Evaluation Process
• Good assessment is dependent upon:
– Knowledge of functional anatomy
– History
– Complete examination
Evaluation
• Structure governs function
– Anatomy is the structure
– Biomechanics/physiology are the function
Evaluation Purpose
• Develop database to establish athlete’s level
of function
• Plan a treatment program and establish
outcomes
• Evaluate results of treatment program
• Modify treatment program
Clinical Evaluation Sequence
• History
• Inspection
• Palpation
• Functional Testing
• A/P/RROM
• Ligamentous Testing
• Special Tests
• Neurological Testing
History
• Most important portion of exam
– Any special test should confirm what is learned
in the history
• Key questions(identify forces on the body)
– Acute Injury= What is the mechanism
– Chronic Injury= Are there changes in training
routines/equipment/posture
• Communication
– Convey respect
– Language Barriers
– Religious considerations
– Gender considerations
History Questions
• Mechanism
– How did injury occur
• Macrotrauma (single traumatic force)
• Microtrauma (accumulation of repeated forces)
• Relevant Sounds or sensations
– Pop
– “Giving Way”
• Location of symptoms
– Localized
– Referred(pain from another source)
– Isolated vs. diffuse
• Onset and duration of symptoms
– Immediate pain v. chronic
– Classification for overuse injuries
• Stage 1
– Pain after activity
• Stage 2
– Pain during/after activity
• Stage 3
– Constant pain
• Description of symptoms
– Sharp/dull/achy
– Intermittent v. constant
– Weakness
– Paresthesia (numbness/tingling)
– Dysfunction/ inability to perform activity
• Change in symptoms
– Intensity change with specific motions,
postures, treatment, modalities, medications
• Previous history
– Previous injury
– When did previous episode occur
– Who evaluated and treated injury
– Diagnosis
– Course of treatment/rehab/surgery performed
– Did previous treatment plan decrease symptoms
• Related history to opposite body part
– Previous history of injury to uninvolved side
• General health status
– congenital abnormality/disease
Inspection
• Gait
• Gross Deformity (Refer)
fracture/discoloration/serious bleeding
• Swelling (localized v. diffuse)
• Bilateral Symmetry
• Discoloration/ Ecchymosis
• Keloids (surgical scars)
• Infection
– Redness/warmth/pus/swelling/red streaks/lymph nodes
Inspection
• Gait/Carry Angle
• Gross Deformity (Refer)
fracture/discoloration/serious bleeding
• Swelling (localized v. diffuse)
• Bilateral Symmetry
Do they mirror one another
• Discoloration/ Ecchymosis
• Keloids (surgical scars)
• Infection
redness/warmth/pus/swelling/red streaks/lymph nodes
Girth Measurements
• Swelling
– Identify joint line using bony landmarks
• Atrophy
– Make incremental marks (2,4,6 inch) from jt. line
• Lay tape symmetrically around body
• Pull tape snug
• Take 3 measurement and record average
• Repeat and record for uninjured limb
Palpation
• Detect tissue damage
– Bones(rule out fracture)
– Ligaments/tendons
– Soft tissue
– Pulses
• Point tenderness
– Visualize structure which lie beneath fingers
– Compare bilaterally
• Trigger Points
– Palpated points in muscle which refer pain to
another body area
• Change in tissue density(or feel of tissue)
may indicate:
– Muscle spasm
– Hemorrhage
– Edema
– Scarring
– Myositis ossificans
• Crepitus- repeated crackling sensations or
sound emanating from the joint or tissue
Felt over bone= possible fracture
Felt over tendon, bursa, joint capsule=
inflammation
• Symmetry
– Compare muscle tone, bony prominence
• Increased tissue temperature
– Indicates active inflammatory process
Range of Motion (ROM)
• Helps to assess functional status
• Compare bilaterally
• Test joints proximal and distal to injured
area
• Only perform if do not suspect a fracture
Functional Testing
AROM
Contraindications:
immature fracture sites
newly repaired
Cardinal Planes(test all planes of ROM)
Painful ARC
compression within range
Functional Testing
PROM
• Quantity of available movement
• “Endfeel” reach limit of available ROM
• Most accurate method is with goniometry
measurements
Normal End Feel
Physiological
Hard Bone contacting bone
elbow extension
Soft Soft tissue approximation
