The Injury Evaluation Process

What is normal breathing?

- Equal chest rise - Neither shallow nor deep -Effortless

What are some considerations when gliding joints?

-"Closed packed" position should be avoided, because Joint surfaces fit together precisely -Joint surfaces are compressed -Ligaments and capsule are at the maximal tightness and there is EFFECTIVELY no separation of the joint surfaces

What should the end feel "feel" like?

-"Endfeel" is the "feel" of the resistance of the tissue at the end of the ROM -However, the "feel" depends upon the structure limiting the joint ROM

What is a Boggy feel like?

-"Squishy" or "mushy" sensation, feels like joint will burst if you continue pushing -Caused by fluid within the joint

What is Normal blood pressure? Adults? Exercises? Systolic <100= problems

-110-140 over/ 60-90 -Athletes lower -Exercise systolic higher & Diatolic is about the same

What is the Respiration Rate for adults?

-12-20 per minute -Problematic if <8 or >24

What is Respiration Rate for Children?

-15-30 per minute

What is Normal Inspiration? Expiration Ratio?

-1:1 -1:3

What is normal Capillary Refill?

-2 seconds -If cold it will be delayed

What if distraction is limited?

-A contracture may be suspected

What muscles are we testing with RROM?

-A group of muscles -Watch for compensation of muscles

What is Differntial Diagnosis?

-A process of diagnosing an injury or illness which shares common signs and sympyoms with other conditions, and thus must be ruled out -Magee Process involves the use of clinical signs and sympyoms, physical examination, knowledge of pathology, and mechanisms of injury, provocatiove and palpation tests, and labatory and diagnostic imaging techniques

What is the main thing of the Secondary Assessment?

-ABC's are stable and no other life threatening injury is present -Potential to "appear"

What do you compare your evaluation to?

-ALWAYS ALWAYS compare bilaterally

What is 5/5 (normal MMT)?

-Able to resist against maximal pressure through FROM

What is 4/5 (normal MMT)?

-Able to resist against moderate pressure through FROM

What to look for with AROM?

-Abnormal movement -Quality -Rhythm -Expression of pain -Changes

What are we supposed to feel with Bone to Bone Endfeel

-Abrupt/hard/unyielding/painless -Boney block (elbow extension)

What is gliding or "joint play" or "accessory movements"?

-Accessory movements that are needed for full painless motion and function of a joint -Not voluntarily controlled

What is a tender point?

-Acute trauma and does not radiate

How to perform a Selective Tension Principle?

-Administer specific Tests -In a Systematic manner -Determine if the lesion is within

What are things to look for with Calluses?

-Alignment -Mechanics

What is Compression/Approximation?

-Approximate the joint surfaces and note if the pain increases or decreases -When the joint is loose, compression may help

What does it mean when isometric resistance to specific muscles reveals Pain after the release of the contraction?

-Articular source, because of the joint glide that occurs w/relaxtion

How do you take a history?

-Ask open ended questions -What movement causes you pain? NOT DOES IT HURT TO RAISE YOUR ARM LIKE THIS? -Allow the athlete to express themselves -Build solid rapport -Don't lead the athlete into questiions

What are things to look for in an athletes emotional state?

-Attitude -Disposition (overall presence) -Facial Expressions -Cooperation

What is A? (AVPU)

-Awake & Alert -Oriented x3 or confused? (person, ask who they are familiar with: Place, where they are at : What time is it?)

Endfeel Example: Why does the elbow joint have a hard endfeel? or a "Soft feel" with flexion?

-Because the olecranon (bone) hits the humerus (bone), while flexion is soft, being limited by the biceps (soft-tissue) musculature

How to test Dermatomes?

-Begin with light touch discrimination over the central portion of the dermatome -"Pin prick" or sharp/dull discrimination (bilateral comparison) -Two-Point discrimination (two point in picking the skin and ask how many needles) -Hot/Cold differentiation -Vibration (Turning fork over bone, "tell me when & where you feel this". "Tell me when it stops"

How to Compare Bilaterally?

-Begin with the non-injured side -What's normal for them?

When the the Inspection/Observation begin?

-Begins as soon as you first see the athlete (field or clinically) -Dominant eye -Bilateral comparison

How to palpate the Muscles?

-Belly, Tendons, attachments -Pain -Deformity -Tone -Point Tenderness

What are some examples of RED FLAGS?

-Bilateral spinal cord -Fainting -Drop Attacks (neurological they just fall and are conscious) -Vertigo -Loss of bowel/bladder control

What are things to look at Skin Apperance?

-Bleediing or open wounds -Infections or dermatological problems -Scars -Calluses -Discoloration -Temperature changes

What happens with Decreased/Hypotension?

-Blood loss -Cardiac problem -Dehydration -Shock (late stage)

What is an Inert Structure?

-Bone -Joint Capsule -Ligament -Bursae -Fascia

What are Abnormal Pulses?

-Bounding & Rapid -Weak and Rapid -Weak and slow

What is referred pain?

-Brain misinterprets the source of the painful impulse

What happens with a Upper motor neuron lesion?

