Injury Evaluation Basics The Process Be systematic on your assessment, but do not have a “cookbook” approach. Be calm (it can’t be an emergency for you!)

Injury Evaluation BasicsInjury Evaluation Basics

The ProcessThe ProcessBe systematic on your assessment, but Be systematic on your assessment, but do not have a “cookbook” approach.do not have a “cookbook” approach.

Be calm (it can’t be an emergency for Be calm (it can’t be an emergency for you!)you!)

Be confident!Be confident!

Listen to your patient!Listen to your patient!

Do NOT overstep your bounds.Do NOT overstep your bounds.– If you don’t know something, do not be If you don’t know something, do not be

hesitant to ask others for assistance.hesitant to ask others for assistance.

HOPS- HistoryHOPS- HistoryHistory: Attitude, mental condition, History: Attitude, mental condition, and perceived physical state.and perceived physical state.– Stated by the athlete.Stated by the athlete.– Primary ComplaintPrimary Complaint– Mechanism of InjuryMechanism of Injury– Characteristics of the SymptomsCharacteristics of the Symptoms– LimitationsLimitations– Past HistoryPast History

Purpose: Find out the Purpose: Find out the symptoms.symptoms.What are the component parts?What are the component parts?USE OPEN-ENDED QUESTIONSUSE OPEN-ENDED QUESTIONSDepending on the injury, you may Depending on the injury, you may have to ask specific questionshave to ask specific questions

LISTENLISTEN– SILENTSILENT

Seven Attributes of a SymptomSeven Attributes of a Symptom

Location:Location:

Quality:Quality:

Quantity or Severity:Quantity or Severity:

Timing:Timing:

Setting in which it occurs:Setting in which it occurs:

Remitting or exacerbating factors:Remitting or exacerbating factors:

Associated Manifestations:Associated Manifestations:

Sample History QuestionsSample History Questions

When did problem start?When did problem start?

What makes it better? What makes it What makes it better? What makes it worse?worse?

Is it better or worse in the morning or Is it better or worse in the morning or at night?at night?

Is it better or worse w/ breathing, Is it better or worse w/ breathing, urination, eating, excitement, stress, urination, eating, excitement, stress, rest, movements, etc.rest, movements, etc.

History of IllnessHistory of Illness

Have you had symptoms like this Have you had symptoms like this before?before?

Have you had x-rays, MRIs, or CT Have you had x-rays, MRIs, or CT scans?scans?

Getting better, worse or same?Getting better, worse or same?

Have you received any treatments?Have you received any treatments?

Do you have any family history of Do you have any family history of chronic disease or health concerns?chronic disease or health concerns?

When Pain is associated!When Pain is associated!Type of PainType of Pain– Acute vs chronicAcute vs chronic– Local vs referredLocal vs referred– Constant vs intermittentConstant vs intermittent– Sharp?Sharp?– Radiating?Radiating?– Burning?Burning?– LocationLocation– Etc.!Etc.!

Purpose: Find out the signs.Purpose: Find out the signs.– AAppearanceppearance

What does it look like?, skin appearance, What does it look like?, skin appearance, signs of traumasigns of trauma

– BBilateral symmetryilateral symmetry– BBleedingleeding– CColor/Discolorationolor/Discoloration– DDeformityeformity– EEdema/Swellingdema/Swelling– EExpressions denoting painxpressions denoting pain

RED FLAGS!RED FLAGS!Constant painConstant painHeart palpitationsHeart palpitationsFaintingFaintingNight pain or sweatsNight pain or sweatsDifficult or painful Difficult or painful swallowingswallowingVision lossVision lossUnexpected weight Unexpected weight losslossInsomniaInsomniaExcruciating painExcruciating painNausea, vomitingNausea, vomiting

Difficult urinationDifficult urinationBlood in urineBlood in urineDizzinessDizzinessChronic fatigueChronic fatigue

Injury Evaluation ProcessInjury Evaluation ProcessSymptom: Athletes perception of his or Symptom: Athletes perception of his or her injury.her injury.

Sign: Objective, measurable physical Sign: Objective, measurable physical finding regarding the individuals condition.finding regarding the individuals condition.

HOPS- History Observation Palpation HOPS- History Observation Palpation Special testsSpecial tests

SOAP- Subjective Objective Assessment SOAP- Subjective Objective Assessment Plan.Plan.

