Chapter 13: Off-the-Field
Injury Evaluation
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Evaluation of Injuries
• Essential skill for athletic trainers
• Four distinct evaluations
– Pre-participation (prior to start of season)
– On-the-field assessment
– Off-the-field evaluation (performed in the
clinic/training room…etc)
– Progress evaluation
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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
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• 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
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Basic Knowledge Requirements
• Athletic trainer must have general knowledge
of anatomy and biomechanics as well as
hazards associated with particular sport
• Anatomy
– Surface anatomy
• Topographical anatomy is essential
• Key surface landmarks provide examiner with
indications of normal or injured structures
– Body planes and anatomical directions
• Points of reference (midsagittal, transverse, and frontal
(coronal) planes)
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– 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
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– Musculoskeletal Anatomy
• Structural and functional anatomy
• Encompasses bony and skeletal musculature
• Neural anatomy useful relative to motion,
sensation, and pain
– Standard Terminology
• Used to describe precise location of structures and
orientation
• 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)
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• 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
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• Descriptive Assessment Terms
– Etiology - cause of injury or disease
– 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)
– Sign - objective, definitive and obvious
indicator for specific condition
– Degree- grading for injury/condition
– Diagnosis- denotes name of specific
condition
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– 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
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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
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• History
– Obtain subjective information relative to
how injury occurred, extent of injury, MOI
– Inquire about previous injuries/illnesses
that may be involved as well as past
treatments
– Ask the following questions
•
•
•
•
•
What is the problem?
How and when did it occur?
Did you hear or feel something?
Which direction did the joint move?
Characterize the pain
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• Observations
– 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?
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• Palpation
– Bony & soft tissue
• Special Tests
– Used to detect specific pathologies
– Compare inert and contractile tissues and their
integrity
– Assessment should be made bilaterally
• Range of Motion Assessment
– Active
– Passive
• Normal vs. Abnormal end points
• Manual muscle tests
• Goniometric measures vs. Digital inclinometers
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Figure 13-4 A & B
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• Neurologic and circulation assessments
– Brain
• Cerebral, cranial nerve function, cerebellar function
– Sensory & motor function
• Dermatome
– Area of skin innervated by a single nerve
• Myotome
– Muscle or group of muscles innervated by a specific
motor nerve
– Reflex testing
• Involuntary response to a stimulus
– Deep tendon – caused by stimulation of stretch reflex
– Superficial – stimulation of skin which causes reflexive
muscle contraction
– Pathological – superficial reflex indicative of upper motor
neuron lesion
» Babinski’s sign, Chaddock’s, Oppenheim’s Gordon’s
– Referred pain
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Figure 13-5
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•
•
•
•
Motor Testing
Testing Joint Stability
Testing Accessory Motions
Testing Functional Performance
– Used to determine athletes readiness to
participate or continue participation
• Other tests
– Postural
– Anthropometric
– Volumetric
Figure 13-6
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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
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• 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
– S (subjective)
• Statements made by patient - primarily history
information and patient’s perceptions including
severity, pain, MOI
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– O (Objective)
• Findings based on athletic trainer’s evaluation
– 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
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SOAP Note
vs.
Progress Note or
Evaluation
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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
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• 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
– Invasive technique, using fiber-optic arthroscope,
used to assess joint integrity and damage
– Can also be used to perform surgical procedures
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X-Ray
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• 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
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CT Scan
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Bone Scan and DEXA Scan
Figure 13-8 F & G
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• 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
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• Magnetic Resonance Imaging (MRI)
– Using powerful electromagnet, 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
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Magnetic
Resonance
Imaging
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• 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
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• 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
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Figure 13-8
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• 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
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• Electrocardiography
– Recording of electrical
activity of heart at
various stages in
contraction cycle
– Assesses impulse
formation, conduction,
depolarization and repolarization of atria and
ventricles
Figure 13-9
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• 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 noninflammatory conditions (degenerative vs.
rheumatoid arthritis)
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• Blood Test
– Complete blood count (CBC) used to
screen for anemia, infection and many
other reasons
– Assesses red blood cell count, hemoglobin
levels, hematocrit levels (RBC per volume),
white blood cell count, platelet deficiency,
& serum cholesterol
• Urinalysis
– Used to assess specific gravity, pH,
presence of ketones, hemoglobin, proteins,
nitrates, red & white blood cells, bacteria,
electrolytes, hormones and drug levels
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– 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.
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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
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• Using ergonomics
– Improve efficiency (time and resources)
– Reduce time lost due to injury
– Reduce decreases in productivity
– Consider how changes could impact
physical requirements and demands
– Investigate worker complaints and
concerns
• Proactive step towards reducing work-related
injuries, workers compensation and time lost
• If workers are experiencing pain and
discomfort, there may be a safer and more
effective way of doing the job
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• If an employee suffers an injury it is
likely due to ergonomic stress
– Must be addressed to prevent further and
future injuries
• Steps and tools of risk assessment
– Identify and prioritize jobs
• Maximizes impact of intervention
– Workers must be briefed
• Review injury statistics, worker concerns,
physical demand analysis
– Direct supervisor must be notified
• Why the modification and what new
expectations will be
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• Steps and tools of risk assessment
(continued)
– Management must be informed
• Aware of costs associated with injuries,
benefits of ERA
– Company support professionals (nurse,
engineer, safety personnel)
– Use of videotape
• Allows more access for people to assessment
process
• Utilize for training purposes as well
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• After risks have been identified
– Athletic trainer should identify those that should
be controlled in an effort to reduce injury rates
– Consult workers, supervisors and management
– May involve
• Physical changes to job (sitting vs. standing, altering
work surfaces)
• Administrative changes (job rotations, lifting policy)
• Personal protective equipment
• Proposed changes should have an ERA
performed on them to ensure that original
risks have been reduced without
introduction of new risks
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