-Brain stem -Cerebral impairment -Spinal cord compression -Neurological disease

What are the ideas behind the Selective Tension Principle?

-By selectively stressing the various structures of a body part in a systematic and reproducible manner, the problem is ascertained -Normal structures are painless when stretched or compressed -Abnormal tissues are painful (may be weak or painful)

If the on-field assessment needs immediate care, what do you do?

-CPR, mouth-mouth, stabilize, ALS -The most experienced should be providing care

What is 3/5 (Fair MMT)?

-Can move body part through FROM against gravity w/o added resistance

What is 2/5 (Poor MMT)?

-Can move body part through FROM in gravity-eliminated position

Head Injury conditions?

-Cardiac Arrest -Stroke -Diabetes -Anaphlaxis -Heat Illness (Heat stroke, syncope, hyponatriema)

What can compromise the ABC's?

-Cardiac arrest/distress -Heat Stroke -Severe head injury -Cervical Spine Injury -Severe Hemorrhaging -Internal Organ Injury -Disease/Medical Condition -Shock

Where can you find a pulse?

-Carotid, brachial, radial, femoral

What is Phalen's Test for?

-Carpal Tunnel Syndrome

What parts of the body are in the Upper Quarter Screen?

-Cervical Spine (head/neck) -Upper Thoracic Spine -Shoulder Complex -Elbow -Wrist -Hand

What changes are you observing with AROM?

-Changes from normal movement -Changes from normal movement for that person -Changes in the persons history

What is External Hemorrhaging?

-Characteristics of bleed

What do you do if you suspect nerve issue?

-Check myotomes, dermatome, and DTR's

What are things required for a differential diagnosis?

-Chief Complaint -Mechanism of Injury -Injury -What is the final injury & what can we do for it

What does white, brittle skin, abnormal nails, loss of hair?

-Chronic Ischemia

What must you do with Inspection/Observation?

-Compare Bilaterally

How to rule out fracture?

-Compression tests -Squeeze Tests -Thump Tests -Fulcrum Tests

What if distraction has increased pain?

-Connective tissues may be injured (Capsule, ligaments)

What is Regular Rhythm?

-Consistent timing of chest rise

What is muscle pain?

-Cramping/dull/ache/may be hard to localize -Increase w/movement

What is a Secondary Survey?

-Deals with the existing non-immediately life threatening problem

What is Posturing?

-Decerbrate -Decorticate

What is Motor deficit?

-Decreased reflex -Decreased muscle tone -Decrease muscle mass

What is Bone pain?

-Deep -Boring -Nagging -Dull and localized

What to look for when palpating bone?

-Deformity -Tenderness -Crepitus -Callous -Rule out fracture

What do we look for with the Overall contour of a body part?

-Deformity/malalignment -Fracture/dislocation or congenital

What do we do if there is a restriction with PROM?

-Determine if it is a Capsular or Non-Capsular Pattern of resticiton

What are things to keep in mind?

-Diffuse pain (Severe) -Myofascial pain (Facia) -Multiple injuries -Dermatomes (Nerve condition)

What causes LMN?

-Direct trauma -Toxins -Infections -Ischemia -Compression

What is muscle atrophy?

-Disuse or neurological injury

What causes Joint effesion or synovial inflammation?

-Due to trauma (traumatic arthritis & capsulitis), arthritis (Rheumotoid, septic, gouty, osteo) -Causes capsular pattern b/c the extra fluid distends the capsule (cause muscle guarding/ spasm & / or reflex inhibition

What is Ligament/joint capsule?

-Dull -Ache

Agonal Breathing?

-Dying Breathing -A huge gasp of air and then fast rapid breathing -Oxygen tanks needed and a medical emergency

What do you do if a problem is noted?

-Each muscle potentially should involved is isolated and tested = MMT

What is Quality with AROM?

-Ease/restrictions? -Amount of restriction & where

What to look for when Palpating a Joints and Ligaments?

-Effusion -Tenderness -Deformity -Alignment -Shape

What are Pathological or abnormal end feels?

-End feel that occurs at a different place than normal for that joint -(Limited ROM due to pathology) -Or with a different quality than what is normal for that joint -Or is Inappropriate for that joint (soft instead of hard)

INERT TISSUE LESIONS: What does pain and limited ROM in every direction?

-Entire joint is affected means it could be arthritis or capsulitis

What does it mean to be thorough with your evaluation?

-Evaluate joint above & below -Kinetic chain

What does 3 mean in Reflexes?

-Exaggerated response/ Hypereflexia

What is RSD?

-Exaggerated, generalized pain response following injury that is out of proportion to the severity of the injury

What to do when you ask the athlete to remove clothing?

-Explain what's going on -Opposite gender (if opposite sex says no, then explain why and that you are moving on) -Age -Location (Public will be better, but if private have witnesses) -Observers (have 3) -Religion

How do you perform Palpation?

-Explain/get permission!! Especially opposite sex! -Always compare bilaterally -Begin with the non-injured side -Begin away from the injured site -Ensure the body part is relaxed, supported and exposed -Remember referred pain/tenderness

What are examples of stretching of capsules?

