Sports Injury Assessment.pdf

7/27/2019 Sports Injury Assessment.pdf

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S e c t i o n

2Sports Injury AssessmentTissue Healing and Wound CareTherapeutic Modalities

Therapeutic Exercise

I n j u r y A

s s e s s m

e n t

a n

d R

e h

a b i l i t a t i o n

CHAPTER5

CHAPTER6

CHAPTER7

CHAPTER8


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OUTCOMES1. Differentiate between the History of the injury, Observation

and inspection, Palpation, and Special tests (HOPS) injury assessment format and the Subjective evaluation, Objectiveevaluation, Assessment, and Plan (SOAP) note format used toassess and manage a musculoskeletal injury.

2. Name and explain the general components that comprise acomplete history of a musculoskeletal injury or illness.

3. Differentiate between visual observation and inspection at theprimary injury site.

4. Describe the various tests included in the physical examina-tion of an injury.

5. Develop an emergency medical systems plan for an athletictraining facility.

6. Identify the responsibilities of each member of the on-site sportsmedicine team in providing emergency care at an athletic event.

7. List supplies and emergency equipment that should be presentat an athletic event.

8. Explain the procedures used in an on-site sports injury assessment.

9. Identify emergency conditions that warrant immediate activa-tion of the emergency medical services (EMS) system.

10. Demonstrate proper procedures for transporting an injuredindividual.

11. Describe testing techniques used by medical specialists tomake an accurate diagnosis.

C h a p t e r

5Sports Injury Assessment


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A ccurate injury assessment is critical to evaluateand render proper care for any musculoskeletalinjury or illness. Although the evaluation processis often thought of in terms of acute injuries, chronicinjuries make up a majority of evaluations. As the indi-

vidual responsible for doing injury evaluations, the ath-letic trainer must have a sound background in human

anatomy, human physiology, and biomechanics. This isbecause the injury evaluation process is nothing morethan searching for atypical or dysfunctional anatomy,physiology, or biomechanics. A strong understanding of these areas as well as the appropriate execution of theevaluation techniques is essential to accurate injury assessment. Poor assessment can have a devastatingeffect on proper treatment and development of appro-priate rehabilitation protocols.

This chapter begins with a description of two popularmethods of injury assessment, namely the HOPS formatand the SOAP note format. Information is then presentedon the various components of the injury assessment

process. Next, the principles for developing and imple-menting an EMS plan are presented, including anoverview of the responsibilities of each member of thesports medicine team. The components of an on-siteemergency assessment are then presented with a list of conditions that warrant activation of EMS. Details ontransporting an injured player from the scene are fol-lowed by information on several tests and proceduresused by the physician to diagnose an injury. As it is im-possible to include basic rst-aid techniques in this book,athletic trainers must maintain current certication in rstaid and cardiopulmonary resuscitation (CPR). For thepurposes of this athletic training text, the authors assumethat students have already completed a basic athletictraining course or a rst-aid course and hold current cer-tication in CPR or its equivalent.

THE INJURY EVALUATION PROCESSWhat components are essential in any injury evaluationprocess? When working with several colleagues, why is it im-portant for each employee to be consistent and thorough in allinjury evaluations and keep accurate records?

When evaluating any injury or condition, symptoms anddiagnostic signs are gathered to determine the extent of injury. A symptom is information provided by the in-jured individual regarding his or her perception of theproblem. Examples of these subjective feelings includeblurred vision, ringing in the ears, fatigue, dizziness, nau-sea, headache, pain, weakness, and the inability to movea body part. A diagnostic sign is an objective, measura-ble physical nding regarding the individuals condition.

A sign is what the evaluator hears, feels, sees, or smells when assessing the patient. Interpreting the symptomsand signs is the foundation used to recognize and iden-tify an injury or condition.

Prior to assessing any injury, the opposite, or nonin-jured body part should be assessed. This preliminary stepin the injury evaluation process serves to establish a ref-erence point to help determine the relative dysfunction of the injured body part. For example, if an injury occurs toone of the extremities, the results of individual tests per-formed on the noninjured body part can be compared

with the injured body part. Differences indicate the leveland severity of injury. The baseline of information gath-ered on the noninjured body part also can be used as areference point to determine when the injured body parthas been rehabilitated, thus allowing the athlete to returnto full participation. Under most circumstances, assess-ment of the noninjured body part should precede assess-ment of the injured body part. However, in some acuteinjuries, such as fractures or dislocations, assessment of the noninjured body part is not necessary.

The injury evaluation process specic to the injuredbody part must include several key components: taking ahistory of the current condition, visually inspecting the

area for noticeable abnormalities, physically palpating theregion for abnormalities, and completing functional andstress tests. Although several models may be used, eachfollows a consistent, sequential order to ensure that noessential component is omitted, unless there is sufcientreason. Two popular methods are the HOPS format andSOAP note format. Each has its advantages, but the SOAPnote format is much more inclusive of the entire injury management process.

History of the Injury, Observation andInspection, Palpation, and SpecialTests (HOPS) Format

The HOPS format uses both subjective information (his-tory of the injury) and objective information (observationand inspection, palpation, and special tests) to recognizeand identify problems contributing to the condition. Thisformat is easy to use and follows a basic consistent for-mat. Often used in the beginning steps of injury assess-ment, the HOPS format has one major disadvantage: Itfocuses only on the evaluation component of sports in-jury management and excludes the rehabilitation process.

Subjective Evaluation The subjective evaluation (history of the injury) includesthe primary complaint, mechanism of injury, characteristicsof the symptoms, and related medical history. This infor-mation comes from the individual and reects his or her at-titude, mental condition, and perceived physical state.

Objective Evaluation

The objective evaluation (observation and inspection, pal-pation, and special tests) provides appropriate, measurable

96 S E C T I O N I I Injury Assessment and Rehabilitation

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documentation relative to the individuals condition. Thisinformation can be repeatedly measured to track progressfrom the initial evaluation through nal clearance for dis-charge and return to sport participation. Measurable factorsmay include edema, ecchymosis, atrophy, range of mo-tion, strength, joint instability, functional disability, motorand sensory function, and cardiovascular endurance. A de-

tailed postural assessment and gait analysis also may bedocumented in this section.

Subjective Evaluation, ObjectiveEvaluation, Assessment, and Plan(SOAP) Note Format

The SOAP note format provides a more detailed and advanced structure for decision making and problem solv-ing in sports injury management. Used in many physicaltherapy clinics, sports medicine clinics, and athletic train-ing facilities, these notes document patient care and

serve as a vehicle of communication between the on-siteclinicians and other health care professionals. Therecords provide information to avoid duplication of serv-ices, and state the present status and tolerance of that in-dividual to the care being rendered by a given healthcare provider.

The supervising physician determines the diagnosis of the patient and may note the results of any diagnostictesting, including x-rays, magnetic resonance imaging(MRI), computed tomography (CT) scans, laboratory test-ing, or personal notes. When appropriate, the patient isreferred to an athletic trainer or physical therapist for de-tailed evaluation to determine an appropriate treatment

and rehabilitation program. The subjective and objectiveevaluation is identical to that used in the HOPS format;however, two additional components are added to thedocumentation: assessment and planning. Abbreviationsare used throughout the notes for brevity. Although ab-breviations vary from facility to facility, commonly usedabbreviations can be seen in Table 5.1 .

Assessment

Following the objective evaluation, the clinician analyzesand assesses the individuals status and prognosis. Al-though a denitive diagnosis may not be known, the sus-pected injury site, damaged structures involved, andseverity of injury are documented. Subsequently, long-term goals are established to accurately reect the indi-

viduals status after a period of rehabilitation. These long-term goals might include pain-free range of motion;bilateral strength, power, and muscular endurance; car-diovascular endurance; and return to full functional sta-tus. In addition, short-term goals are then developed tooutline the expected progress within a week or two of the initial injury. These might include immediate protec-tion of the injured area and control of inammation,

C h a p t e r 5 Sports Injury Assessment 97

hemorrhage, muscle spasm, or pain. Short-term goals areupdated with each progress note. Progress notes may be

written daily, weekly, or biweekly to document progress(Figure 5.1) .

Plan

The nal section of the note lists the modalities, thera-peutic exercises, educational consultations, and func-tional activities utilized to achieve the short-term goals.The action plan includes the following information:

1. The immediate treatment given to the injuredindividual

2. The frequency and duration of treatments, therapeu-tic exercises, therapeutic modalities, and evaluationstandards to determine progress toward the goals

3. Ongoing patient education4. Criteria for discharge

As the short-term goals are achieved and updated, peri-

odic in-house review of the individuals records permitsthe facility and clinicians to evaluate joint range of mo-tion; exibility; muscular strength, power, and endurance;balance or proprioception; and functional status. Thesereviews also allow clinicians to discuss the continuity of documentation, efcacy of treatment, average time todischarge the individuals, as well as other parameters thatmay reect quality of care. As the individual progresses inthe treatment plan, gradual return to activity may helpmotivate him or her to work even harder to return to fullfunctional status. When it is determined that the individ-ual can be discharged and cleared for participation, a dis-charge note is written to close the le. All informationincluded within the le is condential and cannot be re-leased to anyone without written approval from thepatient.

