Chapter 13: Off-the Field Injury
Evaluation
Evaluation of Sports Injuries
• Essential skill
• 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
Injury Evaluation vs. Diagnosis
• While ATC can recognize injury, by law they
cannot diagnose --only a doctor can
• Doctors of specific regions are allowed to
diagnose conditions in those regions (dentist)
• Fine line between evaluation and diagnosis
– Athletic trainer must act within limits of his/her
ability and training and act in accord with
professional ethics
Basic Knowledge Requirements
• ATC 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 (midsagital, transverse, and
frontal (coronal) planes)
– 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
• 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)
• Understanding the Sport
– More knowledge of sport allows for more inherent
knowledge of injuries associated with sport and
better injury assessment
– Must be aware of proper biomechanical and
kinesiological principles to be applied in activity
– Violation of principles can lead to repetitive
overuse trauma
• Descriptive Assessment Terms
– Etiology - cause of injury or disease
– 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
– Prognosis- prediction of the course of the 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
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
– While obtaining history, remain calm, present
simple questions, listen carefully to complaint,
take good records
– Inquire about previous injuries/illnesses that
may be involved as well as past treatments
– Ask the following questions
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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
– Be sure to identify the location of the pain and
injury
– Pain characteristics
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What type of pain?
Where is the pain?
Does it change at different times?
Are there any other types of sensations?
– Joint response
• Is there instability?
• Does it feel loose or like it will give way?
• Does the joint lock?
– Determine chronic vs. acute
• Time frame
• Observations
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How does the athlete move? Is there a limp?
Are movement abnormal?
What is the body position?
Facial expressions?
Asymmetries postural mal-alignments or
deformities?
– Abnormal sounds?
– Swelling, heat, redness, inflammation, swelling
or discoloration?
• Palpation
– Used at the start or further into the evaluation
– Bony and soft tissue palpation
– Perform systematically - begin away from the
injured site
– Start with light pressure followed gradually by
deeper pressure
– Bony
• Compare bilaterally
• Look for abnormal gapping, swelling, abnormal
protuberances associated with bone or joint
– Soft tissue
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Must remain relaxed
Look for lumps, swelling, gaps, tension, temperature
Variations of shape and structure, tightness, textures
Skin dryness, moistness, skin dysesthesia or
anesthesia or hyperesthesia
• Perform bilaterally
• Special Tests
– Used to detect specific pathologies
– Compare inert and contractile tissues and their
integrity
• Lesion in contractile tissue will result in pain with
motion (pain with active motion in one direction and
with passive motion in opposite direction)
• Lesion in inert tissue will elicit pain on active and
passive motion in the same direction
– Active Range of Motion (AROM)
• Should be first movement assessment
• Assess quality of movement through different
ranges and planes at varying speeds and strengths
• Pain free throughout full range should be tested
while applying force or resistance
– Passive Range of Motion (PROM)
• Athlete must remain relaxed to remove influence of
contractile tissue
• Try to classify feel of endpoints
• Normal
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soft tissue approximation- soft, spongy - painless stop
capsular feel-abrupt, hard and firm
bone to bone- distinct abrupt stop
muscular - springy
• Abnormal
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Empty - movement beyond anatomical limits with pain
Spasm - involuntary muscle guarding
Loose - occurs in extreme hypermobility
Springy block - rebound at endpoint
• Throughout PROM ATC looking for limitation in
movement and presence of pain
• Report of pain before end range indicates acute
inflammation (stretching and manipulation would be
contraindicated)
• Pain synchronous with end range indicates subacute
and involves inert tissue fibrosis
• If no pain at end range, injury is chronic and
contractures have replaced inflammation
– Resisted Motions (RROM)
• Evaluate status of contractile tissue
• Isometric contraction at mid range
• Different from manual muscle test which occurs
throughout ROM
• Different grading systems used to identify severity
and degrees of strength (Cyriax)
– Goniometric Measurements
• Measure joint ROM (degrees)
• Full ROM is major factor in determining return to
activity
• To perform measurement goniometer is placed on
lateral aspect of extremity, with 0 or starting
position in anatomical positions
• Athlete will move either active or passively through
available range to endpoint
• Stationary arm should be placed parallel to long axis
of fixed reference part while moveable arm is placed
along axis of moveable segment
• Accuracy and consistency requires practice and
repetition
– Manual Muscle Testing
• Used to determine vary extent of injury to
contractile tissue
• Limitation in muscular strength is generally caused
by pain
• Generally performed so muscle or group of muscles
can be isolated and tested through a full range while
applying manual resistance
• Ability to move through range or offer resistance is
subjectively graded by ATC according to various
classification systems
– Neurological Examination
• Test 5 major areas (cerebral, cranial nerve,
cerebellar, sensory functioning, reflex testing and