elbow flexion
Firm Capsule stretch(ext of MCP jt)
Ligament Stretch
(forearm supination)
Muscle Stretch
(hip flexion with knee extended)
Abnormal End Feel
Pathological
Soft Soft tissue edema
synovitis
Firm Capsular,muscular,
ligamentous shortening
Hard osteoarthritis
Fracture
Empty Bursitis, Joint inflammation
Functional Testing
RROM
• Two types of testing
– Manual muscle testing
– Break test
• Contraindications for RROM
– Patient is unable to voluntarily contract injured
muscle
– Patient is unable to perform AROM
– Underlying fracture site is not healed
– Involved tissues are not yet healed
• Manual Resistance
– Stabilize limb proximally
– Resistance provided distally on bone to which
muscle attaches
– Watch for compensation
Grading system for Manual
Muscle Testing
• 0/5 Zero No contraction
• 1/5 Trace Palpable contraction
No muscle movement
• 2/5 Poor Able to move body part
through gravity eliminated
• 3/5 Fair Move against gravity
throughout ROM
• 4/5 Good Moderate resistance
• 5/5 Normal Maximal resistance
Clinical Significance
• Strength Pain Finding
– Good None Normal
– Good Present Minor soft tissue
injury
– Weak Present Major injury
– Weak None Neurological or
Rupture or Chronic
Ligamentous and Capsular
Testing
• Sprains
Grade Endfeel Damage
I Firm Slight Stretch
II Soft Partial Tearing
“opens up”
III Empty Complete Rupture
motion is restricted by
other structures
Ligamentous testing
compare bilaterally
compare with baseline measures
correct positioning
(if incorrect positioning may lead to
false results)
Special Tests
• Specific procedures applied to joint to
determine presence of injury
• Unique to each structure
• Bilateral comparison
Neurological (Referred Pain)
• Involves Upper/lower quarter screen of:
– Sensory (dermatome)
– Motor (myotome)
– DTR (Deep Tendon Reflex)
Sensory Testing
– Bilateral
– Dermatone
• Area of skin innervated by a single nerve root
– Slight stroke over area/pin prick
– Sharp v. dull
– Hot v. cold
Motor Testing
• Manuel Muscle Testing
Sport Specific Functional Testing
• Ability to perform ADL or sport activities
• May also be tested with isokinetic machines
On the Field Evaluation
• Primary survey
• Secondary Survey
– History
– Inspection
– Palpation
– Testing
Primary Survey(ABC’s)
AT 540
• Breathing
• Pulse
• Life threatening trauma to head or spinal column
• Profuse bleeding
• Fractures
• Joint dislocations
• Other soft tissue trauma
CALL 911
Secondary Survey
• Determine athlete disposition
• On field management
• Safest method of removal
• Urgency of referring to Dr.
• Communication plan prior to event!
(AT 540)
On field history
• Location of pain
– Numbness/tingling/radiating pain
• Mechanism of Injury
• Associated sounds and symptoms
• History of injury
On field inspection
• Is athlete moving?
– Writhing in pain
– No movement or seizing
• Position of athlete
• Conscious
• Primary Survey
• Secondary Survey
On field palpation
• Bony structures
– Bony alignment (fracture)
– Crepitus( bony, soft tissue)
– Joint Alignment
• Soft tissue
– Swelling
– Hypersensitive areas
– Deficits in muscles/tendons
On the field
ROM/functional testing
• Ability and willingness to move
• AROM/PROM/RROM
• WB status
– May walk off if able to:
• Complete A/P/RROM
On field ligamentous testing
• Immediate impression
• May need to do ligamentous test during
history
• Performed in order to prevent chance of
muscle guarding later
On field neurologic testing
• Spine-injured athlete
• Assess neurovascular structures
Removing athlete from field
(AT 540)
• Spine-board
• Fx/dislocation
• Lower extremity- stretcher/cart
Immediate physician referral
• Obvious fracture
• Dislocation
• Gross joint instability
• Neuro dysfunction
• 3rd degree muscle tearing
Universal Precautions
• Blood, Saliva,Synovial fluid, Other body
fluids
– Infectious disease (HIV, HBV)
• Methods to protest against exposure
– Gloves
– Biohazard disposal
Roles of health Care
professionals
• ATC
• PT
• EMT
• Physician
Documentation
• Informed consent
– If unconscious, consent is assumed
– Treatment for minors
• Initial and follow-up evaluations
• Treatments
SOAP Notes
• Subjective
• Objective
• Assessment
• Plan