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Injury Assessment Handout

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  • 1. 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
  • 2. 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 dislocation. History 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,
  • 3. 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
  • 4. 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 factor. Inspection 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 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.
  • 5. FIGURE 1 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 apprehensive athlete. Functional Tests 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.
  • 6. 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. FIGURE 2 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
  • 7. 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. FIGURE 3 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
  • 8. 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 FIGURE 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 paralysis. 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
  • 9. 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. FIGURE 5 Manual muscle test for strength of the triceps Summary 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
  • 10. 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 References 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: Appleton-Century-Crofts, 1976. 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. GD:ps/Z3