KAAP 619: Injury Evaluation Process

Clinical Assessment and Evaluation Environments

• Clinical assessments are bifurcated into two primary types based on the setting and urgency of the situation: Clinical (off-field) assessments and Acute (on-field) evaluations.

• Clinical (Off-Field) Evaluation Characteristics:

  • Relative Environment: Conducted in a relatively controlled environment, such as a sports medicine clinic or doctor's office.

  • Time: Generally slower-paced compared to acute settings, allowing for a more thorough investigation.

  • Evaluation Tools: Access to specialized diagnostic tools including tape measures, goniometers (for measuring joint angles), and other clinical equipment.

  • Record Access: Significantly easier access to the patient's comprehensive medical records and previous history.

• Special Considerations during Evaluation:

  • Discretion: Clinicians must maintain privacy and professionalism, especially when evaluating sensitive areas.

  • Pelvic and Chest Regions: Require heightened sensitivity, appropriate draping, and professional conduct.

  • Religious Considerations: Medical professionals must be mindful of religious beliefs that may impact the examination process or types of treatment accepted.

• Informed Consent:

  • Signed Written Statement: The gold standard for documenting that a patient has been informed of risks and has consented to treatment.

  • Verbal Consent: Obtained through spoken agreement before beginning specific physical tests.

  • Implied Consent: Applicable in emergency medical care situations where the patient is unconscious or unable to communicate, assuming they would want life-saving assistance.

Systematic Evaluation and the HOPS Method

• A systematic evaluation is essential for accuracy and must include two core parts: the justifiable inclusion/exclusion of each step and adaptability to the specific needs of the unique situation.

• The HOPS Method represents the standard structural framework for orthopedic injury assessment:

  • History ($Hx$): Gathering subjective data from the patient.

  • Observation: Visual inspection of the injury site and the patient as a whole.

  • Palpations: Physical touch to identify anatomical deviations, temperature changes, and point tenderness.

  • Special Tests: Clinical procedures (stress tests, ROM, neurological/vascular screens) used to confirm or rule out specific pathologies.

Present Medical History and Pain Assessment

• History is considered the most informative part of the examination. It identifies the Mechanism of Injury ($MOI$), underlying medical conditions, and differentiation between present and past medical histories.

• Present Medical History (MAPPSS Protocol):

  • Mechanism of Injury ($MOI$): How the injury occurred.

  • Acute or Chronic: Duration and onset of symptoms.

  • Pain: Characteristics and severity.

  • Palpation: Initial findings from touch.

  • Sounds: Snaps, pops, or cracks heard at the time of injury or during movement.

  • Signs/Symptoms: Visible or reported indicators of pathology.

• Pain Scales and Quantifying Pain:

  • Wong-Baker Faces Scale: Uses facial expressions to help patients quantify pain on a scale of $1$ to $10$.

  • Visual Analog Scale ($VAS$): A line onto which a patient marks their pain level.

  • Pain Categories:

    • Location: Specific site of the pain.

    • Type: Description of the sensation (e.g., sharp, dull, aching).

    • Referred Pain: Pain felt in a part of the body other than its actual source.

    • Radicular Pain: Pain radiating along the distribution of a spinal nerve root.

• Daily Pain Patterns and Tissue Behavior:

  • Tissue Creep: Pain that is worse in the morning but improves as the day progresses. This indicates the elongation of tissue beyond its intrinsic extensibility.

  • Muscle Fatigue: Pain that is better in the morning but worsens as the day progresses.

• The Descriptive Pain Scale ($0$ to $11$+):

  • $0$: No pain at all.

  • $1$: Unsure if experiencing pain, itching, or a bad taste in the mouth.

  • $2$: Probably just needs a Band-Aid.

  • $3$: Distressing; the patient does not want this to happen.

  • $4$: Pain is "not f_cking around."

  • $5$: Questioning why this is happening.

  • $6$: Pain is "super legit."

  • $7$: "I see Jesus coming for me and I'm scared."

  • $8$: Disturbing amount of pain; "I might actually be dying."

  • $9$: "I am almost definitely dying."

