1. The Injury Examination Process ATHT 305 Fall 2015

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

3.  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.

4. 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

5. 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

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

7. 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:

8. 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?

9. 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?

10. 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

11. 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

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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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.

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

25. 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.