-Extension of MCP

What is the ATC's MAIN RULE & MOTTO?

-FIRST DO NO HARM!!!

Why do we assess Posture?

-Faulty posture causing problem or adapated posture to decrease pain

What is the Joint Capsule?

-Fibrous tissue surrounding and providing stability to a joint -The bones in a freely movable joint (Diarthrodial joint) have a space b/t the bones -With movement the capsule is taut in some areas while loose in others -If the capsule i involved there are "typical" restrictions that will be seen = capsular patterns

How do you clear blockage of airway?

-Finger Sweep -Heimlich Maneuver

What are we supposed to feel with Tissue Stretch/elastic endfeel?

-Firm but "springy" w/slight give -Feel elastic resistance or tension toward end of ROM -Muscular, capsular, ligamentous

What is Cervical ROM?

-Flexion -Extension -Side bend/flexion -Rotation (active, pain-free add overpressure, NOT EXTENSION)

What do you do if someone is not breathing?

-Follow airway procedures -Rescue breathing/CPR

What are examples of stretching of ligaments?

-Forearm Supination

How do you know a patient has referred pain?

-Full and painless PROM w/ painless RROM

What are you inspecting with ADL's?

-Gait -Ability to sit or stand -Dress/undress self -General ease of movement -Activities of sport/work

What is The Upper Quarter Screen used for?

-General observation/inspection -Cervical ROM/strength (AROM,PROM) -UE ROM/strength -Dermatomes -Myotomes -Deep Tendon Reflexes

What are the Grades for Stress test and meaning behind them?

-Grade 1 (No laxity with stress test) -Grade 2 (Laxity with an endpoint) -Grade 3 (Laxity without and endpoint)

Where should you test patients RROM?

-Half of the full ROM. -If short of Mid-Range, back off the,

What does a Bone to Bone feel like?

-Hard bony block at inappropriate time or in inappropriate joint -Bone spur in knee

What happens with Increased/Hypertension?

-Head Injury -Exercise

How do you Maintain Airway?

-Head Tilt -Jaw Thrust -Oral Screw -Tongue Forceps -Oropharyngeal -Nasopharyngeal

What are examples of stretching of muscles?

-Hip flexion with knee extended

What is the kinetic Chain?

-How the body is connected and interacts with each other

What is assessing Physiological and mechanical motion?

-How the body moves and how passively it has more ROM, because the muscle crosslinks are less.

What is Abnormal Movement with AROM?

-Hyper or Hypo -Compensation/Accessory Movement

What conditions cause Bounding and Rapid Pulse?

-Hypertension -Fright -Heat Stroke -Hyperglycemia

What is a tigger point?

-Hypertinisity -Radiating pain

How are Special Tests conducted?

-Identify the anatomic structure involved -State of Pathology -Appropriate therapeutic Treatment can be administered

Is the athlete moving? Thinking about why the athlete is down?

-If so, their CNS and cardio-respiratiry systems are intact.. for now

When do you need to repeat ROM & RROM test?

-If the s/s change ex. overuse injury

Who is going with the athlete to the locker room to monitor?

-If you have help, send someone or you go if team activity has stopped

How are joint play movements Evaluated?

-In a "loose packed" position

What are we looking for with AROM?

-Inability or unwillingness to move may indicate a severe injury -However, some patients may not have a high pain tolerance -May be a malingerer

Morning Pain injuries?

-Inflammation/edema

What is 2- (poor minus)?

-Initiates motion if gravity eliminated

What is 2+ (poor +):?

-Initiates movement against gravity

When would Goniometers be used?

-Insurance wants Range of motion improvement -Surgen does not want more than a specific degree of motion

What does it mean when isometric resistance to specific muscles reveals Painful Arc?

-Internal structure is being squeezed

Can the injured athlete return to activity?

-Is it full or resisted

If you call for help like EMS or Doctor, what happens to the chain of command?

-It becomes their scene

How can you find the cause of pain?

-It is not enough to discover the certain movements and tests evoke pain -Care must be taken to make sure that the tests reproduce the very pain of which the patient complains

What can capsular tightness be caused by?

-Joint effusion or synovial imflammation -Fibrosis & Adhesions

What if distraction has decreased pain?

-Joint surfaces/mechanical obstructions may be suspected

Where is Internal derangement most common?

-Knees -Ankle -Elbow -Jaw -Spinal Joints -HIP!!!!!

How do you know what you are palpating?

-Know your anatomy -Close your eyes to get a better feel of tissues and texture -Visualize what you're palpating

What is Decorticate?

-LE extention -UE Flextion -Injury above brain stem

What Causes shock?

-Lack of blood flow to vital organs & tissues

What colors indicate Whitish, Bluish, Grapish skin?

-Lack of blood flow/02

What are the different eval tests?

-Ligament Stress Tests -Joint Integrity Test -Special Tests -Neurological Tests -Functional Tests

INERT TISSUE LESIONS: What does pain with limited ROM or laxity in some directons but not others?

-Ligament or capsule sprain

What are some examples of non-capsular patterns?