  • $10$: "I am actively being mauled by a bear." (In Athletic Training, a $10$ is extreme trauma).

  • $11$: "Blood is going to explode out of my face at any moment."

  • Too Serious For Numbers: "You probably have ebola… suffering from Stigmata and/or pinkeye."

Past Medical History and Holistic Considerations

• Past Medical History ($PMH$) involves non-acute examinations, including medical history forms and physicals.

• Key Components of $PMH$:

  • Underlying health conditions and previous injuries.

  • Predisposing factors and the course of the current condition.

• Essential Assessment Questions:

  • Is there a history of injury to this body area (either side)?

  • If yes: Describe and compare the current injury to the previous one.

  • Do current symptoms duplicate old symptoms?

  • Are there sources of weakness from previous injuries?

  • What was the previous diagnosis and what diagnostic tests were performed?

  • What was the course of treatment, rehab, surgery, or medication?

  • Did previous treatments change the symptoms?

• General Medical Health and Lifestyle:

  • Smoking: Decreases exercise tolerance, increases risk for Cardiovascular ($CV$) disease, and may delay fracture and wound healing.

  • Relevant illness and lab work.

  • Medications: Documentation of prescriptions, Over-the-Counter ($OTC$) meds, supplements, and herbal remedies.

  • Drug Interactions: Assessing how medications affect healing and proposed treatments.

Observation, Inspection, and Range of Motion

• Goals of Physical Examination:

  • Narrow down the differential diagnosis (e.g., determining if it is a fracture vs. sprain vs. tendinitis).

  • Determine the clinical diagnosis.

  • Identify impairments and functional limitations.

• Passive Range of Motion ($PROM$) Normal End Feels:

  • Soft: Soft tissue approximation (e.g., Knee flexion).

  • Firm: Muscular, capsular, or ligamentous stretch (e.g., Hip flexion with knee extended, extension of MCP joints, forearm supination).

  • Hard: Bone contacting bone (e.g., Elbow extension).

• Passive Range of Motion ($PROM$) Abnormal End Feels:

  • Soft: Occurs sooner or later in $ROM$ than usual; feels boggy (e.g., Edema or synovitis).

  • Firm: Occurs sooner or later in $ROM$ than usual in a joint that is normally soft or hard (e.g., Increased muscle tone or shortening of capsules/muscles).

  • Hard: Occurs sooner or later in $ROM$; a bony block (e.g., Loose bodies or fractures).

  • Spasm: Motion stopped by involuntary or voluntary muscle contraction (caused by inflammation, strain, or instability).

  • Empty: No end-feel reached due to pain and guarding (e.g., Bursitis or fracture).

• Comparing Active Range of Motion ($AROM$) vs. $PROM$:

  • $PROM > AROM$: This is considered normal.

  • $AROM < PROM$: Suspect muscular weakness or a tissue lesion.

  • $PROM = AROM$ and both are deficient: Suspect capsular adhesions or joint tightness.

Manual Muscle Testing (MMT) and Strength Grading

• Manual Muscle Testing ($MMT$): Assesses strength and pain provocation by isolating specific muscles or groups (e.g., changing forearm position to isolate different elbow flexors).

• Resisted Range of Motion ($RROM$): Assesses strength throughout the entire $ROM$.

• Break Test: An isometric $MMT$ performed in the joint's mid-range to differentiate between muscle pathology and injury to non-contractile structures.

• MMT Grading Scale:

  • Normal ($5/5$): Patient resists maximal pressure; examiner cannot break resistance.

  • Good ($4/5$): Patient resists moderate pressure.

  • Fair ($3/5$): Patient moves the body part against gravity through its full $ROM$.

  • Poor ($2/5$): Patient moves the body part through full $ROM$ in a gravity-eliminated position.

  • Trace ($1/5$): No movement produced, but muscle contraction is palpable.

  • Gone ($0/5$): No contraction felt.

Neurological Screening

• Includes Upper and Lower Quarter Screens ($UQS$/$LQS$) to evaluate sensation, motor function, and deep tendon reflexes ($DTR$).

