2. Systematic Process By: Corey Caterina

3.  The systematic evaluation is seven-step process, where each step is designed to obtain specific information.  The individual steps, as well as the components of each step, are presented sequentially, with one task completed before another is begun.  After the examiner is familiar with the evaluation process, tasks can be combined and the sequence altered.

4.  On-Field Evaluation:  Evaluations performed during game/practice competition and the athletic trainer must assist the athlete onto the field.  Off-Field Evaluation:  Clinical evaluations are performed in a relatively controlled environment compared with on-field evaluations.

5.  On-field injuries are divided into ambulatory and athlete-down types.  Ambulatory conditions are marked by the athlete’s coming to the clinician to be evaluated, little difference is evident between ambulatory and clinical evaluations.  However, the amount of time available to perform the evaluation may be decreased during game competition.

6.  Athlete-down conditions are signified by the athletic trainer’s responding to the athlete and the situation.  On-field evaluations are best performed with two responders.

7.  In order of their importance, the on-field evaluation must rule out:  Inhibition of the cardiovascular and respiratory systems  Life-threatening trauma to the head or spinal column  Profuse bleeding  Fractures  Joint dislocation  Peripheral nerve damage  Other soft tissue injury

8.  Based on the findings of this triage, the immediate disposition of the condition must be determined.  This includes the on-field management of the injury, the safest method of removing the athlete from the field, and the urgency of referring the athlete for further medical care.

9.  Seven Steps:  History  Inspection  Palpation  Range of Motion  Ligamentous Tests  Special Tests  Neurological Tests

10.  The most important portion of an examination!  Provides information about the structures involved and the extent of the tissue damage.  Taking a medical history relies on the ability to communicate with the patient. The quality of information gained from the patient’s response will be equal to your ability to communicate.  Avoid yes or no questions! Stick with open-ended questions…

11.  Remember! The history continues throughout the evaluation based on subsequent findings.  At the conclusion of the history-taking process, a clear picture is formed of the events causing the injury:  Predisposing conditions that may have led to its occurrence  Activities, motion, and postures that increase the symptoms.

12.  Examples of Questions:  What happened?  Pain Scale?  Did you hear any sounds?  Were you able to continue to play?  Any previous injuries?  Where is the pain?  What type of pain?  Does anything make the pain better or worse?  Any general medical questions

13.  Begins when the patient enters the facility:  At this time, gait, posture, and functional movement patterns are observed.  Notice the patient’s posture, and if guarding or carrying occurs in a protective manner.  Visually inspect the area for signs of gross deformity or other obvious injury:  Signs of joint displacement or bony fracture warrant the termination of the evaluation and the immediate referral to a physician.  Careful bilateral inspection may reveal subtle differences in otherwise healthy-looking body parts.

14.  Inspect the injured body part and compare the results with the opposite structure for:  Gross deformity  Swelling  Bilateral symmetry  Skin  Infection

15.  The process of touching and feeling the tissues:  Allows the examiner to detect tissue damage that cannot be visually observed by comparing the findings of one body part with those of the opposite one.  Performed in a specific sequence, beginning with structures away from the pain site and progressively moving toward the damaged tissues.

16.  Two methods of sequencing:  1 st Method:  Bones and Ligaments  Muscle and Tendons  Other areas, such as pulses  2 nd Method:  Palpate all structures (listed above) farthest from the suspected injury and then progress toward the injury site.

17.  During palpation, make note of the following potential findings:  Point tenderness  Trigger points  Change in tissue density  Crepitus  Symmetry  Increased tissue temperature  Check out this video for help!

18.  Assessment of the patient’s ability to move the limb through the range of motion actively, passively, and against resistance helps to quantify the person’s current functional status.  Complete tests for a particular body part must include all the motions allowed by the joint.  Additionally, the joints proximal and distal to the affected joint may also need to be evaluated.

19.  When the clinician has the patient move the injured joint and or area.  Looking for the patient’s willingness to move the injured body part.  Also, noticing for the patient’s ability to move the body part through the range of motion.

20.  When the clinician moves the injured joint and or area through the full range of motion.  Attempting to feel the end-feels of the joint:  Abnormal vs. Normal  As well as noting the patient’s quantity of movement:  Use a goniometer to determine specific amounts of the joint’s range of motion.

21.  Tends to assess the strength of muscle groups throughout the full range of motion.  However, the use of isometric break tests isolate individual muscles within their functional planes of motion.  Should not be performed when the patient is unable to voluntarily contract the injured muscle or perform AROM.

