Lecture 3

Assessment Protocols

History, Observation,

ROM/Resisted, Special tests and

Palpations

History

Provides valuable information about the athletes condition

-Listening to the patient / athlete

-Questions – try not to lead the athlete

-Repetition – taken in an orderly sequence

-Try to keep patient focused on relevant information

-Relevant past history and or treatments received

-Surgeries, allergies, major illnesses

-Relevant family history

-X-rays , or any other test results

-Medications

- Age, occupation (student/ sport) , life style (recreational pursuits)

- Chief complaint- what is the major problem

- What was the trauma – Mechanism of injury (MOI)

- Direction , magnitude, force applied

- Predisposing factors ( old injuries, braces , field conditions)

- Onset – sudden (acute) or slow (insidious)

- Pain – during day or night - when is it better ( what makes it feel better) or when is it worse

- Symptoms – what bothers the athlete- can they point to one area – specific / general

- Pain – has it changed since it first started

- Trigger points ( points that are hyperirritable) tender to compression

- Referred pain – is the pain felt somewhere other that the injured site ( referred pain is usually referred segmentally – does not cross midline)

- What causes the pain

Functionally pain is seen in seven levelspain after specific activitypain after specific activity resolving after a warm uppain during and after specific activity which does not

effect performancepain during and after specific activity which does

effect performancepain with all activity of daily livingconstant dull aching pain at rest which does not

disturb sleepconstant dull aching pain at rest which does disturb

sleep

- How long has problem existed – duration /frequency

- Have they had this problem before – did it get better – how – how long

- Type of pain

- Nerve – sharp , bright , burning

- Bone – deep , boring , very localized

- Vascular – diffuse , aching poorly localized

- Muscle – hard to localize, dull and achy

- Sensations - pins and needles - numbness

- Locking – joint can not be fully extended

- Giving way – joint buckles

- Other problems – fainting , bladder , neurological problems etc..

- Stress levels of athlete

Red Flags

Cancer- persistent night pain

- unexplained weight loss ( 10 – 15 lbs in 2 weeks or less)

- loss of appetite

- lumps or growths

Cardiovascular- shortness of breath

- dizziness

- pain / heaviness in chest

- pulsating pain in body

Gastrointestinal- frequent and sever abdominal pain

- heartburn and or indigestion

- nausea and vomiting

- bladder problems

Neurological- changes in hearing /speech or vision

- frequent and or severe headaches

- problems with balance

- fainting spells

- weakness

Miscellaneous- fever or night sweats

- emotional disturbances – depression

- swelling with no apparent history

- severe unremitting pain

- severe pain with no obvious history

- severe spasms

All Red Flags Refer to Doctor immediately

Observations

- observations start right away when athlete walks into clinic – limping .. etc

- looking and or inspecting an area

- gain information on visible defects or abnormalities

- posture

- gait

Dominant Eye

Normal alignmentObvious deformitiesObvious deviationsMuscle wastingLimb position – equal / symmetricalSkin colour and temperatureScarsCrepitus, snapping or abnormal soundsSwelling / rednessWillingness to move

Active Movement

Test joint range, muscle control and willingness of athlete to move.

Things to note

- When and where during each movement the onset of pain occurs

- Does it increase intensity and quality of pain

- Observe restrictions

- Observe pattern of movements

- Observe rhythm and quality of movement

- Willingness to move what are their limitations

Passive Movements

- Athlete is relaxed, movement is through the full ROM of the joint as possible.

- Normal movement is relative – ie. gymnasts as compared to football. (Hyper/hypo)

End FeelsNormal Bone to bone – hard and unyielding –

elbow extensionSoft tissue approximation – yielding

compression stops further movement – knee flexion

Tissue stretch – hard or firm (springy) type of movement with slight give – ankle dorsiflexion – shoulder lateral rotation

Abnormal Muscular spasm - sudden and hard – quad

contusionCapsular – similar to tissue stretch – but occurs

when not expected – frozen shoulderBone to bone – ends meet before normal –

osteophyte formation Empty – considerable pain – no end feel - MCL

rupture – burseaSpringy block – similar to tissue stretch but

again where not suspected – meniscus

Resisted Movement

- Tested last

- Strong static (isometric)contraction

- Voluntary muscle contraction

- Amount of pain and weakness is related to degree of injury

- Athlete resists applied pressure

- Keep movement to a minimal

Muscle Grading

5 – Normal – Complete max resistance4 – Good – Moderate resistance3 – Fair – ROM with gravity2 – Poor – Rom with gravity eliminated1 – Trace – Minimal contraction0 – None – No contraction

Examination Principlestest normal side first Active before passive Passive before resistedMost painful test done lastResisted – joint is in neutral and isometric –

stress on inert tissue is minimalPassive ROM – not only degree of movement

but end feelLigament stress – gentle / repeat and increase

stress but not beyond point of pain

Special Tests

Are available for all joints and most muscles to determine injury

Uses of special tests

- To confirm tentative diagnosis

- Make a differential diagnosis

- Differentiate between structure

Reflexes

Biceps C5-C6Triceps C7-C8Patella L3-L4Achilles S1-S2

Palpations

To palpate the area should be as relaxed as possible

discriminate the difference in tissue tension , ie rigidity and or flaccidity

discriminate the difference in tissue texture – fibrous band

detect abnormalities or deformities (myositis ossificans)

determine tissue thickness

- obvious swelling , intra or extra articular

- blood swelling - rapid (2-4 hours) – hard thick gel like

- fluid swelling – slow (8- 24 hours) – softer more mobile

Joint tenderness

Temperature Abnormal sensations

– hyperesthesia – increased sensations

– dysesthesia – diminishing sensations

– anethesia – absence of sensations

– crepitus etc.