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

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1 Chapter 13: Off-the-Field Injury Evaluation Part 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
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 Anatomical directions
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

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 Bony tissue Soft tissue
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 Evaluation Part 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

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 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 Joint Action Degrees of Motion Shoulder Flexion 180
Extension   Adduction   Abduction   Internal rotation 90   External rotation 90 Elbow Flexion Forearm Pronation 80   Supination 85 Wrist Flexion   Extension   Abduction   Adduction 45 Hip Flexion   Extension   Abduction   Internal rotation 45   External rotation 45 Knee Flexion 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

36 TABLE 13-3 Manual Muscle Strength Grading
Grade Percentage (%) Qualitative Value Muscle Strength 5 100 Normal Complete range of motion (ROM) against gravity with full resistance 4 75 Good Complete ROM against gravity with some resistance 3 50 Fair Complete ROM against gravity with no resistance 2 25 Poor Complete ROM with gravity omitted 1 10 Trace Evidence of slight contractility with no joint motion Zero No evidence of muscle contractility

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

43 Cranial Nerves Function
TABLE 13-4 Cranial Nerves Function I. Olfactory Smell II. Optic Vision III. Oculomotor Eye movement, opening of eyelid, constriction of pupil, focusing IV. Trochlear Inferior and lateral movement of eye V. Trigeminal Sensation to the face, mastication VI. Abducens Lateral movement of eye VII. Facial Motor nerve of facial expression; taste; control of tear, nasal, sublingual salivary, and submaxillary glands VIII. Vestibulocochlear Hearing and equilibrium IX. Glossopharyngeal Swallowing, salivation, gag reflex, sensation from tongue and ear X. Vagus Swallowing; speech; regulation of pulmonary, cardiovascular, and gastrointestinal functions XI. Accessory Swallowing, innervation of sternocleidomastoid muscle XII. Hypoglossal Tongue movement, speech, swallowing

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

51 Figure 13-6


53 Progress Evaluations The scope of the injury
How the injury appears today vs past Still needs to go through HOPS

54 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

55 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

56 SOAP Notes Page 353

57 S (subjective) O (Objective)
Statements made by patient - primarily history information and patient’s perceptions including time, mechanism and site of injury. Also the type and course of pain O (Objective) Findings based on athletic trainer’s evaluation including inspection, palpation and assessments of range of motion. Also the outcome of special tests

58 A (Assessment) P (Plan)
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 Treatment should also include specific short term goals

59 Progress Notes Progress notes- written after each progress evaluation written in SOAP note form

60 ASSIGNMENT Using the standard abbreviations and symbols used in medical documentation in Table 13-7 on page 352, rewrite the sentences

61 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

62 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 (scope) Invasive technique, using fiber-optic arthroscope, used to assess joint integrity and damage Can also be used to perform surgical procedures

63 X-Ray

64 Myelopgraphy, CT scan, Bone Scan
Page 356

65 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

66 CT Scan

67 Bone Scan and DEXA Scan Figure 13-8 F & G

68 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

69 MRI & MRI Anthrography Page 356

70 Magnetic Resonance Imaging (MRI)
Using powerful electromagnets, 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

71 Magnetic Resonance Imaging

72 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

73 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

74 Figure 13-8

75 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

76 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

77 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)

78 Blood Tests Page 358

79 Blood Test Complete blood count (CBC) used to screen for anemia (too few red blood cells), infection (too many white cells) and many other reasons Routine CBC: Assesses red blood cell count Hemoglobin levels Hematocrit levels (RBC per volume) White blood cell count Platelet deficiency Serum cholesterol


81 Urinalysis Used to assess specific gravity, pH, presence of ketones, hemoglobin, proteins, nitrates, red & white blood cells, bacteria, electrolytes, hormones and drug levels 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.

82 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

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