MSK Injury Evaluation Notes
Equipment removal context and secondary survey Overview
Emphasis on knowing what athletes are wearing and the variability between teams and even within a team (e.g., multiple helmet styles).
Rigid cervical stabilization device should be applied prior to transport in suspected cervical injury scenarios; recognition that EMTs have been moving away from rigid immobilization in some cases, so stay updated with evolving guidelines.
The content here is not about memorization but about familiarity with equipment, evaluation steps, and current practices; quizzes may focus on the PowerPoint material discussed.
Secondary survey / off-field evaluation framework
After the primary survey, proceed to the secondary survey to evaluate musculoskeletal and medical status off the field.
PPE (physical examination) serves as the baseline evaluation of the patient.
Progress evaluation involves daily check-ins to determine changes after transport to a quieter environment away from crowd noise and distractions.
Goals of the secondary survey:
Be reproducible: perform a consistent exam each time.
Be comprehensive: cover history, inspections, palpation, and tests to confirm the injury.
Overall flow: History → Observation/Inspection → Palpation → Special tests → ROM/flexibility → Neurological checks and functional assessment.
HOPS: History, Observation, Palpation, Special Tests (and rationale)
HOPS is the common musculoskeletal evaluation acronym; alternatives include HIPS.
The history (H) is the most important part of the assessment because it guides the rest of the exam.
A solid history helps you shape the bedside tests and palpation targets to confirm or rule out injuries.
History (H) – key goals and questions
Start with open-ended questions, e.g., “What happened?” to elicit the athlete’s narrative about the mechanism and positioning.
Determine acute vs. chronic: ask if one event caused worsening or if there has been a gradual decline.
Example framing: “Did one thing happen and then get worse, or has it progressively worsened over time?”
Pain description helps infer structure involved:
Sharp, stabbing: may indicate acute events or bone fracture; one specific area can also suggest a localized tissue involvement (e.g., a single muscle strain).
Shooting or tingling: often nerve-related or referred pain.
Dull ache: more associated with chronic injuries or stress reactions.
Pain level: ask the 0–10 scale, but interpret with caution due to individual pain experience and prior history.
Pain level example: $P \in [0,10]$, where 0 = no pain and 10 = maximum tolerated pain or emergency-level pain.
Pain timing and variation:
Is pain worse with activity or at rest?
Is it worse after practice or at a certain time of day?
Any radiation of pain to adjacent regions?
Past medical and medication history:
Other chronic conditions, current medications (Some meds may mask pain or predispose to injuries).
Important to assess if medications are masking symptoms (e.g., NSAID use may reduce perceived pain).
Mediation of how you phrase questions:
Favor open-ended questions to elicit the athlete’s story and avoid biased answers.
Maintain calm, supportive demeanor; your posture and reactions affect the athlete’s comfort and honesty.
History: sample prompts and considerations
“What happened?” to capture the activation and positions involved (e.g., knee or ankle angles, weight-bearing status).
If injury is observed rather than reported, questions about onset timing and mechanism still help refine the diagnosis.
Distinguish acute versus chronic as this changes management plans (acute vs chronic pain descriptors, duration questions).
Include a brief questions on prior injuries to gauge tendencies (e.g., previous ACL injury or ankle sprains) and any repeat injury history.
Consider medical and medication history and potential drug masking of symptoms.
Open-ended vs closed-ended questioning
Open-ended questions are preferred to help the athlete tell their story (e.g., describe the pain, where it hurts, and how it behaves).
Use selective closed-ended questions to fill gaps (e.g., whether pain is present at rest or with specific movements).
The examiner’s demeanor and communication style influence athlete honesty and comfort.
Observation / Inspection (O)
Generally non-contact at this stage; you visually assess the patient first and bilaterally for comparison.
Bilateral comparison is critical to identify asymmetries.
Look for:
Deformities or obvious dislocations: e.g., patellar dislocation, joint misalignment.
Gait deviations, limping, or unwillingness to bear weight.
Protective postures (guarding, sustaining a limb, refusing to move a part).
Swelling and ecchymosis (bruising): post-traumatic swelling or hematoma patterns.
Redness indicating inflammation or infection.
Posture and alignment; indicators of chronic issues (slumped posture) or predisposition to injury.
Muscle atrophy or hypertrophy; asymmetry can reflect prior injuries or disuse.
Notable examples from the session:
Visible patellar issue (dislocation) in an image example.
Ecchymosis patterns that may extend distally due to gravity after an initial injury.
Murphy’s sign illustrated as an example of lunate dislocation in the wrist.
