Lecture 3

1. Lecture 3 Assessment Protocols

2. History, • Observation, • ROM/Resisted, • Special tests and • Palpations

3. History Provides valuable information about the athletes condition • Listening to the patient / athlete • Questions – try not to lead the athlete • Repetition – taken in an orderly sequence • Try to keep patient focused on relevant information • Relevant past history and or treatments received • Surgeries, allergies, major illnesses • Relevant family history • X-rays , or any other test results • Medications

4. Age, occupation (student/ sport) , life style (recreational pursuits) • Chief complaint- what is the major problem • What was the trauma – Mechanism of injury (MOI) • Direction , magnitude, force applied • Predisposing factors ( old injuries, braces , field conditions) • Onset – sudden (acute) or slow (insidious)

5. Pain – during day or night - when is it better ( what makes it feel better) or when is it worse • Symptoms – what bothers the athlete- can they point to one area – specific / general • Pain – has it changed since it first started • Trigger points ( points that are hyperirritable) tender to compression • Referred pain – is the pain felt somewhere other that the injured site ( referred pain is usually referred segmentally – does not cross midline) • What causes the pain

6. Functionally pain is seen in seven levels • pain after specific activity • pain after specific activity resolving after a warm up • pain during and after specific activity which does not effect performance • pain during and after specific activity which does effect performance • pain with all activity of daily living • constant dull aching pain at rest which does not disturb sleep • constant dull aching pain at rest which does disturb sleep

7. How long has problem existed – duration /frequency • Have they had this problem before – did it get better – how – how long • Type of pain • Nerve – sharp , bright , burning • Bone – deep , boring , very localized • Vascular – diffuse , aching poorly localized • Muscle – hard to localize, dull and achy

8. Sensations - pins and needles - numbness • Locking – joint can not be fully extended • Giving way – joint buckles • Other problems – fainting , bladder , neurological problems etc.. • Stress levels of athlete

9. Red Flags

10. Cancer • persistent night pain • unexplained weight loss ( 10 – 15 lbs in 2 weeks or less) • loss of appetite • lumps or growths • Cardiovascular • shortness of breath • dizziness • pain / heaviness in chest • pulsating pain in body

11. Gastrointestinal • frequent and sever abdominal pain • heartburn and or indigestion • nausea and vomiting • bladder problems • Neurological • changes in hearing /speech or vision • frequent and or severe headaches • problems with balance • fainting spells • weakness

12. Miscellaneous • fever or night sweats • emotional disturbances – depression • swelling with no apparent history • severe unremitting pain • severe pain with no obvious history • severe spasms • All Red Flags Refer to Doctor immediately

13. Observations • observations start right away when athlete walks into clinic – limping .. etc • looking and or inspecting an area • gain information on visible defects or abnormalities • posture • gait

14. Dominant Eye

15. Normal alignment • Obvious deformities • Obvious deviations • Muscle wasting • Limb position – equal / symmetrical • Skin colour and temperature • Scars • Crepitus, snapping or abnormal sounds • Swelling / redness • Willingness to move

16. Active Movement • Test joint range, muscle control and willingness of athlete to move.

17. Things to note • When and where during each movement the onset of pain occurs • Does it increase intensity and quality of pain • Observe restrictions • Observe pattern of movements • Observe rhythm and quality of movement • Willingness to move what are their limitations

18. Passive Movements • Athlete is relaxed, movement is through the full ROM of the joint as possible. • Normal movement is relative – ie. gymnasts as compared to football. (Hyper/hypo)

19. End Feels • Normal • Bone to bone – hard and unyielding – elbow extension • Soft tissue approximation – yielding compression stops further movement – knee flexion • Tissue stretch – hard or firm (springy) type of movement with slight give – ankle dorsiflexion – shoulder lateral rotation

20. Abnormal • Muscular spasm - sudden and hard – quad contusion • Capsular – similar to tissue stretch – but occurs when not expected – frozen shoulder • Bone to bone – ends meet before normal – osteophyte formation • Empty – considerable pain – no end feel - MCL rupture – bursea • Springy block – similar to tissue stretch but again where not suspected – meniscus

21. Resisted Movement • Tested last • Strong static (isometric)contraction • Voluntary muscle contraction • Amount of pain and weakness is related to degree of injury • Athlete resists applied pressure • Keep movement to a minimal

22. Muscle Grading • 5 – Normal – Complete max resistance • 4 – Good – Moderate resistance • 3 – Fair – ROM with gravity • 2 – Poor – Rom with gravity eliminated • 1 – Trace – Minimal contraction • 0 – None – No contraction

23. Examination Principles • test normal side first • Active before passive • Passive before resisted • Most painful test done last • Resisted – joint is in neutral and isometric – stress on inert tissue is minimal • Passive ROM – not only degree of movement but end feel • Ligament stress – gentle / repeat and increase stress but not beyond point of pain

24. Special Tests • Are available for all joints and most muscles to determine injury • Uses of special tests • To confirm tentative diagnosis • Make a differential diagnosis • Differentiate between structure

25. Reflexes • Biceps C5-C6 • Triceps C7-C8 • Patella L3-L4 • Achilles S1-S2

26. Palpations • To palpate the area should be as relaxed as possible • discriminate the difference in tissue tension , ie rigidity and or flaccidity • discriminate the difference in tissue texture – fibrous band

27. detect abnormalities or deformities (myositis ossificans) • determine tissue thickness • obvious swelling , intra or extra articular • blood swelling - rapid (2-4 hours) – hard thick gel like • fluid swelling – slow (8- 24 hours) – softer more mobile • Joint tenderness

28. Temperature • Abnormal sensations • hyperesthesia – increased sensations • dysesthesia – diminishing sensations • anethesia – absence of sensations • crepitus etc.