A SYSTEMATIC APPROACH TO INJURY EVALUATION
Gary Delforge, Ed.D., A.T.C.
First aid and emergency care and the medical referral of serious athletic injuries are two
of the most important responsibilities that an athletic trainer has. Proper execution of
these responsibilities is predicted on sound decision-making (Figure 1) which, in turn, is
largely dependent on the athletic trainer's ability to recognize the nature and severity of
injuries with which he or she is confronted. The athletic trainer will often be faced with
two situations which require evaluation of an acute injury as a basis for sound injury
management. The first situation involves field emergencies during which the athletic
trainer must decide upon and provide on-the-spot emergency care. Almost daily, the
athletic trainer is required to provide field care for mild or moderately severe injuries.
Occasionally, more serious situations demand immediate recognition of life-threatening
signs and symptoms and implementation of life-saving procedures. The second situation
in which the athletic trainer is called upon to evaluate injuries involves the training room
examination. In the absence of a physician, the athletic trainer must conduct a thorough
clinical evaluation of the injury in an effort to determine the necessity for medical
referral. Documentation of clinical signs and symptoms identified during this initial
examination are often of significant interest and value to the attending physician.
Knowledge and Skill Requirements
In either of the above situations, an effective evaluation is based on certain assumptions
with respect to the technical knowledge and skill of the athletic trainer. First, the athletic
trainer must have a sound knowledge of anatomy and biomechanics. Most evaluation
procedures are based on the examiner's ability to differentiate between normal anatomical
and biomechanical characteristics and pathologically significant deviations from the
norm. Anatomical variations among individual athletes due to age, sex, or congenital
factors should also be appreciated. The examiner must understand the anatomical
relationships of bony landmarks, joint structures, and muscle groups as a basis for
effective palpation and functional testing. Knowledge of typical ranges of motion
provides an essential baseline for recognition of pathologically significant restrictions in
joint mobility. Characteristic sensory and motor nerve innervations must be understood in
order that appropriate neurological tests can be conducted.
A second prerequisite to an effective clinical evaluation is the athletic trainer's knowledge
of injury pathology and an awareness of etiological factors typically associated with
injuries common to each sport. An understanding of these two factors raises the athletic
trainer's "level of suspicion" and allows him or her to make certain preliminary
associations between the mechanisms or forces involved in injury and the resulting
pathology. Several examples serve to illustrate this point. The college football player who
reports that he was "hit on the outside of the knee" by an opposing player might
reasonably be expected to have sustained, at the minimum, an attenuation or rupture of
the medial collateral ligament. This same mechanism reported by an adolescent athlete
might lead the athletic trainer to suspect an injury to the distal femoral or proximal tibial
epiphyseal plate, as well trauma to the medial joint structures. The athlete who has
sustained a forceful hyperextension of the wrist might cause the athletic trainer to suspect
a Colles' fracture, a dislocated lunate, or an injury to the distal radial epiphyseal plate in
the adolescent. Further clinical evaluation will, of course, be necessary in order to
substantiate the athletic trainer's initial suspicions.
A third assumption underlying an effective injury evaluation is the athletic trainer's
knowledge of common clinical signs and symptoms. In the event of injury, the athlete
consults the athletic trainer because of unusual or unpleasant sensations which he or she
has experienced. These sensations are referred to as symptoms.8 At times, symptoms
provide specific clues as to the injury involved. In other instances, symptoms may be
more ambiguous and somewhat less indicative of specific injuries. One of the athletic
trainer's initial challenges is to determine the athlete's chief complaint, especially in those
instances in which the mechanism of injury has not been observed. Establishing the chief
complaint involves a determination of the athlete's primary reasons for presenting himself
or herself for examination.8 Typically, an injured athlete's chief complaint will involve
pain, unusual sensations such as "numbness" or "tingling," or vague feelings expressed
by such statements as "My knee gave out" or "My shoulder slips out."
