Chapter 13: Off-the Field Injury Evaluation 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 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 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) – 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 – 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) • 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) – 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 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 • 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 – 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 • 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? • 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 – Soft tissue • • • • 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 – 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 • 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 – 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 • 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 • 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 • Cerebellar Function – 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 • 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 • 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 – 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 – 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 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 • History – 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 • 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? 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 • 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 – O(Objective) • 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 • 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 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 • 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 X-Ray • 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) CT Scan Bone Scan • 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 Magnetic Resonance Imaging • 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 • 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 noninflammatory conditions (degenerative vs. rheumatoid arthritis) • 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 – 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.