The Injury Examination Process

ATHT 305 Fall 2015

Objectives:

Describe systematic examination technique

List appropriate history questions List steps of a clinical examination

in logical order

Human body parts work together to produce normal movement known as biomechanics

Pathomechanics occurs after injury Example: Limping

Examination process connects the findings of dysfunctional anatomy, physiology, biomechanics.

Diagnosing

Initial diagnosis success determines rehabilitative outcomes Need to reexamine

Final determination is differential diagnosis Pathologies with similar signs and symptoms

are excluded based on examination findings Clinical diagnosis achieved via lab tests

Uninjured Pair Structure

The uninjured equivalent, the bilateral structure, should always be compared

Which do you test first: injured or non-injured?

When do you not test the uninjured? Acute situations such as dislocation

Clinical assessment

Have informed consent Under 18 Cross gender Unconscious?

Step 1: History Most informative

portion- info about structures involved, extent of tissue damage

Communication barriers Use jargon-free

language Use pictures or

models Speak slower, not

louder Ask about one

symptom at a time

Use open-ended questions Will get more

information During catastrophic

injury use “yes or no” questions

Example:

Questions to ask- Previous history

Is there a history of injury to the area? Or “have you hurt this before”? Follow up questions:

Is this similar? Does it feel the same as before? When did it happen? How was it treated? Did that help?

Questions to ask- General Medical Health

Looking for comorbidities- presence of multiple unrelated disorders in the person at the same time

Chronic illness? Medications? Smoking?

Questions to ask

Mechanism of Injury How did this

happen? Acute onset or

insidious? Relevant sounds

Did you (or bystanders) hear a “pop” or “crack”?

Location Point with one

finger to the spot it hurts most

OPQRST of Pain

Onset- When did it start? Provoke- What makes it

worse/better? Identifies tissues

stretched/compressed Quality-

Nerve- sharp, burning Bone- localized & piercing Vascular- poorly localized,

aching, reffered from another area

Muscle- dull, aching, referred from another area

Radiating or referred- Radiating is result of nerve

root or peripheral nerve compressed or contused

Referred pain at site other than trauma

Severity-scale of 1-10 Time- when does it hurt?

Morning vs night (muscle fatigue)

After sitting for long periods of time

Goes away during activity= chronic

Other

Weakness? Does it “give out”? Cold? – arterial involvment Heavy? Venous or lymphatic

involvement

Step 2- Inspection & Functional Assessment

Starts as soon as patient walks in-gait, guarding

Looking for: Deformity Swelling- measured by girth or volume Skin- ecchymosis, open wounds,

surgical scars Infection- red, swelling, pus, red

streaks, temperature

Functional Assessment

Perform tasks identified as problematic

What tests would we do for this guy?

Step 3: Palpation

Performed bilateral Start away from pain and move

towards- can rule out sources of pain and identify involved secondary structures Start with bones and ligaments, then

muscles and tendons OR all structures away from then progress towards

Palpation- what to look for

Point tenderness- begin gentle then increase pressure

Trigger points Change in tissue density

Muscle spasm, hemorrage, edema, scarring, myositis ossificans

Crepitus- fx or inflammation Tissue temperature

Increased= inflammation Decreased= vascular insufficiency

Step 4- Joint and Muscle Function Assessment: AROM, PROM, RROM, & MMT

Active Range of Motion- joint motion produced by patient contracting muscles Assesses

physiological and accessory motion

Contraindication: fx or recently repaired soft tissue

Evaluates: Willingness and

ability to move Unwilling is

extreme pain, neurological deficit, or malingering

“Painful arc”- part of ROM causing pain due to compression, impingement or abrasion

Passive Range of Motion

Clinician moves joint through ROM Apply over pressure to identify end

feels to indicate what type of structure stressed at terminal ROM

PROM should be more than AROM When they fall short, capsular

adhesions When AROM less= muscle weakness

Normal End-feelsEnd-feels Structure Example

Soft Soft tissue approximation Knee flexion

Firm Muscle Stretch

Capsular stretch

Ligamentous stretch

Hip flex with knee extExt of MCP joints

Forearm supination

Hard Bone contacting bone Elbow ext

Resistive Range of Motion & MMT

Gross strength of muscle group through cardinal plane of motion

Manual Muscle Tests- Isometric test in mid-range of ROM (also called break test) Differentiates between muscle and

ligament Ligaments not taut in joints midrange Compensation may be seen

MMT GradesVerbal Numerical Clinical Finding

Normal 5/5 Can resist against max pressure. Examiner unable to break patient’s resistance.

Good 4/5 Patient can resist against moderate pressure.

Fair 3/5 Patient can move the body part against gravity through full ROM

Poor 2/5 Patient can move body part in gravity-eliminated position through full ROM

Trace 1/5 Patient cannot produce movement, but contraction is palpable

Zero 0/5 No contraction felt.

Other things to consider

Hyper vs hypomobility Can be congenital laxity

Joint play Accessory motion: roll, spin, glide

Assessed with Pt. relaxed, loose-packed position. Distract joint.

Hyper vs hypomobility Can be congenital laxity

Joint play Accessory motion: roll, spin, glide

Assessed with Pt. relaxed, loose-packed position. Distract joint.

Step 5: Special Tests Step 6: Neurological screening

Dermatomes = sensory Myotomes = motor Reflex= integrity of CNS via GTO

Step 7: Vascular Screen

Homework questions

1. What is the difference between a “sign” and a “symptom”?

2. When asking about medications, what are 2 possible negative effects that could influence the injury. Example: prolonged bleeding time

3. Describe where and what you would start palpating if an athlete told you the lateral side of their ankle hurt.

4. If I say “MMT of knee flexion is 3/5” describe the patient position and results of the test.