HOPS- Observation and HOPS- Observation and InspectionInspection

Observation: Measurable objective Observation: Measurable objective signs.signs.– AppearanceAppearance– SymmetrySymmetry– General Motor FunctionGeneral Motor Function– Posture and GaitPosture and Gait– Deformity, swelling, discoloration, scars, Deformity, swelling, discoloration, scars,

and general skin conditionand general skin condition

Begin away from the pain & move Begin away from the pain & move towards the injurytowards the injury

Pain & Point tendernessPain & Point tenderness

Malalignment of joint/boneMalalignment of joint/bone

CrepitusCrepitus

SwellingSwelling

Tissue temperature & Circulatory Tissue temperature & Circulatory statusstatus

HOPS- PalpationHOPS- Palpation Rule out FX (fracture)Rule out FX (fracture) Skin temperatureSkin temperature SwellingSwelling Point tendernessPoint tenderness CrepitusCrepitus DeformityDeformity Muscle spasmMuscle spasm

HOPS- PalpationHOPS- Palpation

Cutaneous Sensation (nail bed refill)Cutaneous Sensation (nail bed refill)

PulsePulse

Stress TestsStress Tests– Uniplanar tests designed to assess ROM, Uniplanar tests designed to assess ROM,

muscular strength, or ligament stabilitymuscular strength, or ligament stability

Special TestsSpecial Tests– Multiplanar tests designed to assess Multiplanar tests designed to assess

ligament stability and functionalityligament stability and functionality

Neurological TestsNeurological Tests

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

1-7, p. 15)1-7, p. 15)

HOPS- Special TestsHOPS- Special Tests

Functional TestsFunctional Tests– Active Range of Motion (AROM)Active Range of Motion (AROM)– Passive Range of Motion (PROM)Passive Range of Motion (PROM)– Resisted Manual Muscle Testing (RROM)Resisted Manual Muscle Testing (RROM)

Stress TestsStress Tests– Ligamentous Instability TestsLigamentous Instability Tests– Special TestsSpecial Tests

HOPS- Special TestsHOPS- Special Tests

Neurologic TestsNeurologic Tests– DermatomesDermatomes– MyotomesMyotomes– ReflexesReflexes– Peripheral Nerve TestingPeripheral Nerve Testing

Sport-Specific Functional TestingSport-Specific Functional Testing– Proprioception and Motor CoordinationProprioception and Motor Coordination

HOPS- Special TestsHOPS- Special Tests

Sport-Specific Skill PerformanceSport-Specific Skill Performance– Throw the football, baseball, softball, Throw the football, baseball, softball,

javelin...javelin...– Kick the soccer ball, football, Kick the soccer ball, football,

opponent…opponent…– Macarena, Cabbage Patch, Mash Macarena, Cabbage Patch, Mash

PotatoPotato

Special TestsSpecial TestsLigament stabilityLigament stability– Instability & EndpointsInstability & Endpoints– End feel (Starkey Tables 1-3, 1-4, p. 13)End feel (Starkey Tables 1-3, 1-4, p. 13)– Relative ligament laxity (Starkey, Table 1-7, p. Relative ligament laxity (Starkey, Table 1-7, p.

15)15)FunctionFunction– JumpingJumping– PivotingPivoting– BackpedalingBackpedaling– StartsStarts– Change of directionChange of direction– Throwing & other shoulder activitiesThrowing & other shoulder activities– Core activitiesCore activities

Neurological TestsNeurological TestsSensation, Motor function, ReflexesSensation, Motor function, Reflexes– DermatomesDermatomes

Two-point Discrimination TestTwo-point Discrimination TestSharp-Dull Discrimination TestSharp-Dull Discrimination TestHot-Cold Discrimination TestHot-Cold Discrimination Test

– MyotomesMyotomesManual Muscle Test (MMT) or Break TestManual Muscle Test (MMT) or Break Test

– ReflexesReflexesDeep Tendon Reflex Grading (Starkey, Table Deep Tendon Reflex Grading (Starkey, Table 1-8, p. 19)1-8, p. 19)

On-Field vs. Off-Field On-Field vs. Off-Field EvaluationEvaluation

On-field: quick inspection & On-field: quick inspection & evaluationevaluation– What is the seriousness of injury?What is the seriousness of injury?– Is first aid & immobilization needed?Is first aid & immobilization needed?– Does the injury need immediate Does the injury need immediate

referral?referral?– What is the manner of transportation What is the manner of transportation

from the injury site?from the injury site?

Off-field: longer and more in depth Off-field: longer and more in depth

Finish it!Finish it!

Come to conclusions.Come to conclusions.

Differential diagnosisDifferential diagnosis– List the optionsList the options

For example – What could it be?For example – What could it be?– Anterior knee pain Anterior knee pain – Lateral ankle painLateral ankle pain

Documenting InjuriesDocumenting Injuries

Writing SOAP NotesWriting SOAP Notes

IF YOU DON’T DOCUMENT IT, IT IF YOU DON’T DOCUMENT IT, IT DIDN’T HAPPENDIDN’T HAPPEN

Writing a Medical RecordWriting a Medical Record

The ABCsThe ABCsAccuracyAccuracy

BrevityBrevity

ClarityClarity

AccuracyAccuracyNever record false Never record false informationinformationPatient records are legal Patient records are legal documentsdocumentsKeep information objectiveKeep information objective BrevityBrevity