-Ligament or partial capsule adhesions -Internal derangement -Extra-articular limitations

In order to determine what injury/condition, what are 3 ways a clinician can categorize injuries?

-Likely -Possible -Unlikely

What are Extra-Articular Limitations & Inflammation?

-Limitation caused by muscular trauma (contracture or adhesions), bursitis, hematoma -Acute inflammation of structure EX: thigt lats limiting shoulder abduction

What are Non-Capsular Patterns?

-Limitations of motion not corresponding to the capsular pattern -Indicates joint capsule problem is not present -Lesions that are capable of causing restriction of ROM, but not involving the whole joint need to be considered

What is the Capsular Pattern of Shoulder (limited ER)? Capsular pattern?

-Limited ER -Limited Abd -Limited IR IN THAT ORDER!! If not in that order, not a capsular pattern

What does it mean when isometric resistance to specific muscles reveals A strong painful contraction?

-Local muscle or Tendon injury

What is a UMN Lesion?

-Located in spinal cord & CNS -Brain stem, cerebral impairment, spinal cord compression, neurological disease -"Central palsy"

What is LMN?

-Located on the dorsal & ventral roots, spinal nerve, peripheral nerve, neuromusclular junction, muscle-fiber complex -Cell body & axon that travels to a muscle via cranial or peripheral nerve -"Peripheral Palsy

If pain increases with Compression?

-Loose body or internal derangement may be present -The compressive force of muscle contraction may also cause an increased pain

What is Hyporeflexia?

-Lower motor neuron Lession

What happens if you do not know what is wrong?

-Make sure it is not life threating

Where do nerve root problems exisit?

-May show up anywhere distal to the nerve root in any peripheral distribution

What is MOI?

-Mechanism of injury -Watch

What is use RROM for?

-Mid Range isometric contractions are use -SO that there is minimal movement or stress to the non-contractile structures around the joint -If you allow too much movement or compression of the joint (You CAN NOT RULE OUT THE INERT STRUCTURES!!!)

What is Transient Pain?

-Minimal tissue damage -"boo-boo"

What does it mean when isometric resistance to specific muscles reveals A weak and Painful contraction?

-Moderate to severe injury of muscle, tendon, or BONE -Weakness may be reflex inhibition

What is Centralization vs Peripheralization?

-More focal vs more diffuse

What are we looking at with bilateral symatry?

-More muscular on dominant side -Lower shoulder on dominant side -slight scoliosis adjacent to heart

What are signs of life?

-Movement -Moaning -Talking

What does decreased joint play mean?

-Movements will cause a decrease in functional movement

What are ABNORMAL ENDFEELS?

-Muscle Spasm/Guarding -Springy block -Bone to bone (Inappropriate time or joint) -Empty -Boggy -Capsular

How does Muscle Spasm/Guarding feel?

-Muscle Spasm/Guarding (slow vs fast guarding) -Usually painful -Body's attempt to prevent injury EX. Shoulder apprehension test

What are common s/s of LMN?

-Muscle atrophy -Hypotonus -Decreased or no Deep Tendon Reflex -No pathologic reflexes -Flaccid paralysis -Decreased sensation -Trophic skin changes -Decreased sweat from glands

What is slow guarding?

-Muscle contracts and then gives away

What is Fast Guarding?

-Muscle contracts but does not give way indicating a severe and active lesion

What happens with a reaction of the joint capsule?

-Muscle spasm -Capsular contraction -Osteophytes

What is a Contractile Unit?

-Muscle with its tendons and attachments

What does it mean when isometric resistance to specific muscles reveals A Strong painless contraction?

-Muscle, Tendon, & nerve is not injured

What muscles should you always test?

-Muscles that are notoriously weak

Night pain symtoms, what type of injuries?

-Muscular Tumors -Shin Splints -Stress Fractures -Rotator Cuff

In a history, be sure to ask what other complaints the patient has?

-Nausea -Weakness -Numbness -Tingling -Dizziness -HAVE THEY DONE ANY TREAATMENTS OR TAKEN ANY MEDS FOR THIS INJURY, DID IT HELP? -PAST medical history

What is Nerve pain?

-Nerve root (sharp, burning, shooting, PINS/needles w/pain) -Nerve Trunk (Pins/needles w/o pain) -Sympathetic Nerve (Burning/pressure like/stinging/aching)

What is 0/5 (None MMT)?

-No contraction is palpated

What is Empty feel like?

-No real end-feel because there is considerable pain w/ movement without mechanical resistance- pt just tells you to stop b/c it hurts -Or there is no end feel b/c the ligaments & or / capsule have been disrupted (some call the 2nd part a "loose" endfeel -(You cannot get the position without pain/or it just moves freely)

What does 0 mean in Reflexes?

-No response/absent/areflexia

Just because someone has superficial nerve issue, does it mean they have a nerve root issue?

-No, depends on mechanism

Are normal end-feels always correct to every joint?

-No, normal end-feels only apply to specific joints

What does 2 mean in Reflexes?

-Normal Response

What is Swelling/effusion with an injury?