Once the athlete's chief complaint has been established, the athletic trainer should
proceed with a systematic attempt to identify any alterations in anatomical structure or
biomechanical, neurological, or physiological function which may have been produced
by injury. Clinical signs represent the objective evidence of these alterations as elicited
during a physical examination of the injured athlete.8 They include what the examiner
may see, feel, or hear.
The Clinical Evaluation
The clinical evaluation of an acute athletic injury should include the systematic use of
specific evaluation methods and techniques. The examination must be thorough and
should be conducted in a logical, sequential manner. While various approaches may be
taken, it is suggested that following a format including the four basic steps of (1) history,
(2) inspection, (3) palpation, and (4) functional testing helps to insure thoroughness of the
examination. This system is readily adaptable to a clinical evaluation of most types of
athletic injuries with which the athletic trainer will be confronted. Examination of
conditions presenting ambiguous symptoms may require the athletic trainer to exhaust all
basic evaluation procedures. In other instances, only a few selected procedures may be
necessary. Certain functional tests, for example, may not be necessary and, in fact, would
not be appropriate in the event of observable deformity associated with a fracture or
Obtaining a complete and accurate medical history is one of the most important and
useful methods of clinical examination. The history should represent a chronological
record of all factors which may help to explain the nature and severity of the athlete's
present injury. A complete medical history includes obtaining information in two major
categories: (1) past history and (2) history of the present injury.
Past history. Obtaining a past history represents the athletic trainer's initial attempt to
develop rationale for the athlete's chief complaint. The past history should include
information regarding (1) previous injury to the involved body part or related structures,
(2) previous surgery, and (3) pre-existing symptoms including specific characteristics,
anatomical location, date and type of onset, and duration. Aside from information
obtained from the athlete, the athletic trainer may, of course, have firsthand knowledge of
various aspect of the athlete's medical history. Accident reports, treatment and
rehabilitation records, medical and surgical reports, and personal communication with
attending physicians provide additional valuable sources of information. All information
collected should be synthesized in an attempt to determine factors which may have
contributed to the present injury. Several examples serve to illustrate the importance of an
accurate past history. Documentation of the nature and severity of previous joint injuries
may be helpful in differentiating between chronic ligamentous laxity and newly acquired
instability. Chronic inflammatory conditions or inherent muscular strength imbalances
may represent etiological factors which help to explain acute muscle or tendon injuries.
History of the present injury. Obtaining a history of the present injury involves a
gathering of facts relevant to the incident which produced the acute injury. Sources of
information include (1) personal observation of the trauma-producing incident, (2)
questioning of the injured athlete, and (3) questioning of other players or coaches who
may have witnessed the incident. The latter may be necessary if the athletic trainer did
not observe the trauma-producing incident or if the athlete is unconscious and unable to
communicate. A history of the present injury should involve collection of information in
four main areas including (1) the exact anatomical site of injury, (2) the activity engaged
in at the time of injury, (3) the mechanism of injury, and (4) evidence of unusual
sensations experienced by the athlete.
Determining the exact anatomical site of injury is, of course, part of determining the
athlete's chief complaint. It should be emphasized that it is not sufficient to accept, for
example, an athlete's explanation that, "My left knee hurts." The athlete should be asked
to pinpoint the specific areas of maximum tenderness. Asking the athlete to "point to" or
methodically feel for the specific area of greatest pain is often helpful (Figure 1).
