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									         Evaluation Process
• Good assessment is dependent upon:
  – Knowledge of functional anatomy
  – History
  – Complete examination
• 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
• 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
• 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
• 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
• 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
• 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
• 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=
• 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
• Only perform if do not suspect a fracture
          Functional Testing
  immature fracture sites
  newly repaired
Cardinal Planes(test all planes of ROM)
Painful ARC
  compression within range
         Functional Testing
• Quantity of available movement
• “Endfeel” reach limit of available ROM
• Most accurate method is with goniometry
       Normal End Feel
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
Soft        Soft tissue edema
Firm        Capsular,muscular,
            ligamentous shortening

Hard        osteoarthritis
Empty       Bursitis, Joint inflammation
         Functional Testing
• Two types of testing
  – Manual muscle testing
  – Break test
• Contraindications for RROM
  – Patient is unable to voluntarily contract injured
  – 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
  – Weak     Present   Major injury
  – Weak     None      Neurological or
                       Rupture or Chronic
    Ligamentous and Capsular
• 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
• 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
• 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
  – Infectious disease (HIV, HBV)
• Methods to protest against exposure
  – Gloves
  – Biohazard disposal
          Roles of health Care
•   ATC
•   PT
•   EMT
•   Physician
• Informed consent
  – If unconscious, consent is assumed
  – Treatment for minors
• Initial and follow-up evaluations
• Treatments
                 SOAP Notes
•   Subjective
•   Objective
•   Assessment
•   Plan

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