Eval of Injury Unit 1 Injury Evaluation

Examination

To inspect, to test the condition, or to investigate

Assessment

A procedure where the clinician determines the severity, irritability, nature, and state (SINS) of an injury based on the examination findings

• Has steps

Evaluation

A systematic process that allows the clinicians to make a clinical judgement based on examination findings

Diagnosis

Use of clinical/scientific methods to establish cause and nature of patient’s illness, injury, or/and subsequent functional impairment due to pathology

Subsequent functional impairment

Limitation or loss of an individuals ability to perform tasks or activities necessary for everyday life

Physical diagnosis

Diagnosis by external examination only

Physical diagnosis example

• Shoulder pain

• Used for broader grouping

Medical diagnosis

Specific structure, injury, and severity. Usually needs proper testing (MRI, etc)

Direct Access

Patients can go straight to a specialist without the need of referral from their primary physician

SINS of an injury

Severity

Irritability

Nature

Stage

Severity of an injury

Determines whether to refer the patient to a physician or other medical specialist

Major questions to ask when evaluating

1) Are they going to die or are they dying

2) Is there a risk of permanent disability (neck injury, lack of blood flow, etc)

3) No? Continue to evaluate

Irritability of an injury

Determines how tolerant the patient will be to examination

• Depends on pain intensity and how disabling the injury is

Do people have different pain tolerance?

Yes, some may need a bandaid for a fracture, others may need a wheelchair for a papercut

Nature of an injury

Classification of injury

Stage of an injury

Acute vs Subacute vs Chronic

What makes diagnosising a chronic injury “hard”

Difficulty with understanding the orgin, mechanism, and irritability of the injury

4 components of examination

Hops

Observation

Palpation

Special tests

History of examination

Obtaining information about the severity, irritability, nature, and stage of injury

How do you obtain history of an injury

Through observations, interviewing with a patient, and reveiwng medical records

General history questions

1. What was the mechanism of injury?

2. Can you describe the pain you are having?

3. Does any activity make it worse?

4. Previous history of an injury?

5. Change in training level, intensity, volume?

6. Change in daily activities?

4 aspects of pain

Type

Location

Intensity

Time

Type of pain

Sharp, achy, dull, sore, etc

• Pain type may help identify the type of injured structure

Pain discription for muscles

Cramping, dull, aching pain

Pain discription for ligaments, joint capsules

Dull, aching pain

Pain discription for nerve root

Sharp, shooting pain

Pain discription for nerve

Sharp bright, lightening-like pain

Pain discription for sympathetic nerve

Burning, pressure-like, stinging, aching pain

Pain discription for bone

Deep, nagging, dull pain

Pain discription for fracture

Sharp, severe, intolerable pain

Pain discription for vasculature

Throbbing, diffuse pain

Location of pain

Pain location helps to narrow down the injured strucuture

Localized pain

Experienced at the site of the injury

Referred pain

Experienced at a site away from the injury

• Lateral arm pain experienced with subacromial impingement

  • Tendons of the rotator cuff (shoulder) are pinched when arm is raised, (arm also hurts tho)

Severity of pain

Helps to iddentify the inury severity

• “On a scale of 1-10…”

Time course of pain

Pain duration and time course helps differentiate chronic vs acute injuries and identify stage of an injury

Time course pain questions

1. Was it an acute or gradual onset?

2. When does it hurt the most?

3. Is it getting better or worst? (walking, running, sitting, etc)

Acute pain

Most painful at the start, immediate change and the mechanism is known

• Can be a couple months ago (broken wrist)

Chronic pain

Strong to fade but still hurt after a period of time

• Mechanism of injury isnt always clear

Observations of examination

Visual ques

• asymmetries, postual mal-alignments or deformities?

• How does the patient move? Is there a limp?

• Swelling, redness, or discoloration?

• Facial expressions, signs of discomfort?