Involvement of specific structures may, of course, need to be confirmed by subsequent
evaluation procedures. Determining the type of activity at the time of injury (blocking,
sliding into a base, etc.) and the exact mechanism of injury will often provide valuable
clues as to the pathology involved. The athlete should be asked to describe the activity
and the forces involved in his or her own words. It is often helpful to ask the athlete to
use the opposite uninvolved extremity to demonstrate any abnormal joint motions or
body movements that occurred at the time of injury. Usually, answers to open-ended
questions such as "How did you get hurt?" are more informative than are "yes" or "no"
answers to questions such as "Did you fall on your shoulder?" The last important aspect
of obtaining a history of the present injury involves questioning the athlete about any
unusual sensations that he or she may have experienced. Quite frequently, unusual
sensations can be readily associated with specific pathologies. An exclamation that, "I got
kicked in the calf' is often associated with a rupture of the Achilles tendon. Numbness
(anesthesia) or tingling (paresthesia) of the little finger and ulnar one-half of the ring
finger indicates ulnar nerve involvement. "Popping" or "snapping" sensations are
sometimes associated with tendon ruptures or fractures. Pain is a sensation that should be
assessed in some detail. Determination of what provokes the pain can be assessed by
questions such as, "What makes the pain worse?" and "What makes it better?" A question
such as "What does it feel like?" can help determine the quality of pain. Severity can be
determined by asking, "On a scale of one to five, how bad is it?" Radiation of pain can be
assessed by asking a question such as, "Does it hurt anyplace else?" Finally, questions
such as, "When did it start?" or "How long has it lasted?" are used to assess the time
Inspection involves (1) observation of the involved body part and (2) visual inspection
for generalized clinical signs. Swelling, deformity and discoloration (redness ecchymosis,
etc.) are localized signs that can be observed. General conditions that should be observed
during a clinical evaluation of musculoskeletal injuries include the athlete's posture, gait,
and body movements. Facial expressions often provide clues to the severity of pain, or
anxiety as in the case of the patellar and glenohumeral "apprehension" tests.4 Bilateral
observation of specific anatomical areas should be made whenever possible. During an
examination of the shoulder girdle, for example, the athletic trainer should visually
compare the involved sternoclavicular joint with the uninvolved sternoclavicular joint on
the opposite side. The clavicles, acromioclavicular joints, and the glenohumeral joints can
then be compared sequentially in an attempt to identify differences in anatomical
contours that may be due to injury
Palpation is a third important step in the clinical evaluation of the injured athlete. Careful
palpation can be a valuable supplement to visual inspection for swelling, deformity, or
other irregularities in anatomical contours. When examining for these particular signs, it
is often helpful to palpate the opposite uninvolved body part as well in an attempt to
identify pathologically significance differences. One of the most valuable uses of
palpation is the identification of localized pain and pain tenderness. The athlete's reaction
to a progressive increase in digital pressure provides a clue as to the quality of pain and
often helps to identify lesions of specific ligaments, muscles, tendons, or bony structures.
In addition, certain classical signs such as "snowball" crepitation can be identified by
palpation. Circulatory disturbances can be assessed by palpating the pulse for rate,
strength, and rhythm.
Bilateral visual comparison of the clavicles and their articulations
As in the case with other evaluation procedures, palpation should be done in a thorough,
systematic manner. Thoroughness of the examination is enhanced by a sound knowledge
of anatomy which allows the athletic trainer to "visualize" the structures to be palpated.
Evaluation of joint injuries, for example, necessitates an appreciation of the proximal and
distal attachments of ligaments in order that they may be palpated in their entirety.
Flexibility in the sequence of palpation is permitted as long as thoroughness is insured.
The athletic trainer may begin with palpation of bony structures and proceed to palpation
of soft tissues including ligaments and capsular structures, muscles, and tendons. In other
instances, palpation may proceed from medial to lateral, or from proximal to distal
anatomical areas. During a shoulder examination, for example, palpation may begin with
the sternoclavicular joint and progress laterally to the clavicle and acromioclavicular joint
(Figure 1). In any case, the athletic trainer should identify and palpate all "key"
anatomical areas which may conceivably be involved. An understanding of injury
pathology is, of course, important in this respect. The sequence of ligamentous palpation
in a suspected inversion ankle sprain, for example, may begin with the commonly
involved anterior talofibular ligament and progress posteriorly to palpation of the
calcaneofibular and posterior talofibular ligaments. It should be remembered, however,
that certain types of fractures are classically associated with the inversion mechanism.