In a clinical setting, SOAP notes are the sole means of documenting what was done or not done for the patient.It is the ethical responsibility of all clinicians to keep ac-curate and factual records. This information veries spe-cic services rendered, and evaluates patient progressand the efcacy of the treatment plan. Insurance compa-nies use this information to determine if services are be-ing appropriately rendered, and therefore, qualify for re-imbursement. More important, this comprehensiverecord-keeping system can minimize the ever-presentthreat of malpractice and litigation. In general, the pri-mary error in writing SOAP notes is the error of omission,

whereby clinicians fail to adequately document the na-ture and extent of care provided to the patient. Formaldocumentation and regular review of records can reducethis threat, and minimize the likelihood that inappropriateor inadequate care is being rendered to a patient.

Each component of the subjective and objective as-sessment is described in detail in the following sectionsand repeated throughout each chapter on the variousbody regions. A brief outline of the steps can be seen in


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TA B L E 5. 1 COMMON ABBREVIATIONS

abnor. abnormal

AC acute; before meals; acromioclavicular

ADL activities of daily living

ant. anterior

ante before

A&O alert & oriented

AOAP as often as possible

AP anterior-posterior; assessment and plans

AROM active range of motion

ASAP as soon as possible

B bilateral

BID twice daily

c with

CC chief complaint; chronic complainer

ck. check

C/O complained of; complaints; under care of

CP cerebral palsy; chest pain; chronic paind/c, DC discharged; discontinue; decrease

DF dorsiexion

DOB date of birth

DTR deep tendon reexes

Dx diagnosis

E edema

EENT eyes, ears, nose, throat

ELOP estimated length of program

EMS emergency medical services

EMT emergency medical technician

EOA examine, opinion, and advice; esophagealobturator airway

EV eversion

exam. examination

FH family history

FROM full range of movement

Fx fracture

G1-4 grades 1-4

GA general appearance

HA headache

H/O history of

H&P history and physical

HPI history of present illnessht. height; heart

Hx history

IC individual counseling

IN inversion

IPPA inspection, percussion, palpation, andauscultation

L left; liter

LAT lateral

LOM limitation of motion

MAEEW moves all extremities equally well

mm muscle; millimeter; mucous membrane

MMT manual muscle test

MOD moderate

N normal; never; no; not

NC neurologic check; no complaints; notcompleted

NEG negative

NP no pain; not pregnant; not present

NPT normal pressure and temperature

NSA no signicant abnormality

NSAID nonsteroidal anti-inammatory drug

NT not tried

NWB nonweight bearing

o negative; without

O objective nding; oral; open; obvious; often;other

OH occupational history

P&A percussion and auscultation

PA posterior-anterior (x-ray); physician assistant;presents again

PE physical examination

PF plantar exion

PH past history; poor health

PMH past medical history

PNS peripheral nervous system

PPPBL peripheral pulses palpable both legs

prog. prognosis

PROM passive range of motionPWB partial weight bearing

Px physical exam; pneumothorax

R right

rehab rehabilitation

R/O rule out

ROM range of motion

RTP return to play

Rx therapy; drug; medication; treatment; take

s without

S subjective ndings

stat immediately

STG short-term goals

Sx signs, symptom

T temperature

UK unknown

w white; with

WNL within normal limits

W/O without

y.o. year old

1tive positive


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Field Strategy 5.1 . Because of the vast amount of de-tailed information necessary to cover the treatment plan,students should enroll in separate classes on therapeuticmodalities and therapeutic exercise to see how all com-

ponents of the SOAP note relate to the total care providedto an injured athlete.

Essential components in any injury evaluation process are thesubjective evaluation (history of the injury), and the objectiveevaluation (observation and inspection, palpation, and functional/stress tests). In addition, the assessment and treatmentplan should be documented to follow the athlete throughout the rehabilitation program until the criteria to return to partici-pation are met. Clinicians should uniformly document patientassessment ndings, identify specic services rendered, andrecord rehabilitation progression to evaluate patient progressand efcacy of the treatment plan.

HISTORY OF THE INJURYA high school football player is complaining of a sharp, achingpain in the posterior ankle region. Pain increases when hegoes up on his toes, during sprints, and when going up and

down the stairs. What questions should be asked to identify the cause and extent of this injury?

Identifying the history of the injury can be the most im-portant step in injury assessment. A complete history in-cludes information on the primary complaint; cause ormechanism of injury; characteristics of the symptoms; andrelated medical history that may have a bearing on thespecic condition (Figure 5.2) . This information can pro-

vide possible reasons for the symptoms and identify pos-sible injured structures prior to initiating the physicalexamination. An individuals medical history le can be an


Figure 5.1. Progress notes are added to the patients le daily, weekly, or biweekly to docu-ment progress.

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excellent resource for identifying past injuries, subsequentrehabilitation programs, and any factors that may predis-pose the athlete to further injury. The National Collegiate

Athletic Association (NCAA) has identied primary com-ponents that should be in the athletes medical record andreadily accessible to the athletic trainer (Box 5.1) (1).

History taking involves asking appropriate questions,but also requires establishing a professional and comfort-able atmosphere. In taking a history, the athletic trainer

should present a competent manner, listening attentively and maintaining eye contact in an effort to establish rap-port with the injured individual. Ideally, this encouragesthe individual to respond more accurately to questionsand instructions. Often, an unacknowledged obstacle tothe evaluation process is the sociocultural dynamics thatmay exist between the patient and clinician that can hin-der communication. It is important for all clinicians tounderstand and respect cultural groups attitudes, beliefs,

F I E L D S T R AT E G Y 5 . 1 Injury Assessment Protocol

History of the InjuryPrimary complaint

Current nature, location, and onset of the conditionMechanism of injury

Cause of stress, position of limb, and direction of force

Changes in running surface, shoes, equipment, techniques, or conditioning modesCharacteristics of the symptomsEvolution of the onset, nature, location, severity, and duration of symptoms

Disability resulting from the injuryLimitations in occupation and activities of daily living

Related medical historyPast musculoskeletal injuries, congenital abnormalities, family history, childhood

diseases, allergies, or cardiac, respiratory, vascular, or neurologic problems

Observation and InspectionObservation should analyze

Overall appearanceBody symmetryGeneral motor function

Posture and gaitInspection at the injury siteObserve for deformity, swelling, discoloration, scars, and general skin condition

PalpationBony structures: determine a possible fracture rstSoft-tissue structures: skin temperature, swelling, point tenderness, crepitus, deformity,

muscle spasm, cutaneous sensation, and pulse

Functional TestsActive movementPassive movement and end feelResisted manual muscle testing

Stress Tests

Ligamentous instability testsSpecial tests

Neurologic TestsDermatomesMyotomesReexesPeripheral nerve testing

Sport-Specic Functional TestingProprioception and motor coordination

Sport-Specic Skill Performance


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and values as related to health and illness. If English is asecond language to the patient, it may be necessary to lo-cate an interpreter. If an interpreter is used, it is importantto speak to the client, not the interpreter. It may be nec-essary to speak more slowly, not louder, and refrain fromusing slang terms or jargon. To ensure understanding, thepatient should be asked to repeat the instructions.

The history begins by gathering general information,such as the individuals name, sex, age, date of birth, oc-cupation, and the activity in which the individual wasparticipating when the injury occurred. Notes regardingbody size, body type, and general physical condition alsoare appropriate.

Although information provided by the individual issubjective, it should still be gathered and recorded asquantitatively as possible. This can be accomplished by recording a number correlating with the described symp-toms. For example, the individual can rate the severity of pain using a scale from 1 to 10, with 10 being the mostsevere pain. Ask the individual how long the pain lasts.In using such measures, the progress of the injury can bedetermined. If the individual reports that pain begins im-mediately after activity and lasts for 3 or 4 hours, a base-line of information has been established. As the individualundergoes treatment and rehabilitation for the injury, acomparison with baseline information can determine if the condition is getting better, worse, or has remainedthe same. Although the intent of taking a history is to nar-row the possibilities of conditions causing the injury, the

history always should be taken with an open mind. If toofew factors are considered, the athletic trainer may reachpremature conclusions and fail to adequately address theseverity of injury. It is essential to document in writing theinformation obtained during the history.

Primary Complaint

The primary complaint focuses on what the injured individual believes is the current injury. Questions should bephrased to allow the individual to describe the current


Figure 5.2. Components to explore in taking a history of aninjury.

