1. Chapter 13: Off-the-Field Injury Evaluation

2. Evaluation of Injuries
Essential skill for athletic trainers
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. Clinical Evaluation & 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
Topographical anatomy is essential
Key surface landmarks provide examiner with indications of normal or injured structures
Body planes and anatomical directions
Points of reference (midsagittal, transverse, and frontal (coronal) planes)

6. 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

7. 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)

8. 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

9. Descriptive Assessment Terms
Etiology - cause of injury or disease
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)
Sign - objective, definitive and obvious indicator for specific condition
Degree- grading for injury/condition
Diagnosis- denotes name of specific condition

10. 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

11. 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

12. History
Obtain subjective information relative to how injury occurred, extent of injury, MOI
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

13. Observations 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?

14. Range of Motion Assessment
Palpation
Bony & soft tissue
Special Tests
Used to detect specific pathologies
Compare inert and contractile tissues and their integrity
Assessment should be made bilaterally
Range of Motion Assessment
Active
Passive
Normal vs. Abnormal end points
Manual muscle tests
Goniometric measures vs. Digital inclinometers

15. Figure 13-4 A & B

16. Neurologic and circulation assessments
Brain
Cerebral, cranial nerve function, cerebellar function
Sensory & motor function
Dermatome
Area of skin innervated by a single nerve
Myotome
Muscle or group of muscles innervated by a specific motor nerve
Reflex testing
Involuntary response to a stimulus
Deep tendon – caused by stimulation of stretch reflex
Superficial – stimulation of skin which causes reflexive muscle contraction
Pathological – superficial reflex indicative of upper motor neuron lesion
Babinski’s sign, Chaddock’s, Oppenheim’s Gordon’s
Referred pain

17. Figure 13-5

18. Testing Joint Stability Testing Accessory Motions
Motor Testing
Testing Joint Stability
Testing Accessory Motions
Testing Functional Performance
Used to determine athletes readiness to participate or continue participation
Other tests
Postural
Anthropometric
Volumetric
Figure 13-6

19. 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

20. 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 patient - primarily history information and patient’s perceptions including severity, pain, MOI

21. O (Objective) A (Assessment) P (Plan)
Findings based on athletic trainer’s evaluation
A (Assessment)
Athletic trainer'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

22. SOAP Note vs. Progress Note or Evaluation

23. 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

24. 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

25. X-Ray

26. 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) in which there is inflammation

27. CT Scan

28. Bone Scan and DEXA Scan
Figure 13-8 F & G

29. DEXA Scan Dual energy X-ray absorptiometry
Used to measure bone mineral density
Greater mineral density = greater signal picked up
Documents small changes in bone mass
Used on both spine and extremities
Less expensive, less radiation exposure
More sensitive and accurate for measuring subtle bone density changes over time

30. 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
MRI Arthrography
Imaging study involving injection of contrast agent into joint prior to MRI
Allows for more detailed assessment of joint vs. traditional MRI
Contrast agent allows for highlighting of certain areas

31. Magnetic Resonance Imaging

32. Musculoskeletal Ultrasound
Ultrasonography
Diagnostic ultrasound of sonography
Allows clinician 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
Advancements in technology are allowing for 3-D imaging as well
Musculoskeletal Ultrasound
Allows for imaging and evaluation of soft tissue structures
Complimentary technique to MRI or CT
Non-painful, non-invasive, cost effective

33. Doppler Ultrasound
Used to examine blood flow in arms and legs
Alternative to arteriography and venography
Detects blood clots, venous insufficiency, vessel closing, or altered blood flow
Arteriogram
Catheter inserted into blood vessel and contrast medium is injected
Using x-ray, images are taken to determine path of fluid flow in vessels
Venogram
Radiographic procedure used to image veins filled with contrast medium
Used for detecting thrombophlebitis and for tracing of venous pulse

34. Figure 13-8

35. 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

36. Electrocardiography
Recording of electrical activity of heart at various stages in contraction cycle
Assesses impulse formation, conduction, depolarization and re-polarization of atria and ventricles
Figure 13-9

37. 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)

38. 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

39. 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.

40. Ergonomic Risk Assessment (ERA)
If working in a clinic or industrial setting an athletic trainer may be called upon to perform this assessment
Involves evaluation of factors within a job that increase risk of someone suffering a workplace-related ergonomic injury
Assess aspects and movements that could be modified to reduce risk
Injury prevention and intervention through ergonomic control measures and injury statistics

41. Using ergonomics Improve efficiency (time and resources)
Reduce time lost due to injury
Reduce decreases in productivity
Consider how changes could impact physical requirements and demands
Investigate worker complaints and concerns
Proactive step towards reducing work-related injuries, workers compensation and time lost
If workers are experiencing pain and discomfort, there may be a safer and more effective way of doing the job

42. If an employee suffers an injury it is likely due to ergonomic stress
Must be addressed to prevent further and future injuries
Steps and tools of risk assessment
Identify and prioritize jobs
Maximizes impact of intervention
Workers must be briefed
Review injury statistics, worker concerns, physical demand analysis
Direct supervisor must be notified
Why the modification and what new expectations will be

43. Steps and tools of risk assessment (continued)
Management must be informed
Aware of costs associated with injuries, benefits of ERA
Company support professionals (nurse, engineer, safety personnel)
Use of videotape
Allows more access for people to assessment process
Utilize for training purposes as well

44. After risks have been identified
Athletic trainer should identify those that should be controlled in an effort to reduce injury rates
Consult workers, supervisors and management
May involve
Physical changes to job (sitting vs. standing, altering work surfaces)
Administrative changes (job rotations, lifting policy)
Personal protective equipment
Proposed changes should have an ERA performed on them to ensure that original risks have been reduced without introduction of new risks