Consequently, the athletic trainer should palpate the tip of the lateral malleolus for point
tenderness associated with a possible avulsion fracture and the medial malleolus for
evidence of a "push-off" fracture.7 In some instances, it may be advisable to begin
palpation in an uninvolved area in an attempt to alleviate the anxiety of a particularly
Functional testing involves the use of several types of examination procedures designed
to assess the degree to which an injured body part is capable of functioning in a normal
manner. Functional tests include (1) range-of-motion tests, (2) clinical laxity (stress)
tests, and (3) neurological tests. It is generally recommended that functional testing be
done only after the medical history, inspection, and palpation have been completed.
Range-of-motion tests. Range-of-motion tests are used to evaluate joint function. The
athletic trainer should attempt to determine both the degree of restriction in joint motion
and the possible cause(s) of limited joint mobility. Assessment of the degree of restriction
in joint motion is dependent on a comparison with an established baseline. Several charts
illustrating "typical" ranges-of-motion in each major joint appear in the literature.
Possible exceptions to these ranges because of the effects of athletic activity and
individual differences due to sex or congenital factors must be recognized. Assessment of
joint mobility in an uninvolved counterpart can provide a baseline for comparison. While
goniometric measurements may be taken, the athletic trainer can often conduct a
meaningful assessment through a bilateral visual comparison of joint movements (Figure
2). Unless contraindicated, all motions which are normally possible in a particular joint
should be assessed.
Bilateral visual comparison of elbow joint mobility
Impairment of joint motion may be due either to intraarticular abnormalities within the
joint capsule or to periarticular conditions involving the soft tissue around the joint. The
use of both active and passive range-of-motion tests are necessary to assess the
etiological factors in decreased joint mobility. An athlete with an acute knee injury, for
example, may be unable or unwilling to fully extend the knee actively because of a
hemarthrosis, pain, muscle spasm, or a number of other reasons. Should the athletic
trainer experience a "springy block" during passive extension of the knee, however, an
intraarticular lesion involving a torn and displaced meniscus may be indicated.3
Essentially, active range-of-motion tests are used to assess contractile tissues and related
structures including muscles and tendons while passive movements are used to evaluate
noncontractile structures such as bones, ligaments, joint capsules.3 It is suggested that
active range-of-motion be assessed first. Active motion permits the athlete to remain in
control and thus stop or restrict a movement should pain be experienced at any particular
point in the range of motion. Pain elicited during an active range-of-motion may, of
course, be an important clinical finding.
Clinical laxity (stress) tests. While range-of-motion tests are used to assess restrictions
in joint mobility, stress testing' is used to check for joint instability due to ligamentous or
capsular trauma. During stress testing, the joint should be positioned so that the particular
structures being tested are taut. Positioning should also allow for maximum relaxation of
those joint structures not being tested during a particular maneuver. As a basic principle,
the bony segment immediately proximal to the joint is stabilized. Force is then applied by
manual pressure exerted on the body segment distal to the joint and in a line parallel to
the length of the taut ligament. These procedures allow for maximum "isolation" of joint
structures. Consequently, the validity of stress testing is greatly enhanced. Should the
athletic trainer experience a "soft" or "mushy" end point rather than a "hard" end point, a
positive stress test is implied. A grade II or grade m injury may be indicated. Pain during
stress testing without instability may indicate a grade I, or mild ligamentous involvement.
Figure 3 illustrates the basic principles of stress testing as applied to an evaluation of the
anterior talofibular ligament in the ankle. The anterior talofibular ligament is placed in a
position of maximum tension by positioning the foot in plantar flexion. Studies indicate
that the anterior talofibular ligament is taut in plantar flexion while the calcaneofibular
ligament is comparatively relaxed.5 The distal tibia and fibula are stabilized while force is
applied on the dorsal aspect of the foot below the joint line in the direction of inversion
and plantar flexion. As is the case in most stress testing, these maneuvers represent an
attempt to recreate the forces most commonly associated with the suspected injury.