-Not good indicator of severity of injury (Ex. Labrum big injury: Bursities not a big deal) -If swelling very quickly, probably bad

What is OPQRST?

-ONSET -PROVOKING FACTORS -QUALITY -REFERRED PATTERNS -SEVERITY -TIMING

What Information is included in the history?

-Obtain demographic info (Name, age, occupation, sport, position) -Elderly= arthritis, osteoporosis, accumulative trauma, poor circulation -Adolescent= avulsion fractures, growth plate involvement -Occupation/position/activity specific injuries pitchers w/rotator cuff

What is something to look at with Inspection?

-Obvious deformity -How do they walk? (Genu ricorvotum) -How do they move the injured body part? -Can they take off their shirt or shoes -How are they holding limb? -ADL's

INERT TISSUE LESIONS: What does limited ROM, no pain, with abnormal bone on bone endfeel mean?

-Osteoarthritis or -Bone Spur

What is Observation of UQS?

-Overall posture -Bilateral comparison -Include "normal" list of things to look for

What does it mean when isometric resistance to specific muscles reveals Pain on Repetition?

-Overuse Injury

Which will have more ROM, PROM or AROM?

-PROM

What can cause abnormal AROM?

-Pain -Muscle weakness -Spasm -Paralysis -Tight/shortened muscles -Joint Injury -Limited neuromuscular control

What is NOT the painful arch motion?

-Pain at the end of the range is NOT painful arc -A structure is usually still getting pinched, just AT THE END OF THE RANGE

How to determine if it is a Inert Structure Injury?

-Pain with AROM and PROM

How do you know a patient has a Lesion to Inert Structures?

-Pain with AROM and PROM (especially near end of range) but usually not with RROM (especially if you distract the joint as they contract) -Pain may be present if the muscle contraction causes joint compression

How to determine if it is a Contractile Unit?

-Pain with AROM, but not with PROM

What is 1/5 (Trace MMT)?

-Palpable muscle contraction without movement

What is Sensory Deficit?

-Paresthesia (pins, needles, numbness, prickling) -More severe deficit

Anatomical motion is?

-Passive motion

How do you know if RROM indicates a contractile structure is at fault?

-Passive movement painful in one direction and active movement painful in the opposite direction (Stretching the tissue while passively moving the joint in one motion then contracting the tissue while actively moving in opposite direction)

What is Movement Sense?

-Passively move extremity and ask patient to verbalize the direct of movement

What is Position Sense?

-Passively move great toe up or down and ask patient to tell you which direction it''s moving

What is a latent trigger point?

-Patient did not know a trigger point was there

What is Stereognosis?

-Patient identifies common objects by touch alone (coins, pencil, comb)

What is Graphesthesia?

-Patient identifies numbers, letters, objects "drawn" on skin

How to assess AROM?

-Patient moves body part through ROM -Uninjured side 1st or bilateral -Painful motions last -Assesses physiological motion/barrier (Anatomical ex. Elbow extension) -Subjective measurements of motion and ease (How easy is to perform pattern) -Objective measurement and documentation via goniometer

What is a Non-Capsular Pattern?

-Pattern implies that the capsule is not involved and that intra- or extra- articular tissue is inflamed or injured and the source of pain

When to perform PROM?

-Perform Overpressure w/AROM if patient has full, pain less AROM -If not FAROM, Determine the end-feel at the pathological limit

How do you perform a Scanning Examination?

-Perform an upper & lower quarter screen for sensation (dermotomes), motor function (myotomes), and deep tendon reflexes

What does Inelastic, shiny, skin broken down, slow healing, brittle nails?

-Peripheral nerve lesion

What happens with a Lower motor neuron Lesion?

-Peripheral neuropathy, Cauda equina syndrome, spinal nerve root compression

What is Acute Pain?

-Persists beyond a few minutes -Associated w/tissue damage -Extent of pain depends on psychological experiences cultural background & environment also: "tough" "wuss" "babied" traditions

What is Location of pain as part of the History?

-Point with one finger the worst spot -Has the pain moved?

What if pateint hears or feels anything?

-Pop, crack, buckle, locking -Not always indicative of severity -Pop w/knee injury=ACL -Two pops w/joint injury= subluxation -Buckling= instabi;ity or reflex inhibition of muscle

What is Motor weakness or change in sensation?

-Possible nerve, nerve root, or CNS involvement

What are some Past Medical History examples?

-Previous diagnosis and by whom -How they treated it -Was it fully healed -When did they hurt it -How does this injury compare

What are things to look for with scars?

-Previous injury/surgery -Keloids

What are Superficial Reflexes?

-Provoked by superficial stroking

What must you do once you find out what hurts an athlete and the injury?

-Put it together -One positive test doesn't mean you have the answer

How do you assess severity of pain?

-Rank on a 0-10 scale -Get a reference of 1 & 10 (Ask what can they compare the pain to) -Is it better or worse then when they first did it -SUBJECTIVE

What must you do with an athlete that has been injured for a while?

-Reassess Daily -Don't take other diagnosis/assessment for granted

What does a Springy Block Feel like?

