The Injury Examination Process

What governs function?

Structure

What does structure refer to?

Anatomy

What does function refer to?

Physiology and biomechanics

What does the examination process consider?

Considers findings of dysfunctional anatomy, physiology, or biomechanics with the unique circumstances of an individual and correlates those findings to disruption in the patient’s function

What should be repeated at every phase of recovery to determine triage?

The examination process

What should the AT do if a patients’ disposition is not clear?

Referring the patient elsewhere

What are some examples of reasons to refer a patient?

• fractures (ortho)

• Illness (urgent care)

• Tears/ruptures (physician)

What is a DD?

The differential diagnosis includes all the possible diagnoses that have not been excluded by the examination findings

When are DDs needed?

When you are not able to settle on one pathology after an evaluation

A ____ and ____ evaluation is critical and should be efficient, accurate, and consistent.

A systematic and methodical evaluation

What should a comprehensive examination include?

• The justifiable inclusion or exclusion of each step

• Adaptability to the specific needs to the situation

• The ability to rule in or rule out the possible differential diagnosis

Why do we gather data?

To organize, interpret, and monitor patients’ progress and develop treatment priorities

Why is documentation critical?

Documentation is critical to ensure that the medical record can be utilized as a method to communicate the patients’ medical disposition to anyone who reads the medical record

What do ATs use for documentation?

SOAP notes

Subjective - history, patient telling us

Objective - what AT finds, observations (special tests)

Assessment - of injury

Plan - referrals, recommendations

How is the examination model divided?

• Divided into components

• Components are presented sequentially

What is the goal for the examination model?

• Obtain a clinical diagnosis and have sufficient information to plan treatment

• Do not only consider the injured body part but the whole person (ICF)

What does the ICF do?

• Focusing on the patient holistically which includes their pathology and how the injury or illness impacts their ability to function on a personal societal level

• How does the health condition impact contextual factors

Why should we also consider the kinetic chain?

• The lower body is linked to the core and upper body in ways often under appreciated

• The impairment in one body region may contribute to complaints identified in other regions

What is the uninsured paired structure?

Opposite body part if ideal for comparison, it provides an immediate reference point

How is the uninjured side useful?

Patient can demonstrate the mechanism of injury (MOI) with the uninjured side, you can palpate for normal shape and tissue density on the uninjured side, perform special tests on the uninjured side to feel normal integrity of a capsule, muscle, or ligament

Why might the uninjured side may not be beneficial when testing first?

• Muscle guarding

• Fear of pain

What are the evaluation/assessment types?

• Acute evaluation

• Clinical evaluation

What is an acute evaluation?

Quick, to the point

What is clinical evaluation?

Thorough, longer

What is the most important thing before you begin palpating to examining someone?

Asking for consent

What are some considerations for discretion?

• Body area - pelvic or chest

• Sex of patient and clinician

• Religious considerations

What are each of the 12 step components to an evaluation?

1. History (past medical Hx and Hx of present condition)

2. Functional assessment (general)

3. Inspection/observation

4. Palpation

5. Joint and muscle function - AROM, MMT, RROM, PROM

6. Joint stability tests - stress test and joint play

7. Selective tissue tests

8. Neurological tests

9. Vascular screening

10. Clinical impression/differential diagnosis

11. Functional assessment (specific) to determine return to play (RTP)

12. Referral

What is the most important component and can be re-visited throughout the evaluation?

History

What does a history involve?

• Active listening

• Asking relevant questions

• Taking notes

What are open ended questions useful for?

Open ended questions provide most information and best used for clinical evaluation

What are yes/no useful for?

Yes/no questions may be necessary in acute evaluation, potentially catastrophic injury

What are the histories for different conditions?

• Acute conditions: MOI to understand forces

• Chronic conditions: changes in training routine, equipment, posture, etc.

What are some barriers to communicate?

• Cultural

• Language

• Psychological underpinnings

How do ATs show culturally competent care?

