1. Chapter 13: 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
Topographical anatomy is essential
Key surface landmarks provide examiner with indications of normal or injured structures
Body planes and anatomical directions
Points of reference (midsagital, transverse, and frontal (coronal) planes)

5. Abdominopelvic Quadrants
Four corresponding regions of the abdomen
Divided for evaluative and diagnostic purposes
A second division system involves the abdomen being divided into 9 regions

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
Must be aware of proper biomechanical and kinesiological principles to be applied in activity
Violation of principles can lead to repetitive overuse trauma
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 the condition
Sequela - condition following and resulting from disease or injury (pneumonia resulting from flu)
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 setting
May be the evaluation of an acute injury or one several days later following acute injury
Divided into 4 components
History, observation, palpation and special tests
HOPS

10. History
Obtain subjective information relative to how injury occurred, extent of injury, MOI
While obtaining history, remain calm, present simple questions, listen carefully to complaint, take good records
Inquire about previous injuries/illnesses that may be involved as well as past treatments
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. Be sure to identify the location of the pain and injury
Pain characteristics
What type of pain?
Where is the pain?
Does it change at different times?
Are there any other types of sensations?
Joint response
Is there instability?
Does it feel loose or like it will give way?
Does the joint lock?
Determine chronic vs. acute
Time frame

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

13. 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
Compare bilaterally
Look for abnormal gapping, swelling, abnormal protuberances associated with bone or joint

14. Special Tests Soft tissue Used to detect specific pathologies
Must remain relaxed
Look for lumps, swelling, gaps, tension, temperature
Variations of shape and structure, tightness, textures
Skin dryness, moistness, skin dysesthesia or anesthesia or hyperesthesia
Perform bilaterally
Special Tests
Used to detect specific pathologies
Compare inert and contractile tissues and their integrity
Lesion in contractile tissue will result in pain with motion (pain with active motion in one direction and with passive motion in opposite direction)
Lesion in inert tissue will elicit pain on active and passive motion in the same direction

15. 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
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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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?

28. Documenting Injury Evaluation Information
Complete and accurate documentation is critical
Clear, concise, accurate records is necessary for third party billing
While cumbersome and time consuming, athletic trainer must be proficient and be able to generate accurate records based on the evaluation performed

29. SOAP Notes
Record keeping can be performed systematically which outlines subjective & objective findings as well as immediate and future plans
SOAP notes allow for subjective & objective information, the assessment and a plan to be implemented
S(subjective)
Statements made by athlete - primarily history information and athletes perceptions including severity, pain, MOI

30. O(Objective) A (Assessment) P (Plan)
Findings based on ATC’s evaluation
A (Assessment)
ATC’s professional opinion regarding impression of injury
May include suspected site of injury and structures involved along with rating of severity
P (Plan)
Includes first aid treatment, referral information, goals (short and long term) and examiner’s plan for treatment

31. Progress Notes
Need to be routinely written after each progress evaluation
Perform throughout rehab of an injury
Can follow SOAP format, generated daily, or be weekly summaries
Should focus on treatments, athlete’s and injury’s response to treatment, progress and goals
Should also discuss future treatment plans if necessary

32. Additional Diagnostic Tests
Due to the need to diagnose and design specific treatment plans, physicians have access to additional tools to acquire additional information relative to an injury
There are a series of diagnostic tools that can be utilized in order to more clearly define and determine the problem that exists

33. Plain Film Radiographs (X-ray)
Used to determine presence of fractures bone abnormalities and dislocations
Can be used to rule out disease (neoplasm)
Occasionally used to assess soft tissue
Arthrography
Visual study of joint via X-ray after injection of dye, air, or a combination of both
Shows disruption of soft tissue and loose bodies
Arthroscopy
Invasive technique, using fiber-optic arthroscope, used to assess joint integrity and damage
Can also be used to perform surgical procedures

34. X-Ray

35. Computed Tomography (CT scan)
Myelography
Opaque dye injected into epidural space of spinal canal (through lumbar puncture)
Used to detect tumors, nerve root compression and disk disease and other diseases associated with the spinal cord
Computed Tomography (CT scan)
Penetrates body with thin, fan-shape X-ray beam
Produces cross sectional view of tissues
Allows multiple viewing angles
Bone Scan
Involves intravenous introduction of radioactive tracer
Used to image bony lesions (i.e. stress fractures)

36. CT Scan

37. Bone Scan

38. Magnetic Resonance Imaging (MRI)
Ultrasonography
Use of ultrasound to view location, measurement or delineation of organ or tissue by measuring reflection or transmission of high frequency ultrasound waves
Computer is able to generate 2-D image
Magnetic Resonance Imaging (MRI)
Using powerful electromagnet, magnetic current focuses hydrogen atoms in water and aligns them
After current shut off, atoms continue to spin emitting different levels of energy depending on tissue type, creating different images
While expensive, it is clearer than CT scan and the test of choice for detecting soft tissue lesions

39. Magnetic Resonance Imaging

40. Electroencephalography (EEG)
Echocardiography
Uses ultrasound to produce graphic record of cardiac structures (valves and dimensions of left atrium and ventricles)
Electroencephalography (EEG)
Records electrical potentials produced in the brain to detect changes or abnormal brain wave patterns
Electromyography (EMG)
Graphic recording of muscle electrical activity using surface or needle electrodes
Observed with oscilloscope screen or graphic recordings called electromyograms
Used to evaluate muscular conditions

41. Nerve Conduction Velocity
Used to determine conduction velocity of nerves and can provide key information relative to neurological conditions
After applying stimulus to nerve, speed at which the muscle reaction occurs is monitored
Delays may indicate nerve compression or muscular/nerve disease
Synovial Fluid Analysis
Detect presence of infection in the joint
Used to confirm diagnosis of gout and differentiates between inflammatory and non-inflammatory conditions (degenerative vs. rheumatoid arthritis)

42. Blood Test
Complete blood count (CBC) used to screen for anemia, infection and many other reasons
Assesses red blood cell count, hemoglobin levels, hematocrit levels (RBC per volume), white blood cell count, platelet deficiency, & serum cholesterol
Urinalysis
Used to assess specific gravity, pH, presence of ketones, hemoglobin, proteins, nitrates, red & white blood cells, bacteria, electrolytes, hormones and drug levels

43. Urinalysis using dip and read test strips provide fast accurate results for a number of things including, specific gravity, WBC’s, nitrate, pH, protein, glucose, ketones, bilirubin and blood.
Large area on strip is impregnated with reagents which change color when dipped in urine that are then compared to color comparison charts.