Injury Evaluation Basics

1. Injury Evaluation Basics

2. The Process • Be systematic on your assessment, but do not have a “cookbook” approach. • Be calm (it can’t be an emergency for you!) • Be confident! • Listen to your patient! • Do NOT overstep your bounds. • If you don’t know something, do not be hesitant to ask others for assistance.

3. HOPS- History • History: Attitude, mental condition, and perceived physical state. • Stated by the athlete. • Primary Complaint • Mechanism of Injury • Characteristics of the Symptoms • Limitations • Past History

4. H is for history • Purpose: Find out the symptoms. • What are the component parts? • USE OPEN-ENDED QUESTIONS • Depending on the injury, you may have to ask specific questions • LISTEN • SILENT

5. Seven Attributes of a Symptom • Location: • Quality: • Quantity or Severity: • Timing: • Setting in which it occurs: • Remitting or exacerbating factors: • Associated Manifestations:

6. Sample History Questions • When did problem start? • What makes it better? What makes it worse? • Is it better or worse in the morning or at night? • Is it better or worse w/ breathing, urination, eating, excitement, stress, rest, movements, etc.

7. History of Illness • Have you had symptoms like this before? • Have you had x-rays, MRIs, or CT scans? • Getting better, worse or same? • Have you received any treatments? • Do you have any family history of chronic disease or health concerns?

8. When Pain is associated! • Type of Pain • Acute vs chronic • Local vs referred • Constant vs intermittent • Sharp? • Radiating? • Burning? • Location • Etc.!

9. I is for inspection/ O is for Observation • Purpose: Find out the signs. • Appearance • What does it look like?, skin appearance, signs of trauma • Bilateral symmetry • Bleeding • Color/Discoloration • Deformity • Edema/Swelling • Expressions denoting pain

10. Constant pain Heart palpitations Fainting Night pain or sweats Difficult or painful swallowing Vision loss Unexpected weight loss Insomnia Excruciating pain Nausea, vomiting Difficult urination Blood in urine Dizziness Chronic fatigue RED FLAGS!

11. Injury Evaluation Process • Symptom: Athletes perception of his or her injury. • Sign: Objective, measurable physical finding regarding the individuals condition. • HOPS- History Observation Palpation Special tests • SOAP- Subjective Objective Assessment Plan.

12. HOPS- Observation and Inspection • Observation: Measurable objective signs. • Appearance • Symmetry • General Motor Function • Posture and Gait • Deformity, swelling, discoloration, scars, and general skin condition

13. P is for palpation • Begin away from the pain & move towards the injury • Pain & Point tenderness • Malalignment of joint/bone • Crepitus • Swelling • Tissue temperature & Circulatory status

14. HOPS- Palpation • Rule out FX (fracture) • Skin temperature • Swelling • Point tenderness • Crepitus • Deformity • Muscle spasm

15. HOPS- Palpation • Cutaneous Sensation (nail bed refill) • Pulse

16. S is for stress or special • Stress Tests • Uniplanar tests designed to assess ROM, muscular strength, or ligament stability • Special Tests • Multiplanar tests designed to assess ligament stability and functionality • Neurological Tests

17. Stress Tests • Active Range of Motion (AROM) • Passive ROM (PROM) • Resistive ROM (RROM)/Manual Muscle Tests (MMT) • Ligament stability • Instability & Endpoints • End feel (Starkey Tables 1-3, 1-4, p. 13) • Relative ligament laxity (Starkey, Table 1-7, p. 15)

18. HOPS- Special Tests • Functional Tests • Active Range of Motion (AROM) • Passive Range of Motion (PROM) • Resisted Manual Muscle Testing (RROM) • Stress Tests • Ligamentous Instability Tests • Special Tests

19. HOPS- Special Tests • Neurologic Tests • Dermatomes • Myotomes • Reflexes • Peripheral Nerve Testing • Sport-Specific Functional Testing • Proprioception and Motor Coordination

20. HOPS- Special Tests • Sport-Specific Skill Performance • Throw the football, baseball, softball, javelin... • Kick the soccer ball, football, opponent… • Macarena, Cabbage Patch, Mash Potato

21. Special Tests • Ligament stability • Instability & Endpoints • End feel (Starkey Tables 1-3, 1-4, p. 13) • Relative ligament laxity (Starkey, Table 1-7, p. 15) • Function • Jumping • Pivoting • Backpedaling • Starts • Change of direction • Throwing & other shoulder activities • Core activities