• Convey respect

• Language

• Verbal vs. non-verbal communication

• Narrative sequence

• Religious considerations

• Family considerations

• Use of complementary and alternative medicine

What is important to note for inspection?

• Skin assessment (coloration and discoloration)

• Skin conditions

What are some issues regarding physical contact?

• Religious considerations

• Gender considerations

What is another term to use for past medical history?

Non-acute examination

What should be used to gather baseline information from a past medical history?

Medical History form

What is normally given to patients in clinical “office” settings to learn information about the patient and the impact the injury may have on their life?

Questionnaires or outcome measures

What do these questionnaires and outcome measures include?

• Previous history

• General medical history

  • Pre-participation physical exams

• Relevant illness and lab work

• Medications

• Smoking

• Family medical history

What are the components to the history of present condition?

• MOI

• Relevant sounds or sensations at the time of injury

• Onset and duration

• Pain

• Other symptoms

• Treatment to date

• Affective trait

• Resulting activity limitations and participation restrictions

What does the MOI help with?

Helps us determine which structures are involved and the forces placed on those structures

What are the different traumas related to MOI?

• Macrotrauma

• Microtrauma

What is macrotrauma?

Single episode - acute (once)

What is microtrauma?

Accumulation of repeated forces - insidious (repetitive)

What sensations can be experienced?

• Tearing/pull - muscle tear

• Tingling

• Numbness

• Immediate pain or got worse later

• Soreness

• Give way (true versus physical sensation)

What sounds can be heard?

• Crack - bone fracture

• Pop - ligamentos injury (generally full tear)

What are different terms used to describe when the problem began?

• Acute onset

• Chronic onset

• Insidious

What is acute onset?

Signs and symptoms present themselves immediately (just the other day)

What is chronic onset?

Overuse syndrome - progressive worsening with time and continued stresses (weeks or since past season)

What is insidious?

Gradual onset with no apparent cause (came out of nowhere)

How do we define the location of the pain?

Patient points to where it hurts with one finger

What are pain types and referral patterns?

Pain at a different location than actual injury

What is radicular pain?

Injury to nerve or nerve root, pain radiates along nerves path

What are the types of pain?

Sharp, pins/needles, localized, aching, throbbing

What are daily pain patterns?

When is the pain worse versus better? AM/PM

What is provocation and alleviation of pain?

Position - which may impact your evaluation

What are some other symptoms with pain that should be considered?

Weakness, parenthesis (numbness/tingling), effusion, cold, heavy

What is treatment to date?

Self treatment or sought out treatment

What are affective traits?

• Are their any factors that would impede or exaggerate the desire to return?

• Underlying reasons - poor performance, financial gains, depression, emotional distress, fear avoidance

What is resulting activity limitation and participation?

• What is restricted?

• What is the patient unable to accomplish in their day to day or to meet their goals due to this injury?

What should we ask the patient to perform for us to perform a function assessment?

• Ask patient to perform functional tasks that were identified as problematic

• Consider any ADL’s (activities of daily living)

• Ask patient to walk

What should always be kept in the back of your mind when performing an assessment?

Always keep in the back of your mind how the described loss of function will impact the patients’ life (ICF)

When should the inspection/observation begin?

The inspection/observation begins immediately upon a patient walking towards you or you towards them

What is an AT looking at while a patient is walking towards them?

• Gait

• Posture

• Function

• Guarding

• Splinting

• Patients attitude

When we are comparing bilaterally, what are we looking for?

• Deformity

• Swelling

• Skin

• Infection

What is a deformity?

• Deviations can be subtle, gross, or somewhere in between

• Likely with deformity present we rule out other significant trauma, splint, and refer

What is swelling?

• Subtle or dramatic

• Acute joint effusion due to hemarthrosis will be more apparent

• Edema is not within the joint and could take longer to accumulate

• Could be evaluated with girth measurement or volumetric measurements

What is skin?