Stress testing for instability of the anterior talofibular ligament
Neurological tests. Inherent in an understanding of injury pathology is the realization that
certain injuries of the spine and extremities may involve neurological complications.
Unstable fractures or dislocations of the vertebrae with associated spinal cord trauma
serve as unfortunate examples. In the extremities, peripheral nerve injuries involving
sensory or motor loss are often associated with specific types of soft tissue or bony
trauma. Involvement of the median nerve, for example, should be suspected in wrist
injuries involving the carpal tunnel or in an elbow injury involving a supracondylar
fracture of the humerus. Posterior elbow dislocations or contusions to the medial aspect
of the elbow may involve the ulnar nerve. Radial nerve involvement may be associated
with a fracture of the shaft of the humerus. The possibility of these types of nerve injuries
necessitates that the athletic trainer be able to conduct a basic neurological examination
in an attempt to recognize the presence of neurological complications. The clinical
neurological examination includes (1) sensation tests, (2) motor tests, and (3) reflex
testingSensation tests. Sensation testing involves the application of an appropriate
stimulus to specific areas of the skin innervated by particular sensory nerves. Numerous
charts illustrating the cutaneous distribution of sensory nerves can be found in the
literature.4,6 The athletic trainer should be familiar with the most likely areas of sensory
loss associated with specified peripheral nerve and nerve root trauma. These areas should
be tested for light touch and pain sensation.8 Because the loss of sensation is usually
relative, the degree to which the individual perceives a stimulus should be evaluated. This
can be accomplished by noting the athlete's reaction to a stimulus which is applied with
gradually increased intensity. A fluffed cotton ball is used to test light touch. Sensitivity
to touch is evaluated by the athlete's verbal response as the tactile stimulus is perceived.
Pain sensation may be tested with the head and sharp-end of a pin by noting the
appropriateness of the athlete's "dull" or "sharp" verbal responses (Figure 4). Abnormal
sensations which may be elicited during sensory testing include hypoesthesia (decreased
tactile sensation), hyperesthesia (excessive tactile sensitivity), or anesthesia (complete
loss of sensation).8 Other unusual neurological sensations which may be described by the
athlete include paresthesia characterized by numbness, tingling, burning, or formication
(sensation of insects crawling on the skin). Percussion of a peripheral nerve (e.g., ulnar
nerve at the medial elbow) producing a tingling sensation in the distal end of the limb
indicates a positive Tinel's sign and a possible nerve lesion.4
Examination for pain sensation in ulnar nerve distribution
Motor tests. Testing for the integrity of motor nerves involves the use of manual muscle
testing for strength loss. Paralysis (complete loss of motor function) or paresis (partial
paralysis or weakness) may be found.8 Complete loss of motor function is rarely
associated with the types of injuries most commonly seen in athletes. A peroneal nerve
lesion with resulting "foot drop" would illustrate complete paralysis only if the
dorsiflexors of the ankle are unable to demonstrate any degree of muscular contraction.
Inability to dorsiflex the ankle against gravity but with retention of the ability to perform
dorsiflexion with gravity eliminated would indicate partial rather than complete
Muscle testing is based on the examiner's subjective evaluation of strength according to
grading scales developed by Lovett, Lowman, Kendall, and others.2,6 Strength levels are
assessed as a muscle or muscle group is required to contract without resistance or against
varying levels of resistance provided by gravity and/or manual pressure. A muscle that is
capable of moving a body segment through a full range-of-joint motion against
"maximum" resistance would be given a grade of "normal" or "good". A "poor" grade
indicates movement with gravity eliminated.2 Preliminary testing of an opposite
uninvolved extremity is helpful in establishing a baseline for comparison. Validity and
reliability in muscle testing necessitates a working knowledge of muscle innervation and
strict adherence to principles of segmental fixation, muscle isolation, and manual
resistance (Figure 5). The relationship of strength to age and sex must also be considered.