-Rebound feeling related to an intra-articular obstruction -Meniscal tear in knee

What are things to look for with Discoloration?

-Red/flushed= infection or inflammation -Blue/ashy= cyanotic/ischemia -Ecchymosis= bruising

What is RSD stand for?

-Reflex sympathetic Dystrophy

How are Contracile Sturures assessed?

-Requires that the joint be in neutral position and that the various components be stressed by resisted testing of specific motions -AROM -RROM -MMT

What is Resistive Range of Motion?

-Resist the related muscles so that they contract isometrically in the Mid-Range -In order to determine if there is pain pr decreased strength in the contractile units

What causes Fibrosis & adhesions?

-Resolution of an acute articular inflammatory process -Chronic, low-grade articular imflammatory process -Immobilization of the joint

What is Deep Tendon Reflexes used for?

-Reveal integrity of the nerve roots/spinal reflex from the lumbar and cervical spine

What are Pathological Reflexes?

-Reveal something is wrong w/ CNS -EX (UMN)

What does it mean when isometric resistance to specific muscles reveals A Weak and painless contraction?

-Rupture of muscle or tendon or nerve injury -"Faker"

What does it mean to have a RED FLAGS?

-S/s that tell you something major/ severe is going on -s/s that tell you that the problem is not orthopedic in nature -S/s that tell you the problem is not something that you can handle

What are Dermatomes?

-Sensory Distribution of each nerve root -Area of skin supplied by a single nerve root

What is Traction/Distraction?

-Separate joint surfaces and note if the pain increases or decreases and note how easily the bones move apart

What method do we use in an Evaluation?

-Sequential Method

What is Sharp vs Dull vs Ache Pain?

-Shape & localized= peripheral lesion -Dull & aching= deep somatic injury -Intermittent vs consistent

What condition causes Weak & Rapid Pulse?

-Shock -Heat Exhaustion -Hypoglycemia -Faint -Hyperventilation

What is Functional/Sport Specific Testing with neurological effect?

-Should incorporate sport specific or functional tests to determine the amount of incapacitation the injury causing

If someone is hurt, where will the athlete go if they are hurt?

-Sideline, training room, locker room, hospital -How are they getting there?

What is Tripod Position? (after running basketball sprints)

-Sits leaning forward on outstretched arms w/head & chin thrust forward

What is Sniffing Position?

-Sits upright, head & chin thrust forward, appears to be sniffing -Common in children

What should you palpate?

-Skin and subcutaneous Tissues -Muscles -Tendons, -Tendon Sheaths -Bone -Joints -Ligaments

Altered L.O.C s/s?

-Slightly confused/disoriented to unconscious

What are ways to classify Normal End Feel's?

-Soft tissue Aprroximation -Bone to Bone -Tissue Stretch/Elastic

What are we supposed to feel with Soft Tissue Approximation?

-Soft/Mushy/painless, "Could go further w/more force" -Related to compressing or stretching of soft tissues

What to look for in muscle tone?

-Spasm (Overcompensating muscle) -Mushy (not turning on, nerve issues) -Normal

What are common s/s of UMN Lesion?

-Spastic paralysis/paresis -Little / no muscle atrophy -Hyper reflexive DTR -Pathological reflexes -Ataxia (LE=veer/fall to affected side . : UE= decreased accuracy w/reach) -Muscle spasticity -Nystagmus -Dysphasia -Drop attacks -Diplopia -Painless voice hoarseness -Loss of 1/2 visual field (bilaterally) -Ptosis (drooping eyelid) -Miosis (pupils don't dilate) -Articulation changes

What does normal effort breathing look like?

-Speaking smoothly & effortlessly

Manuel muscle testing?

-Specific muscle tensting

Why is it important to take into account Specificity & Sensitivity?

-Specifity does not have condition -Sensitivity person has condition -Clinician does not waste time & money doing things that do not work efficiently

What happens if person needs to be moved?

-Spine board -Carry -Cart -Chair -EMS

What are some ABNORMAL ENDFEELS?

-Springy Block -Bone to bone -Empty -Boggy -Capsular

What does it mean when isometric resistance to specific muscles reveals Pain at end of ROM?

-Squeezing or stretching of the joint

What to look for in muscle deformity?

-Strain -Avulsion

What is a Stress Test?

-Stress a particular structure to detect a lesion (EX. Lachman, Apprehension test)

What is Special Test or Evaluation?

-Stress or special tests or evaluation of function is when you assess the athletes ROM, strength, stability, a=neurological status and functional capabilities

How are Inert Sturctures assesed?

-Such as the joint capsules and ligaments, requires a passive stretch of the joint tested

What does apprehension in the early part of the range mean?

-Suggest anxiety caused by pain

What does it mean for the patient to have apprehension during AROM limits motion at near or full end range ?

-Suggests instability

What happens with the off-field evaulation?

-Take your time to evaluate all potential problems -Very Detailed examination (HIPS/HOPS/HOPE)

Does the athlete need protection?

-Tape, brace, pad

How to palpate the Skin and Subcutaneous tissues?

