Chapter 13: Off-the-Field Injury Evaluation Part I

1. Chapter 13: Off-the-Field Injury EvaluationPart I

2. Evaluation of Injuries • Essential skill for athletic trainers • Four distinct evaluations 1. Pre-participation (prior to start of season) 2. On-the-field assessment 3. Off-the-field evaluation (performed in the clinic/training room…etc) 4. Progress evaluation

3. Clinical Evaluation & Diagnosis • Diagnosis • Use of clinical or scientific methods to establish cause and nature of patient’s illness or injury and subsequent functional impairment due to pathology • Forms basis for patient care • Physicians make medical diagnosis • Ultimate determination of patient’s physical condition

4. Athletic trainers and other health care professionals use evaluation skills to make clinical diagnoses • Clinical diagnosis identifies pathology and limitations/disabilities associated with pathology • Athletic trainers have academically-based credential and in many states some form of regulation which recognizes ability and empowers clinician to make accurate clinical diagnosis

5. Basic Knowledge Requirements • Athletic trainer must have general knowledge of anatomy and biomechanics as well as hazards associated with particular sport • Anatomy • Surface anatomy (Further info in HE 92) • Topographical anatomy is essential • Key surface landmarks provide examiner with indications of normal or injured structures

6. Body Planes & Anatomical Directions • Page 337 & 338

7. Body planes • Points of reference • Midsagittal planes- Left and right • Transverse- Top and Bottom • Frontal (coronal) – Front and back • Anatomical directions • Anterior- in front • Posterior- in back • Superior- above • Inferior- below • Distal- further away • Proximal- closer to • Medial- towards the middle • Lateral- away from the middle

8. 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

9. Musculoskeletal Anatomy • Structural and functional anatomy • Encompasses bony and skeletal musculature • Neural anatomy useful relative to motion, sensation, and pain

10. Standard Terminology for Bodily Position and Deviations • Page 340 Table 13-1

11. Standard Terminology • Used to describe precise location of structures and orientation • Abduction- to draw away or deviate from midline • Adduction- To deviate towards or draw towards • Eversion- turning outward • External (lateral) rotation- rotary motion in a transverse plain away from midline • Flexion- to bend; joint angle increases • Internal (medial) rotation- Rotary motion in a transverse plane towards the midline • Inversion- turning inward • Pronation- Applied to the foot- eversion & abduction, lowering of medial foot; applied to palm- turning downward

12. Supination- Applied to foot- raising the medial arch; applied to the palm- turning the palm upward • Valgus- Deviation of part or portion of the extremity distal to the joint away from the midline • Varus- Deviation of part or portion of the extremity distal to the joint towards the midline

13. Terminology Lab • 6 Total groups; each group will draw the terminology given • Body planes • Anatomical Directions • Quadrants with organs (help pg 828) • Nine regions with organs (help pg 828) • Positions & Deviations (abduction, adduction, eversion, extension, external rotation, and flexion) • Positions & Deviations (Internal rotation, inversion, pronation, supination, valgus and varus)

14. 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)

15. Understanding the Activity • More knowledge of activity allows for more inherent knowledge of injuries associated with activity resulting in more accurate clinical diagnosis and rehab design with appropriate functional aspects incorporated for return to activity • Must be aware of proper biomechanical and kinesiological principles to be applied in activity • Violation of principles can lead to repetitive overuse trauma • Increased understanding = better assessment and care

16. Descriptive Assessment Terms • Page 339- 341

17. Descriptive Assessment Terms • Etiology - cause of injury or disease interchanged with mechanism of injury • Mechanism – mechanical description of cause • Pathology - structural and functional changes associated with injury process • Symptoms- perceptible changes in body or function that indicate injury or illness (subjective) patient describes them • Sign - objective, definitive and obvious indicator for specific condition • Degree- grading for injury/condition from mild, moderate and severe • Diagnosis- denotes name of specific condition

18. Prognosis- prediction of the course of 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 • Differential diagnosis – systematic method of diagnosing a disorder • Refers to a list of possible causes • Prioritizing of possibilities • Also referred to as hypothesis or working diagnosis • Utilize skills to make decision regarding condition

19. 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

20. History • Obtain subjective information relative to how injury occurred, extent of injury, MOI • Mechanism of Injury (MOI)- how, when, what, did you hear or feel anything • Injury location- localized or general • Pain characteristics • Nerve- sharp, bright or burning; Bone- local & piercing; vascular- aching & referred; muscle- dull, aching and referred • Joint- instability • Acute or Chronic • Previous or pre-extisting

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

22. Palpation • Knowledgeable touching • Light pressure to deeper pressure • Away from site towards site of injury • Bony tissue • Abnormal gaps, misalignment • Soft tissue • Swelling, lumps, gaps, temperature • Sensations- dysesthesia (diminished sensation), anesthesia (numbness), and hyperesthesia (increased sensation)