22.  Scale:  Normal: (5/5):  Resistance with maximal pressure  Good: (4/5):  Resistance with moderate pressure  Fair: (3/5):  Moves the body part through a full range of motion against gravity  Poor: (2/5):  Moves the part through a full range of motion in a gravity-eliminated position  Trace: (1/5):  Patient cannot produce movement, but a muscle contraction is palpable  Gone: (0/5):  No contraction is felt

23.  Evaluate the structural integrity of the non- contractile tissues surrounding a joint.  Testing involves the application of a specific stress to a tissue to assess its laxity.  However, a distinction must be made between laxity and instability:  Laxity: describes the amount of “give” within a joint’s supportive tissue.  Instability: a joint’s inability to function under the stresses encountered during functional activities.

24.  Scale:  Grade I: Firm:  Pain is present, but the degree of laxity roughly compares with that of the opposite extremity.  Grade II: Soft:  There is increased glide of the joint surfaces upon one another or the joint line “opens- up”.  Grade III: Empty:  The motion is excessive and becomes restricted by other joint structures.

25.  Involve specific procedures applied to the joint to determine the presence of pathomechanics.  Therefore, these tests are unique to each structure, joint, or body part.  Take special care to perform the test precisely as described to properly stress the involved tissue.  Examples:  Impingement Test (Shoulder)  McMurray’s Test (Meniscal Tear)

26.  Used to identify nerve root impingement, peripheral nerve damage, central nervous system trauma, or disease.  Involves:

27.  Involves a bilateral comparison of light touch discrimination, using a light stroke within the central portion of the dermatome to avoid overlap of multiple nerve roots.  The stroke should be felt to an equal extent on both sides.  Used to perform a peripheral nerve injury assessment.

28.  Lower Extremity:  L1- Upper Thigh  L2- Mid Thigh  L3- Just below mid thigh  L4- Patella, medial leg, and big toe  L5- Lateral leg, and dorsum of foot  S1- Most lateral leg, lateral foot  S2- Posterior Thigh

29.  Upper Extremity:  C1- Top of the head  C2- Temple  C3- Angle of the mandible  C4- Base of the neck into the top of the trapezius  C5- Lateral shoulder (Deltoid region)  C6- Lateral forearm down into the thumb  C7- Middle forearm down into the 3 rd finger  C8- Medial forearm down into the 5 th finger  T1- Medial Humerus

30.  Manual muscle tests are used to test the motor neurons that are innervating the upper and lower extremities.  Although innervation of all muscles tend to overlap, some muscles are more commonly tested for each nerve root.

31.  Lower Extremity:  L1/L2- Hip Flexion  L3- Knee Extension  L4- Ankle Dorsiflexion  L5- Toe Extension  S1- Ankle Plantarflexion, and Eversion  S2- Knee Flexion

32.  Upper Extremity:  C1 & C2- Neck flexion  C3- Lateral Flexion  C4- Shoulder Shrug  C5- Shoulder Abduction  C6- Elbow Flexion & Wrist Extension  C7- Elbow Extension & Wrist Flexion  C8- Thumb Extension  T1- Finger Abduction & Adduction Maybe not the best way to learn, but use whatever works!

33.  Deep tendon reflexes (DTR’s) provide further information about the integrity of the cervical and lumbar nerve roots.  However, reflex testing is limited because not all nerve roots have a DTR.  In an active population, DTR’s may be graded using a four-point scale.

34.  Lower Extremity:  L4- Patella Tendon  S1- Achilles Tendon  Upper Extremity:  C5- Biceps Brachii Tendon  C6- Brachioradialis Tendon  C7- Triceps Brachii Tendon

35.  Scale:  Grade 0: No reflex elicited  Grade 1: Reflex elicited with reinforcement  Grade 2: Normal response  Grade 3: Hyper-responsive reflex

36.  Should indicate a person’s ability to perform the tasks required for sports, work, or the basic activities of daily living.  Functional tests are typically designed to assess how multiple components of the body work together to produce functional activity..  These assessments are then expanded to replicate the activity to be performed by the patient under the precise demands faced during real-life situations.

37.  Systematic evaluation may seem quite confusing at first, but believe me it works!!  Always be sure to use common sense in collaboration with “book smarts” to determine the correct diagnosis and appropriate treatment for your patient!  Any questions?!?!  Just ask your physician or athletic trainer how they do it!  Get some info for what your getting into!