B O X 5 . 1

National Collegiate Athletic Association(NCAA) Guideline 1B: Medical Evaluations,Immunizations and RecordsThe following primary components should be includedin the athletes medical record:

History of injuries, illnesses, pregnancies, and op-erations both athletic and nonathletic

Physician referrals for subsequent feedback re-garding treatment, rehabilitation, disposition, orconsultation

Preparticipation and preseason medical healthquestionnaire including:

Illnesses suffered (acute and chronic); athleticand nonathletic hospitalization

SurgeryAllergies, including hypersensitivity to drugs,

foods, and insect bites/stingsMedications taken on a regular basis

Conditioning statusMusculoskeletal injuries (previous and current)Cerebral concussions or episodes involving loss

of consciousnessSyncope or near syncope with exerciseExercise-induced asthma or bronchospasmLoss of paired-organsHeat-related illnessCardiac conditions and family history of cardiac

disease including sudden death in a familymember less than 50 years of age andMarfans syndrome

Menstrual historyExposure to tuberculosis

Immunization recordsMeasles, mumps, rubella (MMR)Hepatitis BDiphtheriaTetanus

Written permission signed by the athlete andparent if the athlete is less than 18 years of age

Release of medical recordsConsent to treatment

Adapted with permission from the National Collegiate AthleticAssociation, 19971998. NCAA Sports Medicine Handbook.Overland Park, KS: NCAA Sport Sciences, 1997.


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nature, location, and onset of the condition. The follow-ing questions could be asked:

Why are you here? What is the problem? Where does it hurt? What activities or motions are weak or painful?

It is important to realize that the individual may not wishto carry on a lengthy discussion about the injury or may trivialize the extent of pain or disability. The athletictrainer must be patient and keep questions simple andopen-ended. It is advantageous to pay close attention to

words and gestures used to describe the condition, be-cause they may provide clues to the quality and intensity of the symptoms.

Mechanism of Injury

After identifying the primary complaint, the next step is todetermine the mechanism of injury. This is probably the

most important information gained in the history. Ques-tions that might be asked include:

How did the injury occur? Did you fall? If so, how did you land? Were you struck by an object or another individ-

ual? If so, in what position was the involved body part, and what direction was the force?

Did you hear or feel anything? How long has the injury been a problem? Have there been recent changes in running sur-

face, shoes, equipment, techniques, or condition-ing modes?

It is important to visualize how the injury occurred toidentify possible injured structures. This directs the ob-jective evaluation.

Characteristics of the Symptoms

The primary complaint must be explored in detail to dis-cover the evolution of symptoms, including the location,

onset, severity, frequency, duration, and limitations causedby the pain or disability. The individuals pain perception,for example, can indicate what structures may be injured.There are two categories of pain: somatic and visceral.Somatic pain arises from the skin, ligaments, muscles,bones, and joints, and is the most common type of painencountered in musculoskeletal injuries. It is classied into

two major types: deep and supercial. Deep somatic painis described as diffuse or nagging, as if intense pressure isbeing exerted on the structures, and may be complicatedby stabbing pain. Deep somatic pain is longer lasting andusually indicates signicant tissue damage to bone, inter-nal joint structures, or muscles. Supercial somatic pain re-sults from injury to the epidermis or dermis, and is usually a sharp, prickly type of pain that tends to be brief (2).

Visceral pain results from disease or injury to an organin the thoracic or abdominal cavity, such as compression,tension, or distention of the viscera. Similar to deep so-matic pain, it is perceived as deeply located, nagging, andpressing, and it is often accompanied by nausea and vom-

iting (2). Referred pain is a type of visceral pain that trav-els along the same nerve pathways as somatic pain. It isperceived by the brain as somatic in origin. In other words,the injury is in one region but the brain considers it in an-other. Referred pain, for example, occurs when an individ-ual has a heart attack and feels pain in the chest, left arm,and sometimes the neck. Figure 5.3 illustrates cutaneousareas where pain from visceral organs can be referred.

Pain can travel up or down the length of any nerveand be referred to another region. An individual who hasa low back problem may feel the pain down the glutealregion into the back of the leg. If a nerve is injured, painor a change in sensation, such as a numbing or burningsensation, can be felt along the length of the nerve. In as-sessing the injury, the athletic trainer should ask detailedquestions about the location, onset, nature, severity, fre-quency, and duration of the pain. For example, the fol-lowing questions should be asked:

Where does it hurt the most? Can you point to a specic spot?


Figure 5.3. Certain visceral organs can refer pain to spe-cic cutaneous areas. Keep this in mind if all special tests arenegative, yet the individual continues to feel pain at a specic site.

Lung and diaphragm

Spleen

Heart

Stomach

Pancreas

Ovary

Appendix

Colon

Kidney

Urinarybladder

Ureter

Liver andgallbladder

Liver andgallbladder

Smallintestine

A. Anterior B. Posterior


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Is the pain limited to that area, or does it radiateinto other parts of the leg or foot?

How bad is the pain on a scale from 1 to 10, with10 being most severe?

Can you describe the pain (e.g., dull, sharp,aching)?

In chronic conditions, the following questions should beasked:

When does the pain begin (when you get out of bed, while sitting, while walking, during exercise,or at night)?

How long does the pain last? Is the pain worse before, during, or after activity? What activities aggravate or alleviate the

symptoms? Does it wake you up at night? How long has the condition been present? Has the pain changed or stayed the same? In the past, what medications, treatments, or

exercise programs have improved the situation?If pain is localized, it suggests limited bony or soft-

tissue structures may be involved. Diffuse pain aroundthe entire joint may indicate inammation of the jointcapsule or injury to several structures. If pain radiatesinto other areas of the limb or body, it may be travelingup or down the length of a nerve. Obtaining informa-tion about the symptoms can determine if the individ-ual has an acute injury resulting from a specic event(macrotrauma) leading to a sudden onset of symp-toms, or a chronic injury characterized by a slow,

insidious onset of symptoms (microtrauma) that cul-minates in a painful inammatory condition. These an-swers also can determine if the condition is disablingenough to require a physician referral. Table 5.2 pro-

vides more detailed information on pain characteristicsand probable causes.

Disability Resulting from the InjuryThe athletic trainer should attempt to determine the limi-tations of the individual caused by pain, weakness, or dis-ability from the injury. Questions should not be limited tosport and physical activity, but should inquire if the injury has affected his or her job, school, or daily activities. Ac-tivities of daily living (ADLs) are actions most peopleperform without thinking, such as combing hair, brushingteeth, and walking up or down stairs.

Related Medical History

Information should be obtained regarding other prob-lems or conditions that might have affected this injury. In-formation extrapolated from the individuals preseasonphysical examination may verify past childhood diseases;allergies; cardiac, respiratory, vascular, musculoskeletal,or neurologic problems; use of contact lenses, dentures,or prosthetic devices; and past episodes of infectious dis-eases, loss of consciousness, recurrent headaches, heatstroke, seizures, eating disorders, or chronic medicalproblems. Previous musculoskeletal injuries or congenitalabnormalities may place additional stress on joints and


TA B L E 5 . 2 PAIN CHARACTERISTICS AND WHAT MAY BE INDICATED

Characteristics Possible Causes

Morning pain with stiffness that improves withactivity

Pain increasing as the day progresses

Sharp, stabbing pain during activity

Dull, aching pain aggravated by musclecontraction

Pain that subsides during activity

Pain on activity relieved by restPain not affected by rest or activity

Night pain

Dull, aching, and hard to localize; aggravatedby passive stretching of the muscle andresisted muscle contractions

Deeply located, nagging, and very localized

Sharp, burning, or numbing sensation thatmay run the length of the nerve

Aching over a large area that may be referredto another area of the body

Chronic inammation with edema, or arthritis

Increased congestion in a joint

Acute injury, such as ligament sprain ormuscular strain

Chronic muscular strain

Chronic condition or inammation

Soft-tissue damageInjury to bone

Compression of a nerve or bursa

Muscular pain

Bone pain

Nerve pain

Vascular pain


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predispose the individual to certain injuries. The athletictrainer should ask if the individual is taking any medica-tion. The type, frequency, dosage, and effect of a med-ication may mask some symptoms.

The varsity football player is 17 years old. His primary com-plaint is a sharp, aching pain in the region of the Achilles ten-don. He rates the pain as a 6 on a 10-point scale when he is

walking, and a 9 when he does wind sprints. Pain is reducedwhen he ices the region after practice. He cannot recall injur-ing the ankle, but the pain has been present for a week andseems to be getting worse. A physician has not been con-sulted about this injury.

OBSERVATION AND INSPECTIONA detailed history of the injury has been gathered from thefootball player. The next step is to observe the individual andinspect the injury site. What observable factors might indicate the seriousness of injury?

Observation and inspection begins the objective evalua-tion in an injury assessment. Although explained as a sep-arate step, observation begins the moment the injuredperson is seen and continues throughout the assessment.Observation refers to the visual analysis of overall ap-pearance, symmetry, general motor function, posture,and gait (Figure 5.4) . Inspection refers to factors seenat the actual injury site, such as redness, bruising,swelling, cuts, or scars.

