THE EVALUATION
PROCESS IN
REHABILITATION
WILLIAM E. PRENTICE
INTRODUCTION
• Injury evaluation is the foundation of the
rehabilitation process
• The athletic trainer determines the appropriate
rehab goals and plan based on info gathered from
the evaluation.
• Must consider the severity, irritability, nature and stage of
the injury
• A.T. must continuously re-evaluate the status of pathological
tissue throughout rehab to make appropriate adjustments
INTRODUCTION
• On-site evaluation:
• Quickly, but thoroughly evaluate the patient to
determine the injury severity, whether
immobilization is needed, medical referral need,
manner of transportation from field
• Off-site evaluation:
• More detailed
• Used to gain info to effectively design rehab plan
SYSTEMATIC DIFFERENTIAL
EVALUATION
• Subjective evaluation:
• History and symptoms experienced by the patient
• Relate info gathered to objective findings
• Objective evaluation:
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Observation and inspection
Acute injury palpation
Range of Motion (ROM) Assessment (Active and Passive)
Muscle strength
Special test
Neurological assessment
Functional testing
• Pg. 48 and 49 (Figure 3-1)
SYSTEMATIC DIFFERENTIAL
EVALUATION
• History
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Patients impression of the injury
Site of injury (pain)
Mechanism of injury
Previous injuries
General health
• Open-ended, non leading questions
• Use of simple terminology
SYSTEMATIC DIFFERENTIAL
EVALUATION
• Mechanism of Injury
• Identify nature of forces acting on body
• Single traumatic force (macrotrauma) vs. accumulation or
repeated forces (microtrauma)
• Identify body position at time of injury
• Direction, point of application and magnitude of applied
force
• Changes in training, routine, equipment use and posture
• Sound or sensation
• Pop=joint subluxation or ligament tear
• Clicking=cartilage or meniscus tear
• Locking=cartilage or meniscal tear (loose body)
• Giving way=reflex inhibition of muscles in an attempt to
minimize muscle or joint loading
SYSTEMATIC DIFFERENTIAL
EVALUATION
• Objective Evaluation
• Observation and Inspection
• Swelling, deformity, and discoloration
• Overall appearance of athlete
• Observe posture : especially in chronic overuse type injuries
• Postural malalignment creates repeated stress on specific tissue
• Cause muscle imbalances: tight vs. weak tissue
• Figure 3-2 (pg. 52-54
• Compensatory patterns, muscle guarding, facial expressions
• Lower extremity: Observe athletes gait (walking pattern)
• Upper extremity: observe carrying pattern of injured extremity
SYSTEMATIC DIFFERENTIAL
EVALUATION
• Palpation
• Identify damaged tissue
• Point tenderness, trigger points (small nodule or muscle spasm),
tissue quality, crepitus, temperature, symmetry
• Use pain scale of 0(no pain) to 10 (worst pain imaginable)
• Start with gentle superficial touch progress to deeper tissue
palpation
• Palpate unaffected side to identify normal tissue
• Helpful to develop specific sequencing of tissue palpated
• Bones then ligaments then muscle &tendon
SYSTEMATIC DIFFERENTIAL
EVALUATION
• ROM: Ability to move limb through specific pattern of
motion
• Compare bilaterally: unaffected side first to determine
athletes individual range
• AROM, PROM, RROM in that order
• Differentiate between contractile tissue (muscle & tendon)
and inert tissue (bone, ligament, capsule, bursae, periosteum,
cartilage, fascia)
• Pain with AROM in one direction and PROM in the opposite
direction=contractile tissue
• Pain with both =inert tissue
• Pain at end range =inert tissue injury because of compression
of tissue between bony structures
• Crepitus or clicking during PROM may indicate damage to
articular surface or loose body or in muscle tissue adhesions or
tendon subluxation
SYSTEMATIC DIFFERENTIAL
EVALUATION
• End feels (figure 3-1, pg. 57)
• Normal End feel
• Soft tissue approximation=soft and spongy, a gradual painless
stop (elbow flexion)
• Capsular=an abrupt, hard, firm end point with only a little give
(shoulder rotation)
• Bone to bone=a distinct and abrupt en point where 2 hard
surfaces come in contact with another (elbow extension)
SYSTEMATIC DIFFERENTIAL
EVALUATION
• End feels (figure 3-1, pg. 57)
• Abnormal End Feels
• Empty=movement definitely beyond the anatomical limit, or
pain prevents body part from moving through normal ROM
(ligament rupture)
• Spasm=involuntary muscle contraction that prevents normal
ROM due to pain (muscle spasm)
• Loose=extreme hypermobility (chronic ankle sprain)
• Springy Block= a rebound at the end of motion (meniscal tear or
loose body formation )
SYSTEMATIC DIFFERENTIAL
EVALUATION
• Strength testing
• Used to asses state of contractile tissue (muscle, tendon,
nerve)
• Mid-range muscle testing (isometric or “break test”)
• Table 3-2 pg 59
• Specific muscle testing (Table 3-3 pg 59)
• Assess pain and strength
• Used at eval and throughout rehab progression
• May identify muscle strain, pain/reflex inhibition,
peripheral nerve injury, nerve root lesion, tendon strain,
or psychological overlay
MUSCLE IMBALANCES
• Imbalances between agonist muscle and
functional antagonist
• Disrupt normal force-couple relationship
• Action of 2 forces in opposing directions about same axis of
rotation
• Muscle tightness or hyperactivity often the initial cause of
muscle imbalance.
• Shortened agonist muscle vs. lengthened antagonist muscle
• Reciprocal inhibition causes decreased neural drive which
facilitates functional weakness of antagonist
• To compensate for weakness patient relies on synergist or
secondary muscles to specific movements
• Synergistic dominance
• Increases risk of injury to the synergist muscles
• Janda Classification of functional muscle grouping Table 3-4 pg. 61
SYSTEMATIC DIFFERENTIAL
EVALUATION
• Special Test
• Joint stability or stress test
• Joint compression test
• Neurological test
• Dermatome testing
• Sensory distribution is innervated by specific nerve root
• Myotome testing
• Muscles innervated from specific nerve root
• Reflex testing
• Deep tendon, superficial, and pathological reflexes
INJURY PREVENTION
• Functional Movement Screening NASM Video
• Overhead Squat Test
• Figure 3-5 (Pg. 65)
• In-Line Forward Lunge Test
• Figure 3-6 (Pg. 66)
• Plan
DOCUMENTING FINDINGS
• SOAP Notes
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Subjective
Objective
Assessment
Plan
• Progress Reports
• Athletes treatment, goals reached, performance,
symptoms, pain, etc
DOCUMENTING FINDINGS
• Setting Rehab Goals
DOCUMENTING FINDINGS
• Progress Evaluations