referred pain)
• Most musculoskeletal injuries do not require cranial,
cerebral or cerebellar assessment and exam can
focus on peripheral neurological functioning
• Cerebral functioning
– Questions assess general affect, consciousness, intellectual
performance, emotional status, sensory interpretation,
thought content, and language skills
• Cranial Nerve function
– Quality assessed through assessments of smell, eye
tracking, facial expressions, biting down, balance,
swallowing, tongue protrusion, and shoulder shrug
• Cerebellar Function
– Control of purposeful coordinated movement
– Touch finger to nose, finger to finger, heel-toe walking
• Sensory Testing
– Determine distribution of dermatomes and peripheral
nerves
– Assess
» Superficial sensation
» Superficial pain
» Deep pressure pain
» Sensitivity to temperature
» Sensitivity to vibration
» Position sense
• Reflex testing
– Reflex refers to involuntary response to a stimulus
– Three types - deep tendon, superficial and pathological
– Deep tendon reflex (somatic)
» Caused by stimulation of stretch reflex
» Biceps (C5) brachioradialis (C6) triceps (C7) patella (L4)
Achilles (S1)
– Superficial reflexes
» Elicited by stimulation of skin at specific sites producing
muscle contraction
» Upper abdominal (T7,8,9), lower abdominal (T11, 12)
cremasteric (S1, 2), gluteal (L4, S3)
» Absence of reflex = lesion of cerebral cortex
– Pathological
» Also superficial reflexes
» Indicative of lesion in cerebral cortex
» Babinski’s sign, Chaddock’s, Oppenheim’s, Gordon’s
• Determining Projected or Referred Pain
– Deep burning pain, or ache that is diffuse or in area of no
sign of malfunction or disorder is most likely referred
– Cyriax considers common sites of pain in order of
importance - joint, tendon, muscle, ligament, and bursa
– Pressure on dura mater or nerve sheath can also produce
referred pain or sensory response
– Myofascial trigger points are not related to deep, referred
pain (tense tissue bands)
– Testing Joint Stability
• A number of specific tests are used to test
ligamentous stability for each specific joint
• Allows clinician to grade severity of injury and
determine extent of dysfunction
– Testing Accessory Motions
• The manner in which one articular surface moves
relative to another
• Normal accessory motion must occur to allow for
full and un-compromised range of motion
• Can be impacted by capsular tightness or tightness
of musculotendinous units
– Testing Functional Performance
• Used to determine athletes readiness to participate
or continue participation
• Used for progress evaluation during rehab
• Should proceed gradually from relatively easy task
to more challenging --mimicking actual sport
participation
• Questions whether athlete has regained full ROM,
strength, speed, endurance, and neuromuscular
control and is pain free
– Postural Examination
• Many conditions can be attributed to body
malalignment
• Used to look at asymmetries by comparing body
relative to grid or plumb line
– Anthropometric Measurements
• Science of measuring the body
• Includes osteometry, craniometry, skin-fold
measurements, height and weight.
• Also involves measurements of limb girth
– Volumetric Measurements
• Used to determine changes in limb volume caused
by swelling which can be attributed to
hemorrhaging, edema or inflammation
• Measure water that is displaced from a tank in
which limb is immersed
Progress Evaluations
• When rehab is occurring, follow-up evaluations must
be performed to monitor progress
• Seeing the athlete daily allows for daily modification
• Progress evals should be based on healing process at
any given time - providing a framework for the
rehabilitation and sometime constraints on progress
• Progress evaluations are generally more limited in
scope - focus on specific injury and progress relative
to previous day
• Should still follow similar outline to evaluation
• History
– Pain comparison (today vs. yesterday)
– Movement, better or worse relative to pain?
– Treatment - effective or not?
• Observations
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Degree of swelling
Degree of movement relative to yesterday
Is athlete still guarding?
What is athlete’s affect? Attitude and mood?
• Palpation
– What is consistency of swelling and has it changed?
– Is it still tender to touch?
– Deformity compared to yesterday
• Special Tests
– Do ligamentous tests result in pain and what is the
grade?
– How do ROM, accessory motion and manual
muscle tests compare today to yesterday?
– How does the athlete perform in functional tests?
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
– S(subjective)
• Statements made by athlete - primarily history
information and athletes perceptions including
severity, pain, MOI
– O(Objective)
• Findings based on ATC’s evaluation
– A (Assessment)
• ATC’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
• Progress Notes
– Need to be routinely written after each progress
evaluation
– Perform throughout rehab of an injury
– Can follow SOAP format, generated daily, or be
weekly summaries
– Should focus on treatments, athlete’s and
injury’s response to treatment, progress and
goals
– Should also discuss future treatment plans if
necessary
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
– Invasive technique, using fiber-optic arthroscope,
used to assess joint integrity and damage
– Can also be used to perform surgical procedures
X-Ray
• 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)
CT Scan
Bone Scan
• Ultrasonography
– Use of ultrasound 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
• 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
Magnetic
Resonance
Imaging
• 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
• 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)
• 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
– 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.