Observation

Occasionally, the athletic trainer observes an individualsustain an injury. However, in many instances the indi-

vidual comes to the sideline, ofce, athletic trainingroom, or clinic complaining of pain or discomfort. The

athletic trainer should immediately assess the individualsstate of consciousness and body language, which may in-dicate pain, disability, fracture, dislocation, or other con-ditions. It is also important to note the individuals gen-eral posture, willingness and ability to move, ease inmotion, and general overall attitude. Using discretion insafeguarding the athletes privacy, the injured area should

be fully exposed. This may require the removal of pro-tective equipment and clothing.

Symmetry and Appearance

The body should be scanned visually to detect congenital (existing at birth) or functional problems that may becontributing to the injury. This includes observing any ab-normalities in the spinal curves, general symmetry of the

various body parts, and general posture of the body froman anterior, lateral, and posterior view. General questionsthat should be answered include those listed in Field Strategy 5.2 .

If it is not contraindicated , the athletic trainer shouldobserve the normal swing of the individuals arms andlegs during walking. The athletic trainer should stand be-hind, in front, and to the side of the individual to permitobservation from all angles. A shoulder injury may be ev-ident in a limited arm swing, or by holding the arm closeto the body in a splinted position. A lower extremity in-jury may produce a noticeable limp, or antalgic gait .Running on a treadmill can show functional problemsthat may have contributed to a lower extremity injury.

Motor Function

Many individuals begin observation in the examinationroom with a scan exam to assess general motor function.This exam rules out injury at other joints that may be


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Figure 5.4. Components ofobservation and inspection.


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Although the football player appeared to have good body sym-metry, he was unable to raise up on his toes or walk without anantalgic gait. Visual inspection of the Achilles tendon demon-strated redness and slight swelling on the posterior aspect of the tendon.

PALPATIONThe Achilles tendon is red, swollen, and painful. How can thearea be palpated to determine the extent and severity of injurywithout causing additional pain?

Prior to physical contact with the patient, permissionmust be granted to the athletic trainer to touch the pa-tient. If the patient is under 18 years of age, that permis-sion must be granted by the parent or guardian. In somecultures and religions, the act of physically touching anexposed body part may carry with it certain moral andethical issues. Likewise, some patients may feel uncom-fortable being touched by a clinician of the opposite

gender. If a same-gender clinician is not available, theevaluation should be observed by a third party (i.e., an-other clinician, parent, guardian, or coach).

Bilateral palpation of paired anatomical structures candetect eight physical ndings: temperature, swelling,point tenderness, crepitus, deformity, muscle spasm, cu-taneous sensation, and pulse (Figure 5.5) . The clinician

F I E L D S T R AT E G Y 5 . 3 Taking Girth Measurements

1. With the individual nonweight bearing, identify the joint line using prominent bonylandmarks.

2. Using a marked tongue depressor or tape measure, make incremental marks(e.g., 2, 4, and 6 in) from the joint line. (Do not use a cloth tape measure; they tend tostretch.)

3. Encircle the body part with the measuring tape making sure not to fold or twist thetape (Figure A) . If measuring ankle girth, use a gure eight technique by positioningthe tape across the malleoli proximally and around the navicular and base of the fthmetatarsal distally (Figure B) .

4. Take three measurements and record the average.

5. Repeat these steps for the noninjured body part and record all ndings.

6. Increased girth at the joint line indicates joint swelling. Increased girth over a musclemass indicates hypertrophy; decreased girth indicates atrophy.

A

individuals, skin discoloration such as pallor, cyanosis,and jaundice can be determined by looking at the mu-cous membranes, lips, nail beds, palms of the hands,and soles of the feet. Keloids , scars that form at a

wound but grow beyond its boundaries, also may bepresent. This condition is more common in black or African-American patients, and is important to note, par-ticularly if surgery may be indicated. The injured areashould be compared to the opposite side if possible.This bilateral comparison helps to establish what is nor-mal for this individual.

Q

A B

B O X 5 . 2

Scan Exam to Assess General Motor FunctionAsk the athlete to:

Extend, ex, laterally ex, and rotate the neck Bend forward to touch the toes Stand and rotate the trunk to the right and left

Bring the palms together above the head and thenbehind the back

Straight leg raises in hip exion, extension, andabduction

Flex the knees Walk on the heels and toes


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should have clean, warm hands. Latex examinationgloves should be worn as a precaution against diseaseand infection. Palpation should begin with gentle, circu-lar pressure followed by gradual, deeper pressure. Beginon structures away from the injury site and progress to-

ward the injured area. Palpating the most painful area lastavoids any carryover of pain into noninjured areas.

Skin temperature should be noted when the ngersrst touch the skin. Increased temperature at the injury site could indicate inammation or infection, whereas de-creased temperature could indicate a reduction in circu-lation. Swelling can be diffuse or localized in a small area.If swelling is inside the joint, motion often is limited be-cause of congestion caused by extra uid.

Palpation of the bones and bony landmarks can deter-mine the possibility of fractures, crepitus, or loose bony or cartilaginous fragments. Possible fractures can be as-sessed with percussion, vibrations through use of a tun-ing fork, compression, and distraction (Figure 5.6) . Theregion should be immobilized if test results indicate apossible fracture.

Point tenderness and crepitus (crackling sensation) may indicate a fracture when felt over bone, or inammation

when felt over a tendon, bursa, or joint capsule. It is im-portant to note any trigger points that may be found inmuscle and, when palpated, refer pain to another site. Inaddition, palpation should assess differences in the den-sity or feel of soft tissues that may indicate musclespasm, hemorrhage, edema, scarring, myositis ossicans,or other conditions. Cutaneous sensation can be tested by running the ngers along both sides of the body part andasking the patient if it feels the same on both sides. Thistechnique can determine possible nerve involvement,particularly if the individual has numbness or tingling in


Figure 5.5. Begin palpationwith gentle circular pressure fol-lowed by gradual deeper pressure.Feel for skin temperature, swelling,point tenderness, crepitus, defor-mity, muscle spasm, cutaneous sen-sation, and pulse.

Figure 5.6. Determining a possible fracture. A, Compression(axial and circular). B, Distraction. C,Percussion. D,Vibration.

A

B


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out any referred pain. The available active and passiveROM can be measured objectively with the use of agoniometer (Figure 5.9) . The goniometer is a pro-tractor with two rigid arms that intersect at a hingejoint. It is used to measure both joint position and avail-able joint motion, and can determine when the individ-ual has regained normal motion at a joint. The arms of the goniometer measure 0 to 180 of motion, or 0 to360of motion. Measurements are obtained by placingthe goniometers stationary arm parallel to the proximal

bone. The axis of the goniometer should coincide withthe joint axis of motion. The goniometers moving armis then placed parallel to the distal bone, utilizingspecic anatomical landmarks as points of reference.Normal ROM for selected joints is listed in Table 5.3and in the individual joint chapters. Age and gendermay inuence ROM. Women in their teens and early twenties tend to have a greater ROM in all planes thanmen. Range of motion decreases after 20 years in bothgenders, with the decrease occurring to a greater extentin women.

Active Range of Motion Active range of motion (AROM) is joint motion per-formed voluntarily by the individual through muscularcontraction. Unless contraindicated, AROM alwaysshould be performed before passive range of motion(PROM). This indicates the individuals willingness andability to move the injured body part. Active movementdetermines possible damage to contractile tissue (mus-cle, muscle-tendon junction, tendon, and tendon-periosteal union), and measures muscle strength andmovement coordination. Measurement of all motions,

the limb. Peripheral pulses are taken distal to an injury torule out damage to a major artery. Common sites are theradial pulse at the wrist and dorsalis pedis pulse on thedorsum of the foot (Figure 5.7) .

Palpation reveals warmth and slight swelling over the distalAchilles tendon. Sharp pain was elicited directly over the ten-don, approximately 1 inch proximal to its distal insertion into the calcaneus. All fracture tests were negative.

PHYSICAL EXAMINATION TESTSThere is little evidence of a fracture present. How should youproceed to test the integrity of the soft-tissue structures to determine the extent and severity of injury? What factors mightlimit range of motion at the joint?

After fractures and/or dislocations have been ruled out,soft-tissue structures, such as muscles, ligaments, the jointcapsule, and bursae, are assessed using special tests.

Although more extensive explanations are given in theindividual chapters, general principles are discussed here.Special assessments include functional tests (active,passive, and resisted range of motion), ligamentous andcapsular testing, special tests, neurologic testing, andsport-specic functional testing (Figure 5.8) .

Functional Tests

Functional tests identify the patients ability to move abody part through the range of motion (ROM) actively,passively, and against resistance. As with all tests, thenoninjured side should be evaluated rst to establishnormative data . All motions common to each jointshould be tested. Occasionally, it also may be necessary to test the joints proximal and distal to the injury to rule

A

Q

Figure 5.7. Pulses can be taken at the ra-dial pulse in the wrist (A)or the dorsalis pedis on the dorsum of the foot (B).


