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INJURY EVALUATIONATTN: SOPHOMORE ATHLETIC TRAINING STUDENTS
Systematic Process
By: Corey Caterina
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SYSTEMATIC EVALUATION
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.
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TYPES OF EVALUATIONS
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.
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ON-FIELD EVALUATIONS
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.
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ON-FIELD EVALUATIONS
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.
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ON-FIELD EVALUATIONS
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
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ON-FIELD EVALUATIONS
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.
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OFF-FIELD EVALUATIONS
Seven Steps: History Inspection Palpation Range of Motion Ligamentous Tests Special Tests Neurological Tests
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HISTORY
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…
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HISTORY
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.
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HISTORY
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
Now I understand why my professors stressed the
importance of history!?!?!?!
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INSPECTION
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.
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INSPECTION
Inspect the injured body part and compare the results with the opposite structure for: Gross deformity Swelling Bilateral symmetry Skin Infection
I have not a clue what I’m looking for!
But I’m looking!
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PALPATION
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.
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PALPATION
Two methods of sequencing: 1st Method:
Bones and Ligaments Muscle and Tendons Other areas, such as pulses
2nd Method: Palpate all structures (listed above) farthest
from the suspected injury and then progress toward the injury site.
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PALPATION
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!
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RANGE OF MOTION
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.
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ACTIVE RANGE OF MOTION (AROM)
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.
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PASSIVE RANGE OF MOTION (PROM)
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.
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RESISTED RANGE OF MOTION (RROM)
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.
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RROM GRADING SYSTEM
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
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LIGAMENTOUS TEST
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.
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LIGAMENTOUS LAXITY GRADING
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.
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SPECIAL TESTS
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)
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NEUROLOGICAL TESTS
Used to identify nerve root impingement, peripheral nerve damage, central nervous system trauma, or disease.
Involves:Sensory Tests
Motor Tests
Reflex Tests
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SENSORY TESTING
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.
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DERMATOMES
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
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DERMATOMES
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 3rd finger C8- Medial forearm down into the 5th finger T1- Medial Humerus
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MOTOR TESTING
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.
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MYOTOMES
Lower Extremity: L1/L2- Hip Flexion L3- Knee Extension L4- Ankle Dorsiflexion L5- Toe Extension S1- Ankle Plantarflexion, and Eversion S2- Knee Flexion
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MYOTOMES
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!
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REFLEX TESTING
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.
WACK!!!
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DEEP TENDON REFLEXES
Lower Extremity: L4- Patella Tendon S1- Achilles Tendon
Upper Extremity: C5- Biceps Brachii Tendon C6- Brachioradialis Tendon C7- Triceps Brachii Tendon
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GRADING DEEP TENDON REFLEXES
Scale: Grade 0: No reflex elicited Grade 1: Reflex elicited with reinforcement Grade 2: Normal response Grade 3: Hyper-responsive reflex
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ACTIVITY-SPECIFIC FUNCTIONAL TESTING
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.
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WRAP-UP!
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!