State your information State your information concisely but enough concisely but enough information must be information must be presentedpresentedUse sentence fragmentsUse sentence fragmentsUse abbreviationsUse abbreviationsClarityClarity

Meaning should be Meaning should be immediately clearimmediately clearAvoid vague terminologyAvoid vague terminologyYour handwriting should be Your handwriting should be legiblelegible

Writing a Medical RecordWriting a Medical RecordPunctuationPunctuation– Avoid hyphensAvoid hyphens– Semicolon(;) is used to connect two pointsSemicolon(;) is used to connect two points– Colon (:) is used instead of “is”Colon (:) is used instead of “is”

Correcting ErrorsCorrecting Errors– Never erase or white-outNever erase or white-out– Cross out with one line, write the date, and Cross out with one line, write the date, and

initialinitial

SignatureSignature– Use your official titleUse your official title

The SOAP NoteThe SOAP NoteOrganized according to the source the Organized according to the source the informationinformation– S = SubjectiveS = Subjective– O = ObjectiveO = Objective– A = AssessmentA = Assessment– P = PlanP = Plan

Sometimes preceded by a statement of Sometimes preceded by a statement of the problemthe problem– Usually the patient’s chief complaint, the Usually the patient’s chief complaint, the

diagnosis, or a loss of function.diagnosis, or a loss of function.

What goes where?What goes where?SubjectiveSubjective– This information is received from the patientThis information is received from the patient

ObjectiveObjective– Results of tests measurements performed Results of tests measurements performed

and the therapist’s objective observationsand the therapist’s objective observations– Break into separate body parts if necessaryBreak into separate body parts if necessary

AssessmentAssessment– Probable or Differential DiagnosisProbable or Differential Diagnosis

PlanPlan

SOAP- SubjectiveSOAP- SubjectiveHistory: Attitude, mental condition, History: Attitude, mental condition, and perceived physical state.and perceived physical state.– Stated by the athlete.Stated by the athlete.– Primary ComplaintPrimary Complaint– Mechanism of InjuryMechanism of Injury– Characteristics of the SymptomsCharacteristics of the Symptoms– LimitationsLimitations– Past HistoryPast History

SOAP- Objective:SOAP- Objective:

Observation: Measurable objective Observation: Measurable objective signs.signs.– AppearanceAppearance– SymmetrySymmetry– General Motor FunctionGeneral Motor Function– Posture and GaitPosture and Gait– Deformity, swelling, discoloration, scars, Deformity, swelling, discoloration, scars,

and general skin conditionand general skin condition

SOAP- ObjectiveSOAP- ObjectiveRule out FX (fracture)Rule out FX (fracture) Cutaneous Sens.Cutaneous Sens.

Skin temperatureSkin temperature PulsePulseSwellingSwellingPoint tendernessPoint tendernessCrepitusCrepitusDeformityDeformityMuscle spasmMuscle spasm

SOAP- ObjectiveSOAP- Objective

Functional TestsFunctional Tests– Active Range of Motion (AROM)Active Range of Motion (AROM)– Passive Range of Motion (PROM)Passive Range of Motion (PROM)– Resisted Manual Muscle Testing (RROM)Resisted Manual Muscle Testing (RROM)

Stress TestsStress Tests– Ligamentous Instability TestsLigamentous Instability Tests– Special TestsSpecial Tests

SOAP- ObjectiveSOAP- Objective

Neurologic TestsNeurologic Tests– DermatomesDermatomes– MyotomesMyotomes– ReflexesReflexes– Peripheral Nerve TestingPeripheral Nerve Testing

Sport-Specific Functional TestingSport-Specific Functional Testing– Proprioception and Motor CoordinationProprioception and Motor Coordination

SOAP- ObjectiveSOAP- Objective

Sport-Specific Skill PerformanceSport-Specific Skill Performance– Throw the football, baseball, softball, Throw the football, baseball, softball,

javelin...javelin...– Kick the soccer ball, football, opponent…Kick the soccer ball, football, opponent…– Macarena, Cabbage Patch, Mash PotatoMacarena, Cabbage Patch, Mash Potato

SOAP- AssessmentSOAP- Assessment

Analyze and assess the individual’s Analyze and assess the individual’s status and prognosisstatus and prognosis

Suspected injury SiteSuspected injury Site

Damaged Structures InvolvedDamaged Structures Involved

Severity of InjurySeverity of Injury

Progress NotesProgress Notes

SOAP- PlanSOAP- Plan

1.1. Immediate treatment givenImmediate treatment given

2.2. Frequency and duration of Frequency and duration of treatments and modalities and treatments and modalities and evaluationevaluation

3.3. On-going patient educationOn-going patient education

4.4. Criteria for discharge/return to playCriteria for discharge/return to play

Let’s Practice…Let’s Practice…Case Study Case Study – A 20-year old tennis player was chasing after a deep hit A 20-year old tennis player was chasing after a deep hit

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