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except rotation, starts with the body in anatomical posi-tion. For rotation, the starting body position is midway between internal (medial) and external (lateral) rotation.The starting position is measured as 0 . The maximalmovement away from the 0 point is the total availableROM. For example, subjective measurement of plantarexion against gravity involves placing the individualprone on a table with the knees exed. Next, both thighsare stabilized against the table, and the individual is in-structed to plantar flex both ankles. Comparison of movement in both legs indicates if plantar exion is bi-laterally equal.

It is necessary to assess the individuals willingness to

perform the movement, the uidity, and extent of move-

ment (joint ROM). If symptoms are present, their locationin the arc of movement should be noted. Any increase inintensity or quality of symptoms also should be noted.Limitation in motion may result from pain, swelling, mus-cle spasm, muscle tightness, joint contractures, nervedamage, or mechanical blocks, such as a loose body. If the individual has pain or other symptoms on motion, itis difcult to determine at this time if the joint, muscle, orboth are injured. It is important to assess the following: If motion causes pain, at what point in the motiondoes pain begin? Does pain appear only in a limitedROM (painful arc)? Is the pain the same type of pain as-sociated with the primary complaint? Anticipated painful

movements should be performed last to avoid any carry-over of pain from testing one motion to the next.

Passive Range of Motion

If the individual is unable to perform all active movementsat the injured joint because of pain or spasm, passivemovement can be performed. In passive movement , theinjured limb or body part is moved through the ROM withno assistance from the injured individual (Figure 5.10) .

As PROM is performed, the individual should be posi-tioned to allow the muscles to be in a relaxed state. Pas-sive range of motion distinguishes injury to contractile tis-sues from noncontractile or inert tissues (bone, ligament,bursae, joint capsule, fascia, dura mater, and nerve roots).If no pain is present during passive motion but is presentduring active motion, injury to contractile tissue is in-

volved. If noncontractile tissue is injured, passive move-ment is painful and limitation of movement may be seen.

Again, any painful motions should be performed last toavoid any carry over of pain from one motion to the next.

At the end of the ROM, a gentle overpressure is applied todetermine end feel . Overpressure is repeated severaltimes to determine whether pain increases, which could


Figure 5.8. Components of physical examination tests.

Figure 5.9. Goniometry measurement at the elbow. Inanatomical position, the elbow is exed. The goniometer axis isplaced over the lateral epicondyle of the humerus. To accommodateusing a goniometer that ranges from 0 to 180, the stationary arm isheld parallel to the longitudinal axis of the radius, pointing toward the styloid process of the radius. The moving arm is held parallel to the longitudinal axis of the humerus, pointing toward the tip of theacromion process. Range of motion is measured where the pointerintersects the scale.


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signify damage to noncontractile joint structures. The endfeel can determine the type of disorder. There are threenormal end feel sensations and four abnormal end feelsensations (Table 5.4) (3).

Differences in ROM between active and passive move-ments can result from muscle spasm, muscle deciency,neurologic decit, contractures, or pain (4). If pain occursbefore the end of the available ROM, it may indicate anacute injury. Stretching and manipulation of the joint arecontraindicated. If pain occurs simultaneously at the endof the ROM, a subacute injury may be present, and a mildstretching program may be started cautiously. If no painis felt as the available ROM is stretched, a chronic injury is present. An appropriate treatment and rehabilitationprogram should be initiated immediately (4).

Accessory movements are movements withinthe joint that accompany traditional active and passiveROM, but cannot be voluntarily performed by the

TA B L E 5. 3 NORMAL RANGES OF MOTION AT SELECTED J OINTS (NO CHANGES )

Joint Motion Range of Motion Joint Motion Range of Motion

Cervical Flexion 080 Digit 25Extension 070 MCP Flexion 090

Lateral exion 045 Extension 045

Rotation 080 Abduction 020

Lumbar Forward exion 060 PIP Flexion 0100 Extension 035 DIP Flexion 090

Lateral exion 020 Hip Flexion 0120Rotation 050 Extension 030

Shoulder Flexion 0180 Abduction 040

Extension 060 Adduction 030

Abduction 0180 Internal rotation 040

Internal rotation 070 External rotation 050

External rotation 090 Knee Flexion 0135

Horizontal abduction/ 0130 Extension 015

adduction Medial rotation with knee 025

Elbow Flexion 0150 exedExtension 010 Lateral rotation with knee 035

Forearm Pronation 080

exedSupination 080 Ankle Dorsiexion 020

Wrist Flexion 080 Plantar exion 050

Extension 070 Pronation 030

Ulnar deviation 030 Supination 050

Radial deviation 020 Subtalar Inversion 05

Thumb Eversion 05

CMC Abduction 070 ToesFlexion 015 1st MTP Flexion 045

Extension 020 Extension 075

Opposition Tip of thumb to 1st IP Flexion 090

tip of 5th nger 25 MTP Flexion 040

MCP Flexion 050 Extension 040

IP Flexion 080 PIP Flexion 035

DIP Flexion 030

Extension 060

Figure 5.10. Passive movement. The body part is moved through the range of motion with no assistance from the injuredindividual. Any limitation of movement or presence of pain isdocumented. A,Starting position. B, End position.


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individual. Joint play motions, for example, allow thejoint capsule to give so bones can move to absorb anexternal force. These movements include distraction,sliding, compression, rolling, and spinning of joint sur-faces. These motions occur within the joint, but only asa response to an outside force, and not as a result of any

voluntary movement. These movements aid the healing

process, relieve pain, reduce disability, and restore fullnormal ROM. If any joint play movement is found to beabsent or decreased, this movement must be restoredbefore functional voluntary movement can be accom-plished fully (5).

The presence of accessory movement can be deter-mined by manipulating the joint in a position of leaststrain, called the loose packed or resting position (Table 5.5) . The resting position is the position in thejoints ROM in which the joint is under the least amountof stress, and is also the position in which the jointcapsule has its greatest capacity. The advantage of testingaccessory movements in the loose packed position is that

the joint surface contact areas are reduced, proper jointlubrication is enhanced, and friction and erosion in thejoints is decreased.

In contrast, a close packed position is the position in which two joint surfaces t precisely together. The liga-ments and joint capsule are maximally taut, and joint sur-faces are maximally compressed and cannot be separatedby distractive forces, nor can accessory movements occur.Therefore, if a bone or ligament is injured, pain increasesas the joint moves into the close packed position. If swelling is present within the joint, the close packed po-sition cannot be achieved. Table 5.6 lists the closepacked positions of the major joints of the body.

Resisted Manual Muscle Testing

Resisted manual muscle testing can assess muscle strengthand detect injury to the nervous system. To test resistance,an overload pressure is applied in a stationary or static po-sition, sometimes referred to as a break test , or may beapplied throughout the full ROM. Muscle weakness andpain indicate a muscular strain. Muscle weakness in theabsence of pain may indicate nerve damage.

In performing a break test, overload pressure is applied with the joint in a neutral or relaxed position to relax jointstructures and reduce joint stress. As such, contractile tis-sues (muscles) are more effectively stressed. The limb isstabilized proximal to the joint to prevent other motionsfrom compensating for weakness in the involved muscle.Resistance is provided distally on the bone to which themuscle or muscle group attaches, and should not be dis-tal to a second joint. In a xed position, the individual isasked to elicit a maximal contraction while the body partis stabilized to prevent little or no joint movement. For ex-ample, to test strength in the elbow exors, ex the elbow


TA B L E 5 . 4 NORMAL AND ABNORMAL J OINT END FEELS

Normal End Feel Sensations

End Feel Structure Example

Soft

Firm

Hard

Soft-tissueapproximation

Muscular stretch

Capsular stretch

Ligamentous stretch

Bone to bone

Elbow exion (contactbetween soft tissueof the forearm andanterior arm)

Hip extension (passivestretch of iliopsoasmuscle)

External rotation at theshoulder (passivestretch of anteriorglenohumeral jointcapsule)

Forearm supination(tension in the palmarradioulnar ligament of the inferior radioulnarjoint, interosseousmembrane, obliquecord)

Elbow extension (con-tact between olecra-non process and ole-cranon fossa)

Soft

Firm

Hard

Empty

Occurs sooner or laterin the ROM than isusual or in a jointthat normally has arm or hard end feel;feels boggy

Occurs sooner or laterin the ROM than isusual; or in a jointthat normally has asoft or hard end feel

Occurs sooner or laterin the ROM than isusual; or in a jointthat normally has asoft or rm end feel;a bony grating orbony block is felt

No end feel becauseend of ROM is neverreached owing topain. No resistance isfelt except forpatients protectivemuscle splinting ormuscle spasm

Soft-tissue edemaSynovitisLigamentous stretch or

tear

Increased musculartonus

Capsular, muscular, liga-mentous shortening

ChondromalaciaOsteoarthritisLoose bodies in jointMyositis ossicansFracture

Acute jointinammation

BursitisFracture

Psychogenic in origin

Abnormal End Feel Sensations

End Feel Description Example


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at 90 and stabilize the upper arm against the body. Thepatient is instructed to keep the arm in that position as theexaminer applies downward overpressure on the distalforearm (Figure 5.11) . Pressure should be held for atleast 5 seconds and repeated 5 to 6 times to indicate mus-cle weakening and the presence or absence of pain (5). Astandardized grading system can be used to measure mus-cle contraction, but the results are negated if the contrac-tion causes pain (Table 5.7) .