-Temperature -Swelling/effusion/edema -Texture -Determines sensation differences on the part of the patient

What to look for when Palpating Tendons, Tendon Sheaths, and Bursae?

-Tenderness -Texture -Deformity -Crepitus

What happens when Both Contractile and Inert Structures are influenced by AROM, specific problems are not isolated?

-Tension placed on contractile tissues by stretching or contraction (muscles, tendons, attachments) -Tension placed on Inert Structures by stretching or pinching/compressing

How may you need to change RROM?

-Test specific areas of ROM -Test Concentric or eccentric -Test reps -Test entire ROM

What are Myotomes?

-Testes w/MMT -Groups of muscles supplied by a single nerve root

Who provides the care if an emergency?

-The highest trained person

If pain is decreased with Compression?

-The joint capsule may be irritated

What if AROM and PROM are limited or painful in the same direction?

-The lesion is in the INERT TISSUE

What if the AROM and PROM are limited or painful but in opposite directions?

-The lesion is in the contractile tissue

Who is in charge of evaluation?

-The most experienced that is available

Who makes the call on the athlete?

-The person who did the evaluation determines the plan of action unless they specifically instruct otherwise

What motions should be assessed with PROM?

-The same movements that the patient did actively are repeated passively; therefore, all the movements of specific tissue -Assesses anatomical movement/barrier

INERT TISSUE LESIONS: What does Full ROM, no pain?

-The structure you are testing is not injured by that stress, but it may be injured by another stress

What can we do to check Functionality?

-The tests can be simple as walking, hopping, skipping, jumping, throwing, catching -Can be more complex activities that more closely resemble the activities the athlete is expected to perform (cone drills, running passing routes, reaction drills)

What is a Conscious person?

-They have an Airway, Breathing, and Circulation -Talking and Interacting. FOR NOW

What things to look for in Abnormal breathing?

-Throat/neck trauma (tracheal injury) -Blockage of airway (remove with tongue forceps) -Swollen tissues (Anaphylaxis) -Chest Trauma (Heart, Lungs) -Major head/cervical spine trauma

What is vascular pain?

-Throbbing -Aching -Diffuse

Capsular Pattern of Shoulder (limited ER)? Non-Capsular pattern

-Tight Internal Rotation (Subscap) -Loose Joint Body

What is RROM used for?

-To determine the extent of the injury. -Make sure it is muscle, tendon, or bone

What are Scanning Examination?

-To rule out that something else is causing the problem -Rule out involvement from spine/nerves/other joints

Why AROM?

-To test what they can do and rule out certain conditions

What to look for in point tenderness?

-Trigger points (has to cause Radiating pain)

Disturbs Sleep Injuries?

-Tumor?

S/S when you suspect and Spinal Cord Injury?

-Unconscious -Neck pain/stiffness -Numbess, tingling, burning -Weakness, paralysis -Loss of bladder/ bowel control, priapism -Decrease or not equal response to painful stimulus (sternal rub, pitching)

What are scanning Examination?

-Upper Quarter Screen -Lower Quarter Screen

What is Hyperreflexia?

-Upper motor neuron lesion -Pathological reflexes

Why do we tests?

-Use to rule out or confirm joint or capsule lesions -Always compare bilaterally, beginning with the non-injured body part -Caution on amount of force used

What is Special Tests?

-Used to detect a condition or injury (Phalen's test for carpal tunnel syndrome)

CONTRACTILE TISSUE MISC

-Usually pain with AROM and RROM but not PROM

What are we doing with PROM?

-WIth the muscles relaxed, only INERT Structures are being stressed -Any of the motions provoke the patient's symptoms -Compare PROM to AROM

What are things to look for with Temperature Changes in the skin?

-Warm= infection or inflammation -Cold= Ischemia

What does 1 mean in Reflexes?

-Weak Response/diminished/ hyporeflexia

When is there a Capsular Pattern?

-When a synovial joint is traumatized, inflamed, or immobilized, the joint capsule's mobility may become limited -The limitations in motion follow a pattern of restriction -Which is typical for that joint when capsular/ joint problems exist -Detected by performing PROM -Caused by reaction of the joint capsule

How to test Myotomes?

-When testing myotomes, hold contraction for at least 5 seconds as myotomal weakness takes time to show up

What is an End Feel?

-When the end of the available range is reached, pressure (Overpressure) is applied in order to determine the endfeel

What is the "loose packed" position?

-When the joint is under the least amount of stress and the joint capsule has the greatest capacity for movement -Minimal congruency b/t the articular surfaces and the joint capsule -Ligaments are the greatest laxity -There is the greatest passive separation of the joint surfaces

What else is in the history?

-Why are they here? (Chief complaint) -What happened? (specific mechanism of injury) -When did it happen? (Acute vs chronic)

What is Internal derangement?

-With a loose fragment in a joint the onset is sudden -Pain is localized -The movement which engages against the block is limited, other areas are pain0free and normal -The direction of limitations may change due to movement of the loose fragment -Painful arc is possible

What are ligament adhesions?

