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© 2011 McGraw-Hill Higher Education. All rights reserved. Chapter 13: Off-the-Field Injury Evaluation Part I.

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1 © 2011 McGraw-Hill Higher Education. All rights reserved. Chapter 13: Off-the-Field Injury Evaluation Part I

2 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Clinical Evaluation & Diagnosis Diagnosis –Use of clinical or scientific methods to establish cause and nature of patients illness or injury and subsequent functional impairment due to pathology –Forms basis for patient care Physicians make medical diagnosis –Ultimate determination of patients physical condition

4 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Body Planes & Anatomical Directions Page 337 & 338

7 © 2011 McGraw-Hill Higher Education. All rights reserved. –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 © 2011 McGraw-Hill Higher Education. All rights reserved. –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 © 2011 McGraw-Hill Higher Education. All rights reserved. –Musculoskeletal Anatomy Structural and functional anatomy Encompasses bony and skeletal musculature Neural anatomy useful relative to motion, sensation, and pain

10 © 2011 McGraw-Hill Higher Education. All rights reserved. Standard Terminology for Bodily Position and Deviations Page 340 Table 13-1

11 © 2011 McGraw-Hill Higher Education. All rights reserved. –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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Descriptive Assessment Terms Page 339- 341

17 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. –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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Palpation –Knowledgeable touching 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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

24 © 2011 McGraw-Hill Higher Education. All rights reserved.

25 Chapter 13: Off-the-Field Injury Evaluation Part II

26 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. End Points Page 344-345

29 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Measurements Goniometry- Measures the joint range of motion –Measure 0- 180 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Joint Action Degrees of Motion Shoulder Flexion 180 Extension 50 Adduction 40 Abduction 180 Internal rotation 90 External rotation 90 Elbow Flexion 145 Forearm Pronation 80 Supination 85 Wrist Flexion 80 Extension 70 Abduction 20 Adduction 45 Hip Flexion 125 Extension 10 Abduction 45 Adduction 40 Internal rotation 45 External rotation 45 Knee Flexion 140 Ankle Plantar flexion 45 Dorsiflexion 20 Foot Inversion 40 Eversion 20

33 © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 13-4 A & B

34 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Manual Muscle Strength Grading Page 346 Table 13-3

36 © 2011 McGraw-Hill Higher Education. All rights reserved. TABLE 13-3 Manual Muscle Strength Grading GradePercentage (%)Qualitative ValueMuscle Strength 5100NormalComplete range of motion (ROM) against gravity with full resistance 475GoodComplete ROM against gravity with some resistance 350FairComplete ROM against gravity with no resistance 225PoorComplete ROM with gravity omitted 110TraceEvidence of slight contractility with no joint motion 00ZeroNo evidence of muscle contractility

37 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Cerebral Function –Questions to assess general affect, level of consciousness, intellectual performance, emotional status, though content, sensory interpretation & language skills

39 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Normal: 25 points Need to get back to baseline to return

41 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Cranial Nerves & Their Function Page 347 Table 13-4

43 © 2011 McGraw-Hill Higher Education. All rights reserved. TABLE 13-4 Cranial NervesFunction I. OlfactorySmell II. OpticVision III. OculomotorEye movement, opening of eyelid, constriction of pupil, focusing IV. TrochlearInferior and lateral movement of eye V. TrigeminalSensation to the face, mastication VI. AbducensLateral movement of eye VII. FacialMotor nerve of facial expression; taste; control of tear, nasal, sublingual salivary, and submaxillary glands VIII. VestibulocochlearHearing and equilibrium IX. GlossopharyngealSwallowing, salivation, gag reflex, sensation from tongue and ear X. VagusSwallowing; speech; regulation of pulmonary, cardiovascular, and gastrointestinal functions XI. AccessorySwallowing, innervation of sternocleidomastoid muscle XII. HypoglossalTongue movement, speech, swallowing

44 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 13-5

49 © 2011 McGraw-Hill Higher Education. All rights reserved. Reflex Testing Reflex: involuntary response to a stimulus Types –Deep tendon (somatic), superficial, and pathological

50 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 13-6

52 © 2011 McGraw-Hill Higher Education. All rights reserved. PART III OFF-THE-FIELD INJURY EVALUTION

53 © 2011 McGraw-Hill Higher Education. All rights reserved. Progress Evaluations The scope of the injury How the injury appears today vs past Still needs to go through HOPS

54 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. SOAP Notes Page 353

57 © 2011 McGraw-Hill Higher Education. All rights reserved. –S (subjective) Statements made by patient - primarily history information and patients perceptions including time, mechanism and site of injury. Also the type and course of pain –O (Objective) Findings based on athletic trainers evaluation including inspection, palpation and assessments of range of motion. Also the outcome of special tests

58 © 2011 McGraw-Hill Higher Education. All rights reserved. –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 examiners plan for treatment Treatment should also include specific short term goals

59 © 2011 McGraw-Hill Higher Education. All rights reserved. Progress Notes Progress notes- written after each progress evaluation written in SOAP note form

60 © 2011 McGraw-Hill Higher Education. All rights reserved. ASSIGNMENT Using the standard abbreviations and symbols used in medical documentation in Table 13-7 on page 352, rewrite the sentences

61 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. X-Ray

64 © 2011 McGraw-Hill Higher Education. All rights reserved. Myelopgraphy, CT scan, Bone Scan Page 356

65 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. CT Scan

67 © 2011 McGraw-Hill Higher Education. All rights reserved. Bone Scan and DEXA Scan Figure 13-8 F & G

68 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. MRI & MRI Anthrography Page 356

70 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Magnetic Resonance Imaging

72 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 13-8

75 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Blood Tests Page 358

79 © 2011 McGraw-Hill Higher Education. All rights reserved. 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

80 © 2011 McGraw-Hill Higher Education. All rights reserved. SCENARIO- BLOOD TESTS

81 © 2011 McGraw-Hill Higher Education. All rights reserved. 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, WBCs, 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 © 2011 McGraw-Hill Higher Education. All rights reserved. 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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