1. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company The Injury Examination Process Chapter 1

2. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Systematic Examination Technique  Objective data  Baseline measures  Re-evaluations  Rehabilitation and treatment protocols  Documentation  Medical records  Legally required  Communication tool

3. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Table 1.1. Role of the Noninjured Limb in the Examination Process Evaluation Strategies 1.Perform each task on uninjured limb first. 2.Perform each task on injured limb first. Increase or decrease apprehension and muscle guarding?

4. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Clinical Assessment  Clinical assessment vs. acute evaluations  What are the differences?  Special considerations  Discretion  Religious considerations  Informed consent  Signed written statement  Verbal  Emergency medical care

5. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company History  Identifies  Mechanism of injury  Past medical history  Underlying pathology  Impact injury may have on patient’s life  Communication skills  Open-ended questions  Avoid “yes” or “no” questions unless critical

6. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Past Medical History Past medical history  Non-acute examinations (physicals)  Health conditions  Previous injuries  Predisposing factors  NCAA Guideline 1B: Medical Evaluations, Immunizations, and Records (Box 1-3) Previous history questions  Is there a history of injury to the body area? On either side?  Describe and compare current injury  Do the current symptoms duplicate the old symptoms?  Are there any possible sources of weakness from a previous injury?

7. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Past Medical Health  General medical health  Current health status?  Comorbidities present?  Relevant illness and lab work  Note during exam if they may affect injury management or the healing process.  Medications  What medications are they currently taking?  What interactions or effect may they have on healing, treatments, etc.?  Smoking  Decrease exercise tolerance  Increased risk for CV disease  May delay fracture and wound healing

8. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company History of Present Condition  Mechanism of injury (MOI)  How did the injury occur?  Macrotrauma  Microtrauma  Identifies structures involved  Relevant sounds or sensations  Onset and duration of symptoms  Acute  Chronic

9. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company History of Present Condition  Pain  Location  Type  Referred  Radicular  Daily pain patterns  Provocation and alleviation patterns  Other symptoms  Treatment to date  Affective traits  Disability/limitations

10. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Physical Examination  Goals  Rule out differential diagnosis  Determine clinical diagnosis  Identify impairments and functional limitations  Standard precautions against bloodborne pathogens (Box 1-5)

11. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Inspection Immediate observations Physical examination observations (bilateral)  Deformity  Subtle or gross?  Swelling  Hemarthrosis  Edema  Girth measurements (Special Test 1-1)  Skin  Redness  Ecchymosis  Infection signs  As soon as patient enters facility observe  Gait  Posture  Function  Guarding  Splinting

12. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Inspection  Functional assessment  Perform functional tasks that were identified as problematic.  Impairments should be identified and measured.

13. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Palpation  Bilaterally performed in specific sequence  Sequencing strategy #1  Bones  Ligaments  Muscles and tendons  Sequencing strategy #2  Palpate all structures  Begin away from pain site and progress toward suspected injury.

14. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Palpation  Point tenderness  Trigger points  Change in tissue density  Crepitus  Tissue temperature

15. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company  Perform bilaterally  Involves  Active range of motion (AROM)  Manual muscle testing (MMT)  Passive range of motion (PROM)  Joint stability tests  Stress testing  Joint play Joint and Muscle Function Assessment

16. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Active ROM  Joint motion produced by the patient contracting the muscles  Evaluated first (unless contraindicated)  Note  Ease of movement  Range of motion achieved  Painful arc  Compensation

17. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Manual Muscle Testing  Assesses strength and provocation of pain by relatively isolating the muscle  Resisted range of motion (RROM) assesses strength throughout the muscle’s entire ROM  Procedure  Stabilize limb proximally  Apply resistance distal to muscle attachment, not joint  Grade accordingly (Table 1-6)

18. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Manual Muscle Testing

19. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Passive ROM  Clinician moves the joint through the ROM  Identifies the available movement and pain patterns  Apply over-pressure to determine end-feel  Findings  PROM > AROM — suspect muscular weakness or tissue lesion  PROM = AROM and are deficient — suspect capsular adhesions or joint tightness

20. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Joint Stability Tests  Procedure  Apply specific stress to non-contractile tissue  Hypermobile — more laxity than normal  Hypomobile — below normal laxity  Laxity — clinical sign of the amount of “give” within a joint; identified by stress testing  Instability — joint’s inability to function under the stresses of function activity

21. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Stress Testing

22. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Joint Play  Accessory/arthrokinematic motion  Rolling  Spinning  Gliding  Procedure  Patient relaxed in loose-pack position  Gliding or distracting stress is applied  Degree of movement assessed  Compare bilaterally

23. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Special Tests  Specific procedures applied to selected tissues  Unique to each structure  Results are compared  Side to side  Cause provocation  Cause alleviation  Reported as positive (+) or negative (-)

24. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Neurologic Screening  Upper and lower quarter screen  Evaluate  Sensation  Motor function  Deep tendon reflexes  Identify  Nerve root impingement  Peripheral nerve damage  CNS trauma  Disease  Indicated by  Numbness  Paresthesia  Muscular weakness  Pain of unexplained origin  Injury to cervical or lumbar spine

25. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Neurological Screening 1-1. Lower Quarter Screen

26. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Neurological Screening 1-2. Upper Quarter Screen

27. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Sensory Testing  Dermatome — area of skin innervated by a spinal nerve root  Bilaterally performed  Patient position  Eyes closed and head turned away  Discrimination tests  Light touch discrimination  Sharp and dull discrimination  Two-point discrimination

28. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Motor Testing  If muscle weakness is noted during neurological screening, test another muscle innervated by the same nerve root.  If one muscle is weak, suspect muscle pathology or peripheral nerve patholgy.  If both muscles are weak, suspect nerve root or peripheral nerve pathology.

29. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Reflex Testing  Increased response upper motor neuron lesion  Decreased response lower motor neuron lesion  Deep tendon reflex (DTR)  Muscle stretched and relaxed  Patient should look away  Strike tendon with reflex hammer  Jendrassik maneuver for difficult patients

30. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Table 1–10. Deep Tendon Reflex Grading

31. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company Vascular Screening Gross assessment of blood flow to and from the extremities  Capillary refill  Nail beds  Pulses  Lower extremity  Femoral  Posterior tibial  Dorsal pedal  Upper extremity  Brachial  Radial  Ulnar  Systemic  Carotid

32. Examination of Orthopedic and Athletic Injuries, 3rd Edition Copyright © 2010. F.A. Davis Company  Results from the history and functional assessment can reduce the number of tests to be performed.  Example  Symptoms: Gradual onset  No need to perform acute fracture special tests  Use best evidence  Efficient  Eliminate time wasted performing unnecessary special tests  Makes examine more accurate  Eliminate false positives The Role of Evidence in the Examination Process