Redness, ecchymosis, open wounds scars, previous trauma

What is infection?

Redness, pus swelling, red streaks, warmth, swollen lymph nodes

Palpation is considered what?

An art and a skill

What dos palpation include?

• Locating a structure

• Coming aware of its characteristics

• Assessing its quality or condition so you can determine how to treat it

What does palpation require?

• Palpation requires thorough knowledge of functional anatomy and experience through hands-on practice

• Palpation requires receptive hands and fingers, open eyes, listening ears, calm breath, and a quiet mind to find the injury

What are palpation essentials?

• Making contact

• Work smart versus hard

• Less is more

• Rolling and strumming

• Movement and stillness

• Movement as a palpation tool

Work smart versus hard…

• Talk aloud

• Self-palpate to learn

• Practice palpation on various bodies

Work smart versus hard…

• Talk aloud

• Self-palpate to learn

• Practice palpation on various bodies

Less is more…

• Consider layer palpation, start lighter and add more pressure

• Be intentional

• Ask for feedback - you are palpating someone else

Rolling and strumming…

• Move along a muscle and across it

• Consider fiver direction

Movement and stillness…

• Find a structure first and then explore it

• Move your hands along and around, if a structure is moving it it move first

• Pay attention to what is attached to a structure

Movement as a palpation tool…

• Passive and active movement may be required by the clinician or patient, respectively

• Palpate while patient is performing an isometric contraction

What are the 3 palpation principles?

1. Move slow - rushing can interfere with sensation

2. Avoid using excessive pressure, less it more

3. Focus your awareness on what it is you are feeling, be present

What are all the structures we palpate?

• Skin

• Bone

• Muscles

• Tendon

• Ligaments

• Fascia

• Retinaculum

• Arteries and veins

• Bursa

• Nerves

• Lymph nodes

• Adipose tissue

What are the palpation findings?

PTSD CTC

P - point tenderness

T - trigger points

S - swelling

D - deformity

C - crepitus

T - tissue temperature

C - changes in tissue density

What are the bony aspects that can be palpated on the ankle & foot (dorsal)?

• Tibial plafond

• Talus

• Navicular

• Medial cuneiform

• Middle cuneiform

• Lateral cuneiform

• Base of the metatarsals

What are the soft tissue that we can palpate on the ankle and foot? (Medial aspect)

• Deltoid ligament

• Spring ligament (plantar calcaneonavicular)

• Tibialis posterior muscle tendon

• Flexor digitoum longus muscle tendon

• Flexor hallucination longus muscle tendon

• Tibial artery

• Tibial vein

• Tibial nerve

How do we assess joint and muscle function?

Range of motion and joint stability tests

What are the ways to assess range of motion?

• AROM

• MMT

• RROM

• PROM

What are the joint stability tests we can use to assess joint and muscle function?

• Stress testing

• Joint play

What do we aim to learn about what injuries can cause?

We aim to learn the functional changes an injury may have caused

What is important to assess with joint and muscle function?

We need to assess all available motions of the affected joint and the joint proximal and distal

What are some factors that influence ROM?

Age and gender

How is active range of motion performed?

Joint motion is produced by the patient

What does active range of motion assess?

The physiological motion and osteokinematics (bone motion)

What are some reasons that evaluating AROM first is not advised?

• Fracture

• Post-Sx

• Told by physician

What else does AROM determine?

The willingness and ability of patient to move the body part

What could an un-willingness of the patient to move the body part signify?

• Extreme pain

• Neurological deficit

• Malingering (faking)

What does osteokinematics describe?

Describes the motion of bones relative to the three cardinal planes

What are the three cardinal planes?

1. Sagittal plane

2. Frontal plane

3. Horizontal (transverse) plane

How does the sagittal plane dive the body?

Divides the body into right and left halves

What are the motions that can be performed in the sagittal plane?

Flexion/extension, dorsiflexion/plantarflexion