Testing resistance throughout the full ROM offers twoadvantages: (1) a better overall assessment of weaknesscan be determined, and (2) a painful arc of motion canbe located, which might otherwise go undetected if thetest is only performed in the mid-range. In performing re-sisted testing, the body segment is placed in a specicposition to isolate the muscle(s). The muscle(s) tobe tested is placed in a stretched or elongated position.

TA B L E 5. 5 LOOSE PACKED POSITION OF SELECTED J OINTS

Joint(s) Position

Glenohumeral 55 abduction, 30

horizontal adduction

Elbow (ulnohumeral) 70 elbow exion, 10

forearm supination

Radiohumeral Full extension, fullforearm supination

Proximal radioulnar 70 elbow exion, 35

supination

Distal radioulnar 10 forearm supination

Wrist (radiocarpal) Neutral with slightulnar deviation

Carpometacarpal Midway betweenabduction-adductionand exion-extension

Metacarpophalangeal Slight exion

Interphalangeal Slight exion

Hip 30 exion, 30 abduc-tion, slight lateralrotation

Knee 25 exion

Ankle (talocrural) 10 plantar exion,midway betweenmaximum inversionand eversion

Subtalar Midway betweenextremes of inver-sion and eversion

Tarsometatarsal Midway between

extremes of range of motion

Metatarsophalangeal Neutral

Interphalangeal Slight exion

TA B L E 5 . 6 CLOSE PACKED POSITIONS OF SELECTED J OINTS

Joint(s) Position

Glenohumeral Abduction and lateralrotation

Elbow (ulnohumeral) Extension

Radiohumeral Elbow exed 90 , 5

forearm supination

Proximal radioulnar 5 forearm supination

Distal radioulnar 5 forearm supination

Wrist (radiocarpal) Extension with radialdeviation

Metacarpophalangeal (ngers) Full exion

Metacarpophalangeal (thumb) Full opposition

Interphalangeal Full extension

Hip Full extension, medialrotation and abduction

Knee Full extension, lateral

rotation of tibiaAnkle (talocrural) Maximum dorsiexion

Subtalar Full supination

Midtarsal Full supination

Tarsometatarsal Full supination

Metatarsophalangeal Full extension

Interphalangeal Full extension

Figure 5.11. Resisted manual muscle testing in a staticposition. Stabilize the arm against the body. Apply downwardpressure on the distal forearm, and ask the individual to preventany movement.

This position prevents other muscles in the area fromperforming the movement. Manual pressure is exertedthroughout the full ROM, and is repeated several times to

reveal weakness or pain. The presence of pain duringmotion should be noted. In this manner, both subjective


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applied to a ligament to test its laxity (Table 5.8) . Laxity describes the amount of give within a joints support-ive tissue. Instability is a joints inability to function un-der the stresses encountered during functional activities.

All ligamentous testing should be done bilaterally andcompared with baseline measures. It is essential to per-form the test at the proper angle, because a seemingly minor change in the joint angle can signicantly alterthe laxity of the tissue being stressed (6). Figure 5.12demonstrates a valgus stress test on the elbow joint toassess the integrity of the joint medial collateral liga-

ments. During an on-site assessment, tests to determinea possible fracture and major ligament damage at a jointalways should be performed before moving an injuredindividual. Only the specic tests deemed necessary forthe injury should be used. Because of the wide variety of stress tests, each is discussed within subsequentchapters.


TA B L E 5 . 8 GRADING SYSTEM FOR LIGAMENTOUS LAXITY

LigamentousGrade End Feel Damage

I Firm (normal) Slight stretching of theligament with little or notearing of the bers. Painis present, but the degreeof stability roughlycompares with that

of the opposite extremity.

II Soft Partial tearing of the bers.The joint line opens upsignicantly whencompared with theopposite side.

III Empty Complete tearing of theligament. The motion isrestricted by other jointstructures, such astendons.

TA B L E 5. 7 GRADING SYSTEM FOR MANUAL MUSCLE TESTING

Numerical Verbal Clinical Findings

5 Normal Complete range of motion (ROM) againstgravity with maximal overload

4 Good Complete ROM against gravity with moderateoverload

3 Fair Complete ROM against gravity with minimaloverload

3 Fair Complete ROM against gravity with no overload

3 Fair Some, but not complete ROM against gravity

2 Poor Initiates motion against gravity

2 Poor Complete ROM with some assistance andgravity eliminated

2 Poor Initiates motion if gravity is eliminated

1 Trace Evidence of slight muscular contraction, nojoint motion

0 Zero No muscle contraction palpated

Figure 5.12. Stress tests. Applying a valgus stress on the elbowjoint can assess the integrity of the joint medial collateral ligaments.

(what the individual feels) and objective information(weakness) is gathered.

Ligamentous and Capsular Testing

Each body segment has a series of tests to assess jointfunction and integrity of joint structures. These tests as-sess noncontractile tissues (e.g., ligaments, intra-articu-lar structures, and joint capsule stability), impingementsigns, muscle balance, and vascular integrity (6). For ex-ample, sprains of ligamentous tissue are generally

graded on a three-degree scale after a specic stress is


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Neurologic Testing

A segmental nerve is the portion of a nerve that origi-nates in the spinal cord and is referred to as a nerve root.Most nerve roots share two components: (1) a somaticportion, which innervates a series of skeletal musclesand provides sensory input from the skin, fascia, mus-cles, and joints; and (2) a visceral component, which ispart of the autonomic nervous system. The autonomicsystem supplies the blood vessels, dura mater, perio-steum, ligaments, and intervertebral discs, among many other structures.

Nerves are commonly injured by tensile or compres-sive forces and are reected in both motor and sensory decits. The motor component of a segmental nerve istested using a myotome , a group of muscles primarily innervated by a single nerve root. The sensory compo-nent is tested using a dermatome , an area of skin sup-plied by a single nerve root. An injury to a segmentalnerve root often affects more than one peripheral nerve

and does not demonstrate the same motor loss or sen-sory decit as an injury to a single peripheral nerve. Der-matomes, myotomes, and reexes are used to assess theintegrity of the central nervous system. Peripheral nerves

are assessed using manual muscle testing and noting cu-taneous sensory changes in peripheral nerve patterns.Neurologic testing is only necessary in orthopedic in-juries when an individual complains of numbness,tingling, or a burning sensation, or suffers from unex-plained muscular weakness.

Dermatomes

The sensitivity of a dermatome can be assessed by touch-ing the person with a cotton ball, paper clip, pads of thengers, and ngernails. In doing so, the clinician shouldask the individual about the sensations being experi-enced. It is important to determine the nature of the sen-sation (e.g., a sharp or dull sensation) and assess whetherthe same sensation was experienced in testing the unin-jured body segment. Abnormal responses may be de-creased tactile sensation (hypoesthesia) , excessive tac-tile sensation (hyperesthesia) , or loss of sensation(anesthesia)

.Paresthesia

is another abnormal sensa-tion characterized by a numb, tingling, or burning sensa-tion. Figure 5.13 illustrates dermatome patterns for thesegmental nerves.


Figure 5.13. Cutaneoussensation. The cutaneous sensationpatterns of the spinal nervesdermatomes differ from the patternsinnervated by the peripheral nerves.


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tegrity, muscle contractions must be held at least 5 sec-onds (5). A normal response is a strong muscle contrac-tion. Weakness in the myotome indicates a possiblespinal cord nerve root injury. A weakened muscle con-traction may indicate partial paralysis (paresis) of themuscles innervated by the nerve root being tested. In aperipheral nerve injury, there is complete paralysis of the

muscles supplied by that nerve. For example, the L 3myotome is tested with knee extension. If the L 3 nerveroot is damaged at its origin in the spine, there is a weakmuscle contraction. This is because the quadriceps mus-cle is receiving nerve root innervation from L 2 and L 4 seg-mental nerves. If, however, the peripheral femoral nerve,

which contains segments of L 2 , L3 , and L 4 , is damagedproximal to the quadriceps muscle, the muscle cannotreceive any nerve impulses; therefore, it is unable to con-tract to execute knee extension.

Reexes

Damage to the central nervous system (CNS) can be de-tected by stimulation of the deep tendon reflexes(DTRs) (Table 5.10) . However, reex testing is limitedas not all nerve roots have a DTR. The most familiardeep tendon reex is the patellar, or knee-jerk, reexelicited by striking the patellar tendon with a reflexhammer, causing a rapid contraction of the quadricepsmuscle (Figure 5.14) . Deep tendon reexes tend to bediminished or absent if the specic nerve root beingtested is damaged. Exaggerated, distorted, or absent re-exes indicate degeneration or injury in specic regionsof the nervous system. This may be demonstrated be-fore other signs are apparent. However, abnormal DTRsare not clinically relevant unless they are found withsensory or motor abnormalities.