When is Palpation introduced

After an assumption has been gathered from the information gathered

What structures can you palpate

Bony and soft tissue

What can palpating help identify

• Swelling

• Pain with palpation

• Spasms

• Deformity

• Temperature

• Abnormal skin sensations

Abnormal skin sensations: Dysesthesia

Diminished sensation

Abnormal skin sensations: Anesthesia

Numbness

Abnormal skin sensations: Hyperethesia

Increased sensation

What is the purpose of palpating?

To localize the injury, find the issue, know and find the structure

Why is it important to learn the mechanism of injury before palpating

The mechanism will inform you of where to palpate

Why and what are Special tests for?

They help you focus on the tissue, and used once you know what tissue (tendon, ligament, muscles) is involved

Examples of Special tests

• Movement assessment (range of motion)

• Manual muscle testing (strength)

• Neurologic/circulation assessment

• Injury or joint specific special tests

• Functionsl performance testing

Why are special tests performed?

Want to mirror the mechanism on the tissue to know you’re in the right spot

Bilateral comparison

When you compare the injured side of the body with the other non-injured side

Purpose of a bilateral comparison

To get the “baseline” of that area

• comaping natural ROM to ROM of injured area

• normal level on sensation or irritability

Why can’t you always use bilateral compairson?

Not everything is equal

• Different ROM

• Different muscle mass

Radiograph uses

Uses x-ray to visualize bone

Radiography is best used to see

Bone lesions

Joint surfaces

Joint spaces

• Hard tissue specific

• 2D one view

Computed tomography (CT scan) uses

Penetrates the body with thin, fan-shaped x-ray beams

What does a CT scan produce?

Produces cross sectional (3D) views of tissues

A CT scan is best used for

Rapid imaging to see bony or articular cartilage lesions

Soft tissue lesions

DEXA scan uses

Dual Energy X-ray Absorptiometry

DEXA scan is best used for

Used to measure bone mineral density and subtle bone density changes over time, as well as body compostion

• less expensive option

Bone Scans use

Involves intravenous introduction of a radioactive tracer which attaches to osetoblasts

What are bone scans used for?

Used to identify increased metabolic activity

To image bony lesions (stress fractures) where inflammation is present

Why use bone scans to view a stress fracture instead of an X-ray?

A bone scan can catch a stress fracture in its early stage while an X-ray can not

Positron Emission Tomography (PET scan) uses

Uses an injection of a radioactive tracer chemical to produce 3D images

What does a PET scan do?

Can help distinguish between living and dead tissue or between benign and malignant tissue

• blood flow to see healthy and unhealthy tissue

Magnetic resonance imaging (MRI) uses

Uses a powerful elctromagnet

MRI is best used for

Best for ligament tears or meniscal injuries

• very expensive

• Soft tissues

• very accurate

MRI Arthography uses

Uses an injection of contrast agent into the joint space before the MRI to highlight certain areas

Ultrasonography allows for

Allows imaging and evaluation of soft tissue structures by measuring reflection/transmission of high frequency ultrasound waves

• non invasive and not painful

Ultrasonography is best used for

Best used for Tendon and other superficial soft tissue

Arthroscopy uses

Uses fiber-optic arthroscope to assess joint integrity and damage

What comes with an Arthroscopy

Has an increased risk of infection and is very invasive

Synovial fluid analysis is used to

Used to detect presence of infection in the joint

• To confirm diagnosis of gout

• Differentiates between inflammatory and non-inflammatory conditions

Fluid injected into the joint space

What does a test have to be in order to be useful

It must have a high reliability (consistant) and validity (accurate)

A good example of a reliable test

A weight scale is a good reliable test because it’s most likely to give you the same number each time regardless if its correct

A decent example of validity and its factors

An oura ring reading your body temperature and having to calibrate based on the environmental conditions

Reliability of clinical exams/diagnositics

• Does the patient perform the same way each time?

• Does the test produce the same outcome each time?

• Does the test produce the same outcome when performed by someone else?

Validity of clinical exams/diagnositics

Ability of the test to correlate with an established assessment

• Validating a positive Lachman’s test with an MRI scan confirming an ACL tear

True positive