Practical note: always perform bilateral observation to identify subtle differences and baseline variations.
Palpation consent: ask for consent before palpating if you are not in a long-standing team context.
Palpation (P)
Palpation is performed after history and observation when appropriate; it requires consent and clear communication.
Palpation approach (BLT order): Bones → Ligaments → Tendons
Starting away from the injury helps reduce the athlete’s anxiety and protects against unnecessary pain.
If the injury is known to be on the right side, you may start palpation on the left to avoid bias or to gain a baseline feel.
Assess bilaterally to detect asymmetries.
Start with proximal structures and move toward the injury; adjust based on the suspected region and patient response.
Build trust by describing the level of pressure you will apply and demonstrating the amount of pressure before pressing on the injury.
Probing approach:
Identify landmarks: bones first (e.g., lateral malleolus, navicular), then underlying ligaments and tendons for localization.
For joints like the knee, palpate around the patella, tibial tuberosity, and collateral ligaments, noting tenderness, warmth, and deformity.
Use bidirectional palpation when necessary (e.g., palpate both fibulae to compare).
Note crepitus (crepitus is a crackling/grating sensation) which may indicate fracture or joint pathology.
Recognize scar tissue and post-injury changes.
Special cautions:
Only start palpation away from the injury to minimize pain and protect the athlete’s cooperation and comfort.
Some cases need palpation to determine if movement of a structure (e.g., ligament or tendon) reproduces pain, guiding diagnosis.
Practical notes on palpation technique:
BALANCE between sufficient pressure to elicit tenderness and avoiding excessive pain that may obscure assessment.
Proximal-to-distal versus distal-to-proximal approach may vary by injury region (e.g., distal-to-proximal for ankle or tarsal injuries).
If a suspected injury is local (e.g., suspected patellar fracture), begin palpation away from the area and move toward it to limit guarding.
AYE: In the BLT order, bones help establish landmarks which can simplify subsequent ligament/tendon assessment; this strategy improves accuracy of the palpation exam.
Special tests (ST) and functional assessment
Special tests are used to further rule in or rule out specific pathologies (e.g., ligament sprains, stability issues).
They typically involve stretching a structure beyond its normal range to provoke a test-specific response.
They complement ROM and flexibility assessments rather than replace them.
When performing any special test:
Compare bilaterally to establish normal vs injured motion.
Use a systematic sequence to maintain consistency and reproducibility.
Contextual cue: a video example demonstrates a test related to rehab and neurological connection checks; the key principle is bilateral comparison and controlled motion.
Range of motion (ROM), flexibility, and neurological checks
ROM and flexibility assessment is an important part of evaluating function and injury severity.
Practical approach: observe and quantify motion, often using simple cues or tools (e.g., a shirt with lines to gauge range visually); compare sides to identify deficits.
Neurological checks include assessment of distal sensation and vascular status (e.g., radial pulse, distal distribution of sensation).
The goal is to ensure intact neurovascular status and to identify any deficits that could alter treatment decisions.
Re-evaluation and environmental considerations
Reproducibility and standardization of the evaluation are emphasized so that future assessments yield comparable results.
Re-evaluate daily to monitor progression or improvement after injury and transfer to a quieter environment away from crowds.
Environment management is important to reduce anxiety and improve the reliability of the assessment.
Always document and compare with prior assessments and baseline findings to inform treatment and transport decisions.
Practical implications and professionalism
Ethical considerations: obtain consent for palpation; respect patient comfort; provide clear explanations of procedures.
Professional demeanor matters: stay calm, communicate clearly, and avoid causing additional fear or panic in the athlete.
Real-world relevance: recognizing the evolving standards in immobilization and transport; staying informed on current best practices is essential for safe management.
Quick reference summary (core takeaways)
Primary vs. secondary survey distinction: after ABCs, perform secondary survey for a comprehensive MSK evaluation.
History is foundational: use open-ended prompts; differentiate acute vs. chronic pain; capture pain quality, location, and progression.
Observation is powerful: bilateral comparison, gait, willingness to move, swelling, ecchymosis, posture, and signs like distraction or guarding.
Palpation requires consent and a methodical BLT approach, starting away from the injury and building from bones to ligaments to tendons; check for tenderness, crepitus, and tissue quality.
Special tests and ROM checks provide diagnostic specificity and should be performed with bilateral comparison and standardized procedures.
Re-evaluate regularly and control the environment to maintain reliable assessments.
Practical notes: be mindful of evolving immobilization guidelines and incorporate evidence-based practice as guidelines change.