TA B L E 5 . 9 MYOTOMES USED TO TEST SELECTED NERVEROOT SEGMENTS

Nerve Root Segment Action Tested

C1 C 2 Neck exion*C3 Neck lateral exion*C4 Shoulder elevation

C5 Shoulder abductionC6 Elbow exion and wristextension

C7 Elbow extension andwrist exion

C8 Thumb extension andulnar deviation

T1 Intrinsic muscles of thehand (ner abductionand adduction)

L1 L 2 Hip exionL3 Knee extensionL4 Ankle dorsiexionL5 Toe extension

S 1 Ankle plantar exion, footeversion, hip extension

S 2 Knee exion

*These myotomes should not be performed in an individual with asuspected cervical fracture or dislocation because they may causeserious damage or possible death.

Myotomes

The majority of muscles receive segmental innervationfrom two or more nerve roots. However, selected mo-tions may be innervated predominantly by a single nerveroot (myotome). Resisted muscle testing of a selectedmotion can determine the status of the nerve root thatsupplies that myotome (Table 5.9) . In assessing nerve in-

TA B L E 5. 1 0 DEEP TENDON REFLEXES

Reex Stimulation Site Normal Response Segmental Level

Jaw Mandible Mouth closes Cranial nerve V

Biceps Biceps tendon Biceps contraction C 5 C 6

Brachioradialis Brachioradialis tendon Flexion of elbow and/or C 5 C 6or just distal to the pronation of forearmmusculotendinous junction

Triceps Distal triceps tendon just Elbow extension/muscle C 7 C 8superior to olecranon contractionprocess

Patella Patellar tendon Leg extension L 3 L4

Medial hamstrings Semimembranosus tendon Knee exion/muscle L 5 , S 1contraction

Lateral hamstrings Biceps femoris tendon Knee exion/muscle S 1 S 2contraction

Tibialis posterior Tibialis posterior tendon Plantar exion of foot with L 4 L5behind medial malleolus inversion

Achilles Achilles tendon Plantar exion of foot S 1 S 2


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Rectus femoris(extensor)

Vastus lateralis

Hamstrings(flexors)

Tibia

Fibula

Patellar ligament

Patella

Figure 5.14. Reexes. Reexes can indicate if there is nerveroot damage. The most familiar stretch reex is the knee jerk, orpatellar reex, performed by tapping the patellar tendon with a re-ex hammer, causing involuntary knee extension.

TA B L E 5. 1 1 SUPERFICIAL REFLEXES

Normal SegmentalReex Response Level

Upper abdominal Umbilicus moves T 7 T 9up and toward areabeing stroked

Lower abdominal Umbilicus moves T 11 T 1down andtoward areabeing stroked

Cremasteric Scrotum elevates T 12 , L1

Plantar Flexion of toes S 1 S

Gluteal Skin tenses in the L 4 L5 , S 1 S 3gluteal area

Anal Anal sphinctermuscles contract S 2 S 4

Superficial reflexes (Table 5.11) are reflexes pro- voked by supercial stroking, usually with a moderately sharp object that does not break the skin. This actionproduces a reex muscle contraction. An absence of asupercial reex indicates a lesion in the cerebral cortexof the brain (upper motor neuron lesion).

Pathologic reexes (Table 5.12) may indicate uppermotor neuron lesions if bilateral, or lower motor neuronlesions if unilateral. The presence of the reex oftenserves as a sign of some pathologic condition.

Peripheral Nerve Testing

Motor function in peripheral nerves is assessed withresisted manual muscle testing throughout the full ROM.

Sensory decits are assessed in a manner identical to der-matome testing, except the cutaneous patterns differ (seeFigure 5.13). Special compression tests also may be used onnerves close to the skin surface, such as the ulnar and me-dian nerves. For example, the Tinel sign test is performedby tapping the skin directly over a supercial nerve (seeFigure 13.20). A positive sign, indicating irritation or com-

pression of the nerve, results in a tingling sensation travel-ing into the muscles and skin supplied by the nerve.

Activity-Specic Functional Testing

Before permitting an individual to return to sport andphysical activity after an injury, the individuals conditionmust be fully evaluated so risk of reinjury is minimal.

Activity-specic tests involve the performance of activemovements typical of the movements executed by theindividual during sport or activity participation. Thesemovements should assess strength, agility, exibility, jointstability, endurance, coordination, balance, and sport-specic skill performance. In the rehabilitation process,the individual initially performs these skills at low inten-sity and increases intensity as the individuals conditionimproves. For example, in a lower leg injury, testingshould begin by assessing walking, jogging, and thenrunning forward and backward. If these skills are per-formed pain-free and without a limp, the individual mightthen be asked to run in a gure eight or zigzag pattern.

Again, each test must be performed pain-free and withouta limp. An individuals balance can be tested by perform-ing tasks with the eyes closed, such as walking a straightline on the toes and heels, balancing on a wobble board,or walking sideways on the hands while in a push-up po-sition. Any individual who has been discharged from re-habilitation also should pass the functional tests and becleared by a physician for participation.

Special tests were completed on the football player. Activeplantar exion and passive dorsiexion were painful. Resistedplantar exion was weak and caused sharp pain in the distalAchilles tendon. Joint stability tests were negative and did notproduce an increase in pain. The individual has normal bilateralsensation on the feet and a good distal pulse. After reviewing thesubjective and objective evaluation, did you determine that thisathlete has a strain of the Achilles tendon? If so, you are correct.

THE EMERGENCY MEDICALSERVICES SYSTEM

A basketball player goes up for a lay-up shot, gets tangled withanother player, and falls onto his back striking his head on theoor. The athlete is not moving. As you approach the player, think for a minute about how you will handle this situation, andwhat actions should be performed if his condition requires im-mediate transportation to a local medical facility.

Serious injuries can be frightening, particularly if breathingor circulation is impaired. As the rst responder on the

A

Q


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scene, the athletic trainer is expected to evaluate the situ-ation, assess the severity of injury, recognize life-threaten-ing conditions, provide immediate emergency care, andinitiate any emergency procedures to ensure the individ-ual is transported to the nearest medical facility withoutdelay. Although few musculoskeletal injuries are seriousenough to require immediate transportation to the nearestmedical facility, these injuries do occur. An emergency medical services system is a well-developed process thatactivates the emergency health care services of the athletic

training facility and community to provide immediatehealth care to an injured individual. As discussed in Chap-ter 1, the team physician, athletic trainer, and coach havea legal duty to develop and implement an emergency planto provide health care for participants.

Preseason Preparation

Prior to the start of the sport season, the emergency re-sponse team should meet with representatives from localEMS agencies to discuss, develop, and evaluate the emer-gency procedures plan. This is an excellent opportunity to review individual responsibilities and protocols for an

emergency situation. Questions to be answered include: What emergency equipment must be available at

each event, particularly at contact and collisionsporting events?

What equipment will be provided by the local EMSagency (spine board, splints, blankets) if in atten-dance at the event?

Who will be responsible for ensuring that all emer-gency equipment is operational prior to the event?

What type of communication will be used to contactemergency personnel, and who will activate EMS?

Who will assess the injured individual on-site, andunder what circumstances will EMS be called ontothe site?

If a physician is present, what will be the responsi-bilities of the athletic trainer(s) and EMS?

If a physician is not present and the athletic traineris evaluating the situation, what will be the respon-sibilities of the EMS?

Who will bring supplies or equipment on-site asrequested by the athletic trainer or team physician?

If it becomes necessary to stabilize and transportthe individual to a medical facility, who will directthe stabilization and what protocol will be fol-lowed for the removal of protective equipment?

A written emergency plan should be developed foreach activity site to address these questions. When anemergency occurs inside a facility with multiple activity areas, several additional questions need to be answeredprior to rendering care:

Who will render emergency care and control thesituation?

What type of immediate care will this individual

initiate while EMS is en route to the facility? Who will supervise the other participants if the ath-

letic trainer is assessing and providing care to theinjured individual?

Who will be responsible for the proper disposal of items and equipment exposed to blood or otherbodily uids?

It is critical during emergencies that everyone work to-gether to ensure that medical attention is not delayed.Field Strategy 5.4 summarizes several important issuesin developing an emergency care plan.


