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.
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.
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.
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.
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
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.
Seven Steps: History Inspection Palpation Range of Motion Ligamentous Tests Special Tests Neurological Tests
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…
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.
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
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.
Inspect the injured body part and compare the results with the opposite structure for: Gross deformity Swelling Bilateral symmetry Skin Infection
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.
Two methods of sequencing: 1 st Method: Bones and Ligaments Muscle and Tendons Other areas, such as pulses 2 nd Method: Palpate all structures (listed above) farthest from the suspected injury and then progress toward the injury site.
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!
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.
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.
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.
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.
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
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.
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.
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)
Used to identify nerve root impingement, peripheral nerve damage, central nervous system trauma, or disease. Involves:
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.
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
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 3 rd finger C8- Medial forearm down into the 5 th finger T1- Medial Humerus
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.
Lower Extremity: L1/L2- Hip Flexion L3- Knee Extension L4- Ankle Dorsiflexion L5- Toe Extension S1- Ankle Plantarflexion, and Eversion S2- Knee Flexion
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!
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.
Scale: Grade 0: No reflex elicited Grade 1: Reflex elicited with reinforcement Grade 2: Normal response Grade 3: Hyper-responsive reflex
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.
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!