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

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

Chapter 13: Off-the-Field Injury Evaluation

Part I


Evaluation of Injuries

• Essential skill for athletic trainers

• Four distinct evaluations1. 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


Clinical Evaluation & Diagnosis

• Diagnosis– Use of clinical or scientific methods to establish

cause and nature of patient’s illness or injury and subsequent functional impairment due to pathology

– Forms basis for patient care

• Physicians make medical diagnosis– Ultimate determination of patient’s physical

condition


• 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


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


Body Planes & Anatomical Directions

• Page 337 & 338


– 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


– 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


– Musculoskeletal Anatomy• Structural and functional anatomy• Encompasses bony and skeletal musculature• Neural anatomy useful relative to motion,

sensation, and pain


Standard Terminology for Bodily Position and Deviations• Page 340 Table 13-1


– 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


• 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


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)


• 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)


• 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


Descriptive Assessment Terms

• Page 339- 341


• 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


– 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


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


• 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


• 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?


• 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)


• 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”


Chapter 13: Off-the-Field Injury Evaluation

Part II


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


• 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


End Points

• Page 344-345


• 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)


• 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)


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


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


Figure 13-4 A & B


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


Manual Muscle Strength Grading

• Page 346 Table 13-3


TABLE 13-3 Manual Muscle Strength GradingGrade Percentage (%) Qualitative Value Muscle Strength

5 100 Normal Complete range of motion (ROM) against gravity with full resistance

4 75 Good Complete ROM against gravity with some resistance

3 50 Fair Complete ROM against gravity with no resistance

2 25 Poor Complete ROM with gravity omitted

1 10 Trace Evidence of slight contractility with no joint motion

0 0 Zero No evidence of muscle contractility


Neurological Examination

• Usually follows manual muscle testing

• Includes 6 major areas– Cerebral Function– Cranial Nerve Function– Cerebellar Function– Sensory Testing– Reflex Testing– Motor Testing


• Cerebral Function– Questions to assess general affect, level of

consciousness, intellectual performance, emotional status, though content, sensory interpretation & language skills


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


• Normal: 25 points

• Need to get back to baseline to return


Cranial Nerve Functions

• Twelve total cranial nerves that can be assessed through smell, eyes, facial expressions, biting balance, swallowing, tongue protrusion and shoulder shrugs


Cranial Nerves & Their Function

• Page 347 Table 13-4


TABLE 13-4

Cranial Nerves FunctionI. Olfactory Smell

II. Optic Vision

III. Oculomotor Eye movement, opening of eyelid, constriction of pupil, focusing

IV. Trochlear Inferior and lateral movement of eye

V. Trigeminal Sensation to the face, mastication

VI. Abducens Lateral movement of eye

VII. Facial Motor nerve of facial expression; taste; control of tear, nasal, sublingual salivary, and submaxillary glands

VIII. Vestibulocochlear Hearing and equilibrium

IX. Glossopharyngeal Swallowing, salivation, gag reflex, sensation from tongue and ear

X. Vagus Swallowing; speech; regulation of pulmonary, cardiovascular, and gastrointestinal functions

XI. Accessory Swallowing, innervation of sternocleidomastoid muscle

XII. Hypoglossal Tongue movement, speech, swallowing


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


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


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


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


Figure 13-5


Reflex Testing

• Reflex: involuntary response to a stimulus

• Types– Deep tendon (somatic), superficial, and

pathological


• 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


Figure 13-6


PART IIIOFF-THE-FIELD INJURY

EVALUTION


Progress Evaluations

• The scope of the injury

• How the injury appears today vs past

• Still needs to go through HOPS


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


• 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


SOAP Notes

• Page 353


– S (subjective)• Statements made by patient - primarily history

information and patient’s perceptions including time, mechanism and site of injury. Also the type and course of pain

– O (Objective)• Findings based on athletic trainer’s evaluation

including inspection, palpation and assessments of range of motion. Also the outcome of special tests


– 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 examiner’s plan for treatment• Treatment should also include specific short term goals


Progress Notes

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


ASSIGNMENT

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


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


• 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


X-Ray


Myelopgraphy, CT scan, Bone Scan

• Page 356


• 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


CT Scan


Bone Scan and DEXA Scan

Figure 13-8 F & G


• 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


MRI & MRI Anthrography

• Page 356


• 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


Magnetic Resonance

Imaging


• 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


• 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


Figure 13-8


• 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


• 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


• 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)


Blood Tests

• Page 358


• 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


SCENARIO- BLOOD TESTS


• Urinalysis– Used to assess specific gravity, pH, presence of

ketones, hemoglobin, proteins, nitrates, red & white blood cells, bacteria, electrolytes, hormones and drug levels

– Urinalysis using dip and read test strips provide fast accurate results for a number of things including, specific gravity, WBC’s, nitrate, pH, protein, glucose, ketones, bilirubin and blood.

• Large area on strip is impregnated with reagents which change color when dipped in urine that are then compared to color comparison charts.


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

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

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Transcript of © 2011 McGraw-Hill Higher Education. All rights reserved. Chapter 13: Off-the-Field Injury...