The reader is referred to the writings of Kendall, et al.6 and Daniels and Worthingham2
for a more detailed discussion of the principles and techniques of muscle testing.
Reflex testing. The integrity of sensory and motor nerve fibers can be evaluated by
testing muscle stretch reflexes. Assuming spinal reflex integrity, a brief muscle stretch
provides a stimulus to stretch receptors in the muscle which, in turn, transmit afferent
impulses to the spinal cord via sensory fibers. Efferent impulses transmitted from the
spinal cord to the muscle via motor fibers produce a brief contraction, the stretch reflex.8
Clinically, a stretch reflex is initiated in the muscle being tested by a tap on its tendon
with a reflex hammer. The extremity to be tested is placed in a relaxed position but with
slight tension in the muscle. Prior and Silberstein8 suggest that the examiner place his
finger on the tendon and tap the finger, thus permitting better assessment of muscular
tension, the strength of the tap, and the quality of reflex action. The reflex action should
be noted as being normal, increased, decreased, or absent. Abnormal responses include
hyporeflexia (diminished reflex) which may be associated with lower motor neuron
lesions and hyperreflexia (exaggerated reflex) indicating an upper motor neuron
involvement.1,3 Most commonly tested reflexes include the biceps, brachioradialis,
triceps, quadriceps, and gastrocnemius-soleus.
Manual muscle test for strength of the triceps
The athletic trainer's contributions to the health care of the competitive athlete are. widely
recognized. None is more important than early recognition of the nature and severity of
athletic injuries. Through the systematic use of history, inspection, palpation, and
functional testing, the athletic trainer develops an "impression" regarding the injury
which provides the basis for proper first aid and emergency care and appropriate medical
referral. Through academic preparation and clinical experience, the athletic trainer may
become quite adept at recognition of athletic injuries. From a medicolegal viewpoint,
however, a clear distinction must be made between recognition of an injury and a
diagnosis. The term "recognition" is defined as "the perception of something" and has no
medical connotation.9 A "diagnosis" involves not only "the process of determining by
examination the nature. . .of a diseased condition," but also "the decision reached from
such an examination."9 While the athletic trainer develops certain "perceptions" based on
his or her clinical evaluation of an injury and acts accordingly with respect to initial
management and medical referral, the "diagnosis" or decision regarding the specific
nature of the injury remains solely within the domain of the physician. The athletic
trainer must be acutely aware of this distinction and must refrain from actions or words
that would in any way imply that he or she has made a diagnosis.
View Slide Show
1. Barber, Janet M. and Budassi, Susan A. Manual of Emergency Care. St. Louis: The
C.V. Mosby Co., 1979.
2. Daniels, Lucille and Worthingham, Catherine. Muscle Testing, 4th Ed., Philadelphia:
W.B. Saunders Co., 1980.
3. Davies, George J. and Larson, Robert. "Examining the Knee," The Physician and
Sports Medicine, 49-67, April, 1978.
4. Hoppenfeld, Stanley. Physical Examination of the Spine and Extremities. New York:
5. Inman, Verne T., (Ed.) DuVries' Surgery of the~Foot", 3rd Ed., St. Louis: The C.V.
Mosby Co., 1973.
6. Kendall, Henry O., Kendall, Florence P., and Wadsworth, Gladys E. Muscles: Testing
and Function, 2nd Ed., Baltimore: The Williams and Wilkins Co., 1971.
7. O'Donoghue, Don H. Treatment of Injuries to Athletes, 3rd Ed., Philadelphia: W.B.
Saunders Co., 1976.
8. Prior, John A. and Silberstein, Jack S. Physical Diagnosis: The History and
Examination of the Patient, 4th Ed., St. Louis: The C.V. Mosby Co., 1973.
9. The American College Dictionary. New York: Random House, Inc., 1962.