23. Special Tests • Used to detect specific pathologies • Compare inert and contractile tissues and their integrity • Assessment should be made bilaterally • Start with uninjured side first for “normal”

25. Chapter 13: Off-the-Field Injury EvaluationPart II

26. Special Tests • Movement Assessment • Contractile- muscles and tendons • Lesion (tear)- pain with AROM in one direction and pain with PROM in opposite • Pain with active contraction and with stretch • Inert- bones, ligaments, joint capsule, fascia, nerves, bursae, nerve roots and dura mater • Pain with AROM and PROM in same direction

27. Active Range of Motion (AROM) • Joint motion that occurs because of muscle contraction • Passive Range of Motion (PROM) • Movement that is performed completely by the examiner • Endpoints- what the examiner “feel” during special tests

28. End Points • Page 344-345

29. Normal endpoints • Soft tissue- soft and spongy, gradual painless stop (knee flexion) • Capsular- abrupt, hard, firm with very little give (hip rotation) • Bone to bone- distinct, abrupt (elbow extension) • Muscular- springy with some associated discomfort (shoulder abduction)

30. Abnormal Endpoints: • Empty- movement is beyond the anatomical limit, pain occurs before the end range (ligament rupture) • Spasm- involuntary muscle contraction that prevents motion, also called guarding (back spasm) • Loose- extreme hypermobility (previous sprained ankle) • Springy block- a rebound endpoint (meniscus tear)

31. Measurements • Goniometry- Measures the joint range of motion • Measure 0- 180 degrees • Placed along the lateral surface with patient in anatomical neutral; middle on the joint, each end on axis using bony landmarks • Digital Inclinometer- measures the slope of elevation • Digital using gravity

32. JointActionDegrees of Motion Shoulder Flexion 180   Extension 50   Adduction 40   Abduction 180   Internal rotation 90   External rotation 90 Elbow Flexion 145 Forearm Pronation 80   Supination 85 Wrist Flexion 80   Extension 70   Abduction 20   Adduction 45 Hip Flexion 125   Extension 10   Abduction 45   Adduction 40   Internal rotation 45   External rotation 45 Knee Flexion 140 Ankle Plantar flexion 45   Dorsiflexion 20 Foot Inversion 40   Eversion 20

33. Figure 13-4 A & B

34. Manual Muscle Testing • The ability of the injured patient to tolerate varying levels of resistance (usually caused by pain) • Muscle is isolated and tested through full ROM

35. Manual Muscle Strength Grading • Page 346 Table 13-3

37. Neurological Examination • Usually follows manual muscle testing • Includes 6 major areas • Cerebral Function • Cranial Nerve Function • Cerebellar Function • Sensory Testing • Reflex Testing • Motor Testing

38. Cerebral Function • Questions to assess general affect, level of consciousness, intellectual performance, emotional status, though content, sensory interpretation & language skills

39. LAB • Get into groups of 2-3 • Using the SAC form check • Orientation • Immediate memory • Concentration • Delayed recall • Each person should be tested and administer the test

40. Normal: 25 points • Need to get back to baseline to return

41. Cranial Nerve Functions • Twelve total cranial nerves that can be assessed through smell, eyes, facial expressions, biting balance, swallowing, tongue protrusion and shoulder shrugs

42. Cranial Nerves & Their Function • Page 347 Table 13-4

44. Cranial Nerve Lab • Class broken into 12 groups; 2-3 people per group. • Each group is given a cranial nerve. • Make a drawing of the cranial nerve, include the roman numeral, the name and the function. • On the back of the sheet, write how you would test a patient for your assigned nerve • Give a presentation

45. Mnemonics • Some Say Marry Money, But My Brother Says Big Business Makes Money • S: Sensory • M: Motor • B: Both • OLd OPie OCcasionally TRies TRIGonometry And Feels VEry GLOomy, VAGUe, And HYPOactive • Oh Once One Takes The Anatomy Final Very Good Vacations Are Heavenly

46. Cerebellar Function • Controls purposeful coordinated movements • Tests include • Touching finger to nose • Touching patients finger to examiners • Drawing alphabet in air with foot • Heel-toe walking

47. Sensory Testing • Dermatome: area of skin innervated by a single nerve • Touch, pain, temperature, vibration, position sense • Myotomes: muscles or groups of muscles innervated by a specific motor nerve

48. Figure 13-5

49. Reflex Testing • Reflex: involuntary response to a stimulus • Types • Deep tendon (somatic), superficial, and pathological

50. Motor- Manual muscle testing • Joint Stability- discussed in HE 92 (chapters 18-25) • Functional Performance- progression, return to play • Postural- malalignments • Anthropomtric- measuring the human body • Volumetric- swelling, displacement of water