury
A.T. get the most accurate testing in first 10 minutes after injury before pain and swelling have developed

21. Clinical Examination General Principles of the Clinical Examination
If injury not witnessed or is chronic, examination may be broader and more detailed
Continuation of on site or acute exam or first encounter with athlete
Subjective Segment

22. Clinical Examination Objective Segment Comparable sign
Negative response if tissue is not injured
Positive response if tissue is injured
Reproduction of patients symptoms is called comparable sign
Bilateral Comparison
Always perform all test bilaterally
Understand purpose of the test and what is normal for the patient

23. Clinical Examination Observation Palpation Range of Motion Strength
Posture, movement patterns, Contour, alignment, discoloration and symmetry
Palpation
Feel anatomical structures for pain, swelling, deformity, spasm, tissue thickening, crepitus
Superficial to deeper structures
Bony to Soft tissue
Range of Motion
AROM, PROM, RROM
Quality and quantity of physiological and accessory movement
End feels: abnormal end feels may be indicative of injury
Strength
Isometric or Break test
Strength test through ROM
Grading scale of 0 to 5

24. Clinical Examination Stress Tests Special Tests Neurological Tests
Rule out brain, spinal, or peripheral nerve pathology
Performed if you suspect nerve injury or if patient symptoms include sensory deficits (radiating pain, tingling, burning, numbness, etc.,)
Sensory, motor and reflex responses
Unilateral changes=nerve root or peripheral nerve lesion
Bilateral changes-central cord or brain pathology

25. Clinical Examination Vascular Tests
Examine integrity of vascular system
Palpate pulses
Check capillary refill distal to injury
If absent, weakness or disappears=medical emergency
Functional Tests
Used only to when patient is ready to return to former participation levels
Determine patients ability to return safely and fully resume all activities
Increase patients confidence and readiness to return
Sidebar Page 198

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28. Documenting the Examination
Accurate and thorough documentation of your findings
Legal standpoint
Continuity of care
Re-examining of injury
Follow HIPAA (Health Insurance Portability and Accountability Act) guidelines