TA B L E 5. 1 2 PATHOLOGIC REFLEXES *

Reex Elicitation Positive Response Pathology

Babinskis Stroke lateral aspect of Extension of big toe; Pyramidal tract lesionsole of foot fanning of four small toes

Test is normal in newborns Organic hemiplegia

Chaddocks Stroke lateral side of Same response as above Pyramidal tract lesion

foot beneath lateral malleolusOppenheims Stroke anteromedial tibial Same response as above Pyramidal tract lesion

surface

Gordons Squeeze calf muscle rmly Same response as above Pyramidal tract lesion

Brudzinskis Passive exion of one Similar movement occurs Meningitislower limb in opposite limb

Hoffmans (Digital) Flicking of terminal Reex exion of distal phalanx Increased irritabilityphalanx of index, middle, of thumb and of distal of sensory nerve inor ring nger phalanx of index or middle tetany

nger (whichever one was Pyramidal tract lesionnot icked)

*Bilateral positive response indicates an upper motor neuron lesion. Unilateral positive response may indicate a lower motor neuron lesion.Tests most commonly performed in lower limb and upper limb.


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F I E L D S T R AT E G Y 5 . 4 Developing an Emergency Care Plan

Personnel:

All medical and staff members working with sport participants must be currentlycertied in emergency rst aid and cardiopulmonary resuscitation.

Appoint one individual as the medical liaison or captain. Ensure that this individualhas advanced rst-aid training.

Preseason Planning: Have all sport participants been medically cleared to participate? Are appropriate

documents completed (e.g., physical examination, permission to participate, informedconsent, and emergency information)? Have the athletic trainers and coaches beeninformed of any orthopedic or health problems that might affect participation?

Do you have emergency cards for each participant with family phone numbers,physicians names and phone numbers, special instructions/considerations, and whoto contact when parents/guardians are unavailable?

Is the athletic training facility and activity areas checked regularly for safety hazards?Does everyone know the location and have easy access to rst-aid kits, splints,stretchers, re extinguishers, and a phone? Are emergency numbers posted in clearview near each phone (e.g., emergency medical services [EMS], hospital, athletictraining room, school nurse, facility medical liaison, and re and police departments)?

Are all medical staff, including local EMS agencies, familiar with the activity areasand informed of the most accessible routes to the athletic training room, elds,gymnasia, and pool?

Do you have different emergency procedures for the various facilities (pool,gymnasia, weight room, training room, and elds)? If so, is the staff aware of them?

What type of communication will be used by the entire medical staff (e.g., handsignals, two-way radios, cell phones)?

At what events will the team physician and EMS providers be present? If EMS is in attendance, what emergency equipment will be available through them?

Who will ensure that it is operational? What other emergency equipment will beneeded on the eld/court? Who will ensure that it is available and operational?

Who will contact the visiting team and inform them of what emergency equipmentand services will be available on-site?

What procedures will be followed if a head or neck injury is suspected andprotective equipment is worn by the athlete? Who will direct the stabilization of theathlete and removal of any protective equipment?

In the Event of an Emergency: Do all medical staff understand their roles during an emergency situation?

Who will complete the initial injury assessment?Who will activate emergency medical services (EMS) for additional assistance?Who will be on the sideline to bring additional supplies onto the eld?Who has access to locked gates or doors?Who will direct the ambulance to the accident scene?

Under what conditions will the team physician go onto the eld? Under what conditions will the EMS providers be summoned onto the eld? If the team physician or EMS must be summoned, what information should be

provided over the phone or radio (e.g., type of emergency situation, possibleinjury/condition, current status of the injured party, type of assistance being given tothe injured party, exact location of the facility or injured individual [give cross streetsto assist EMS] and specic point of entry to the facility, telephone number of phonebeing used)?

Who will decide the best methods with which to transport the individual off the eld?

After an Emergency: Who will be responsible for informing the individuals parents/guardians that an

emergency has occurred? Are proper injury records completed after the injury and kept on le in a central,

secure location?


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The emergency response team, along with local EMTsor paramedics, should practice the emergency planthrough regular educational workshops and trainingexercises. These workshops can provide continuing edu-cation in emergency care management and recerticationin rst aid and cardiopulmonary resuscitation protocols.This helps prepare individuals to assume their roles in

rendering emergency care to an injured sport participant.

Responsibilities of Medical Personnel

The emergency response team consists of the team physi-cian, athletic trainers, athletic training students, coachingstaff, and EMS providers from the local EMS agency. Eachhas specic responsibilities associated with emergency medical care of sport participants. Prior to an event, theemergency response team should meet to review emer-gency procedures. Everyone should know the locationand proper use of medical supplies and equipment, andthey must be operational and easily accessible. A method

of communication should be established (e.g., hand sig-nals or two-way radios to summon the team physician,EMS providers, and equipment and supplies). For exam-ple, a right hand on the head may summon the teamphysician onto the eld, and crossed arms may indicatethe need for a spine board; both hands on the head may indicate the need to summon EMS.

Team Physician

Prior to the season, the team physician should delineatethe responsibilities for all personnel so there is no confu-sion about treatment decisions. It must be clearly under-stood what events the team physician will attend, whatrole he or she will play in the assessment of injuries, and

what, if any, responsibility he or she will have in providingemergency medical services to bystanders and spectators.

Although present at the event, the team physician isnot always the rst responder to an injured athlete; themost experienced certied athletic trainer assigned tocover that sport usually is the rst individual to assess theathlete. Once called onto the eld, however, the teamphysician should evaluate any serious injury (e.g., head,neck, or spinal injuries, cardiac emergencies, joint in-juries) and determine the level of severity. If needed, theteam physician summons additional supplies or assis-

tance and directs the athletic trainer to assist as needed. When appropriate, the physician also directs the stabi-lization and immobilization of the athlete in preparationfor transportation to the nearest medical facility. If trans-portation is not necessary, the team physician decides

whether to return the individual to competition.

Athletic Trainer

The athletic trainer is responsible for setting up the eventarea with appropriate equipment and supplies for the med-ical kit (Box 5.3) and emergency crash kit (Box 5.4) , and

B O X 5 . 3

Checklist for Athletic Training Medical KitAdhesive bandages (assorted sizes)Adhesive tape

1/2 inch1 inch

1 1/2 inch2 inchAirway (pocket mask and oropharyngeal)Alcohol (isopropyl)Antacid tablets or liquidAntifungal powder or sprayAntiseptic/antibiotic ointmentAntiseptic soapAspirin tabletsBlister tape (Dermiclear )Buttery bandage and Steri-stripsCloth ankle wrapsContact lens case and solutionCotton balls

Cotton-tipped applicatorsElastic tape (Elastikon or Conform )

1 inch2 inch3 inch

Elastic wraps4 inch6 inchDouble-length 6 inch

Emergency kitCoins for pay phoneEmergency telephone numbersLocation of nearest trauma centerHealth information cards

Injury reportsInsurance information

Eye patches (sterile)Eyewash and eye cupFelt (compression/horseshoe pads)

1/4 inch1/2 inch

Fingernail clipperFlexible collodion

1/8 inch1/4 inch1/2 inch1 inch

Forceps (tweezers)Fungicide creamGauze pads (sterile and nonsterile)Germicide solutionHeel and lace padsHeel cupsHydrogen peroxideLatex glovesMirror (handheld)MoleskinNasal pledget (plug)

Continued


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B O X 5 . 4

Checklist for Emergency Crash KitOn the Sideline or Court

Blood pressure cuff StethoscopeImmobilizer splints and slingsCrutchesCervical collars (soft and Philadelphia )Spine board, stretcher, cart, and chairOropharyngeal airwayBiohazard equipment

Hazardous waste disposal containers with labels

Spill kitsPersonal protective equipmentWater and cupsIce bagsTowels

Carried by the Athletic TrainerLatex glovesSterile gauzePenlightCardiopulmonary resuscitation pocket maskDevice for removing face masks

B O X 5 . 3

Checklist for Athletic TrainingMedical Kit Continued

Nonadhering sterile padsNonocclusive dressingOral thermometerPaper, pen or pencilPenlightPlastic bags for iceRing cutterScalpel and blades, disposableScissors

BandageHeavy dutySurgicalTapingTrainer s Angel

Second skinSkin lubricant (petroleum jelly)Sling or triangular bandagesStethoscope and blood pressure cuff Suntan lotion or sunblockTape adherentTape cutterTape removerTongue depressorsTowelettes, moistUnderwrap

providing a method of communication (e.g., telephone,two-way radio, or cellular phone). The equipment mustmeet the needs, size, and age of the participants, andbe compatible with equipment used by other healthprofessionals.

For home events, the host athletic trainer should con-tact the visiting teams athletic trainer to inform him or

her of services and supplies that will be made available tothe visiting team. Emergency procedures also can be ex-plained at this time. When the team arrives, the host ath-letic trainer should immediately introduce himself or her-self to the visiting athletic trainer and answer any questions concerning access to the athletic training facili-ties, emergency equipment, emergency procedures, andlocation of the nearest medical facility. For an away event, if the team physician does not travel with the team,the athletic trainer should be informed of what services

will be provided by the on-site team physician.If a physician is present at the event, the certied ath-

letic trainer assists as needed. The athletic trainer may be

responsible for giving hand signals to summon additionalequipment or supplies, assisting in stabilizing an injury site,and removing the athlete from the eld. If the team physi-cian is not present, the at

Documents

Sports Injury Assessment.pdf