• Purpose: Identify nerve root impingement, peripheral nerve damage, $CNS$ trauma, or disease.

• Red Flags: Numbness, paresthesia, unexplained muscular weakness, pain of unexplained origin, or injury to the cervical/lumbar spine.

• Sensory Testing (Dermatomes):

  • An area of skin innervated by a specific spinal nerve root.

  • Procedures: Performed bilaterally; patient has eyes closed and head turned away.

  • Tests: Light touch discrimination, sharp/dull discrimination, and two-point discrimination (set at $4-5\,mm$ apart).

• Motor Testing (Myotomes):

  • Testing muscles innervated by a specific nerve root.

  • Interpretation: If one muscle is weak, suspect muscle pathology or peripheral nerve pathology. If multiple muscles innervated by the same root are weak, suspect nerve root pathology.

• Reflex Testing:

  • Evaluates the integrity of the reflex arc. Asymmetry is more significant than bilateral changes.

  • Increased Response: Indicates an Upper Motor Neuron ($UMN$) lesion.

  • Decreased Response: Indicates a Lower Motor Neuron ($LMN$) lesion.

  • DTR Grading Scale: $0$ to $4+$.

Lower and Upper Quarter Screen Tables

• Lower Quarter Screen ($LQS$):

  • $L1$: Sensory: $ASIS$; Motor: Hip Flexion; Reflex: None.

  • $L2$: Sensory: Anterior Thigh; Motor: Hip Flexion; Reflex: Patellar Tendon.

  • $L3$: Sensory: Medial Aspect of Knee; Motor: Knee Extension; Reflex: Patellar Tendon.

  • $L4$: Sensory: Medial Lower Leg; Motor: Ankle Dorsiflexion; Reflex: Patellar Tendon.

  • $L5$: Sensory: Lateral Lower Leg & Dorsum of Foot; Motor: Great Toe Extension; Reflex: Tibialis Posterior Tendon.

  • $S1$: Sensory: Lateral Plantar Aspect of Foot; Motor: Ankle Eversion; Reflex: Achilles Tendon.

  • $S2$: Sensory: Posterior Thigh & Posterior Lateral Heel; Motor: Knee Flexion; Reflex: Lateral Hamstring Tendon.

• Upper Quarter Screen ($UQS$):

  • $C1-C2$: Sensory: Sides & Back of Head; Motor: Neck Flexion; Reflex: None.

  • $C3$: Sensory: Neck; Motor: Lateral Neck Flexion; Reflex: None.

  • $C4$: Sensory: Top of Shoulder; Motor: Shoulder Elevation; Reflex: None.

  • $C5$: Sensory: Deltoid; Motor: Shoulder Abduction; Reflex: Biceps Tendon.

  • $C6$: Sensory: Lateral Forearm, Thumb, & Index Finger; Motor: Elbow Flexion & Wrist Extension; Reflex: Brachioradialis Tendon.

  • $C7$: Sensory: Middle Finger; Motor: Elbow Extension & Wrist Flexion; Reflex: Triceps Tendon.

  • $C8$: Sensory: Medial Forearm, Ring Finger, & Pinky Finger; Motor: Opposition; Reflex: None.

  • $T1$: Sensory: Medial Elbow; Motor: Finger Abduction/Adduction; Reflex: None.

Vascular Screening and Evidence-Based Practice

• Vascular Screening: Gross assessment of blood flow to and from extremities.

  • Arterial Issues: Decreased blood flow leads to pain from oxygen deprivation.

  • Venous Issues: Failure of flow leads to pain from edema (swelling).

  • Pulse Locations:

    • Lower Extremity: Femoral, Popliteal, Posterior tibial, Dorsal pedal.

    • Upper Extremity: Brachial, Radial, Ulnar.

    • Systemic: Carotid.

  • Capillary Refill: Checked at the nail beds.

• Role of Evidence in Examination:

  • Efficiency: Use history and functional data to minimize unnecessary tests.

  • Accuracy: Eliminate false positives and wasted time by matching tests to the specific condition (e.g., do not perform acute fracture tests for a gradual onset injury).