22. Neurological Tests • Sensation, Motor function, Reflexes • Dermatomes • Two-point Discrimination Test • Sharp-Dull Discrimination Test • Hot-Cold Discrimination Test • Myotomes • Manual Muscle Test (MMT) or Break Test • Reflexes • Deep Tendon Reflex Grading (Starkey, Table 1-8, p. 19)

23. On-Field vs. Off-Field Evaluation • On-field: quick inspection & evaluation • What is the seriousness of injury? • Is first aid & immobilization needed? • Does the injury need immediate referral? • What is the manner of transportation from the injury site? • Off-field: longer and more in depth

24. Finish it! • Come to conclusions. • Differential diagnosis • List the options • For example – What could it be? • Anterior knee pain • Lateral ankle pain

25. Documenting Injuries • Writing SOAP Notes • IF YOU DON’T DOCUMENT IT, IT DIDN’T HAPPEN

26. Writing a Medical Record The ABCs • Accuracy • Brevity • Clarity

27. Accuracy Never record false information Patient records are legal documents Keep information objective Brevity • State your information concisely but enough information must be presented • Use sentence fragments • Use abbreviations Clarity • Meaning should be immediately clear • Avoid vague terminology • Your handwriting should be legible

28. Writing a Medical Record • Punctuation • Avoid hyphens • Semicolon(;) is used to connect two points • Colon (:) is used instead of “is” • Correcting Errors • Never erase or white-out • Cross out with one line, write the date, and initial • Signature • Use your official title

29. The SOAP Note • Organized according to the source the information • S = Subjective • O = Objective • A = Assessment • P = Plan • Sometimes preceded by a statement of the problem • Usually the patient’s chief complaint, the diagnosis, or a loss of function.

30. What goes where? • Subjective • This information is received from the patient • Objective • Results of tests measurements performed and the therapist’s objective observations • Break into separate body parts if necessary • Assessment • Probable or Differential Diagnosis • Plan

31. SOAP- Subjective • History: Attitude, mental condition, and perceived physical state. • Stated by the athlete. • Primary Complaint • Mechanism of Injury • Characteristics of the Symptoms • Limitations • Past History

32. SOAP- Objective: • Observation: Measurable objective signs. • Appearance • Symmetry • General Motor Function • Posture and Gait • Deformity, swelling, discoloration, scars, and general skin condition

33. SOAP- Objective • Rule out FX (fracture) Cutaneous Sens. • Skin temperature Pulse • Swelling • Point tenderness • Crepitus • Deformity • Muscle spasm

34. SOAP- Objective • Functional Tests • Active Range of Motion (AROM) • Passive Range of Motion (PROM) • Resisted Manual Muscle Testing (RROM) • Stress Tests • Ligamentous Instability Tests • Special Tests

35. SOAP- Objective • Neurologic Tests • Dermatomes • Myotomes • Reflexes • Peripheral Nerve Testing • Sport-Specific Functional Testing • Proprioception and Motor Coordination

36. SOAP- Objective • Sport-Specific Skill Performance • Throw the football, baseball, softball, javelin... • Kick the soccer ball, football, opponent… • Macarena, Cabbage Patch, Mash Potato

37. SOAP- Assessment • Analyze and assess the individual’s status and prognosis • Suspected injury Site • Damaged Structures Involved • Severity of Injury • Progress Notes

38. SOAP- Plan • Immediate treatment given • Frequency and duration of treatments and modalities and evaluation • On-going patient education • Criteria for discharge/return to play

39. Let’s Practice… • Case Study • A 20-year old tennis player was chasing after a deep hit ball. While he was maneuvering to the right, he fell forward and felt a pop in his lateral ankle. He reports today with swelling along the lateral malleolus measuring 12 cm in circumference. He is able to partial weight bear to 75% on the left. He admits that he is fearful of bearing weight on the leg because he feels it will give way. His hip and knee strength is grossly 4+/5. Ankle dorsiflexion and inversion are 3/5, and ankle eversion is 2+/5. His active ankle range of motion is -5o dorsiflexion, 40o plantarflexion, and 5o eversion. Negative tests include Kleiger’s and Talar Tilt (inv and ever). Positive tests include anterior drawer (mild opening) and obvious peroneal tendon subluxation with active inversion. Pedal pulse is normal and dermatomes are normal. He was planning on participating in Regional Finals beginning in two days.