-With slight limitation in one direction but full painless ROM in other directions -Proportionate limitation -Characteristic of he involved ligament

If the person is breathing, is their heart working? Do they have circulation of blood?

-Yes & Yes

With an On-Field Evaluation, do you take a history?

-Yes but it is abbreviated

Example of Special Test: Perform a Finkelstein's test. Is it painful? Do they have n injury there?

-Yes painful, but only when the test is forced upon. No pain with activity, so this is BOGUS!

Example of Special Test: Palpate the posterior aspect of your neighbor's proximal tib-fib juction. Is it painful? Do they have an injury there?

-You are probably pushing to hard bro!

How do you check for the quality and quantity of the joint play movement?

-You glide one of the joint surfaces on the other -Check how easily the bones move and whether or not the joint movement causes pain

How do you perform RROM?

-You passively place the body part in the mid-range -Then Perform the strength test (This increase the tendency for the inert tissues to be unaffected) -Gradually put more pressure -Hold for at least 5 seconds -Then Slight overpressure

What is the PAINFUL ARC OF MOTION DEF?

-pain with active or passive motion somewhere within the ROM indicating some sensitive structure is being pinched during that ROM

What is a Capsular Feel like?

-the end feel described when the end ROM is limited primarily by the joint capsule (due to capsular tightness) -Similar to tissue stretch, but too early and restricts ROM (firm "leathery" feel) -May have resistance through range

What is the order of Tests?

1) AROM 2) PROM 3) RROM (MMMT) 4) Stress/Special Tests 5)Evaluate Function

What is reflex pain?

: Accompanied by hyperalgesia , hyperesthesia & vasomotor, sudomotor & trophic changes

What are some examples of referred pain?

: Deep burning or aching along a limb : Pain from back of trunk to anterior aspect : Pain w/ indefinite boundaries : Probable if upon further examination the area is without signs of disorder and there is no altered function of the painful part : Brain misinterprets the source of the painful impulse : Visceral involvement in referred pain (Kehr's sign)

What is Nociceptive Pain?

: Related to ongoing tissue damage

What is projected/transmitted/transferred pain?

: transmitted along the course of a nerve -Segmental (dermatomal) or peripheral distribution

What is the AVPU scale?

Checks for a persons level of consciousness

What is DTR?

Deep Tendon Reflexes

What is History?

History is the subjective information that the athlete or someone else provides

What is a Systematic Approach?

Includes the HIPS/HOPS

What are you looking for with tension being placed on inert structures by stretching or pinching/compressing?

Injuries regarding: -Not contractile or neuro -Joint capsules -Ligaments -Bursae -Cartilage

What are the categories of pain?

Nociceptive, Projected/transmitted/transferred pain, reflex pain, referred pain

What is Referred Pain?

Pain from deep somatic or visceral structures to a distant region w/in the same neural segment

What is chronic pain?

Persist beyond the expected recovery time : 3-6 months : accompanied with depression, sleep disturbances, and decreased appetite : Can be a neuro issue

What is Hyperventilation?

Quick/rapid breathing

What is the sequence of Overuse Injury?

TENDONOPATHY -Pain w/ specific activity -Pain at start of activity decrease w/ warm up -Pain during & after specific activity w/o decrease performance -Pain during & after specific activity w/ decrease perfermance -Pain w/ Activities of daily living -Constant aching pain at rest w/o disturbed sleep -Dull aching pain w/ disturbed sleep

What is Apnea?

Temporary cessation of breathing

Systolic is the pressure going out. What is Diastolic?

The pressure in refilling the heart. Residual pressure

What is Painful Arc?

When patient raises shoulder and has ouch, ooouch, then fuuucckk pain!

What is 3+ (fair+)?

complete ROM vs gravity w/minimal resistance

What is 3- (fair -)?

limited ROM vs gravity

What are Normal Pulse Rate? Adult, Child?

- Adult (60-80) - Child (80-100) - Athlete (40-60)

What happens on an On-Field Examination?

-Abbreviated "clinical exam" to rule out "serious" injuries -Spinal cord, head injury, fracture, dislocation, major strain/sprain -Injuries requiring immediate treatment/ stabilization -Determine immediate course of action (EMS, refer now, refer later, re-evaluate, limited return, return"

What is Internal Hemorrhaging?

-Abdominal rigidity -Abdominal pain, DIB -s/s of shock with little to no external bleeding

How should breathing look like?

-Breaths should be successive without interruption -Normal breathing is effortless, relatively free from sounds, and painless -How well are they breathing

What happens with Reaction to light?

-Brisk/normal -Sluggish -Nonreactive -Fixed -Inappropriate

What if you have hot skin?

-Burn -Fever -Inflammation -Infection

What is Abnormal breathing noises?

-Crackle -Rub -Stridor -Wheeze

Should breathing be Bilaterally equal?

-DUH! Yes! If not they have a collasped lung!

What is Shallow breathing?

-Decrease chest -Decrease Abdomen Rise

What is Delirious? (L.O.C)

-Disoriented, Restless, irritable

If ABC's are not established?

-Do nothing but ABC's -LIFE OVER LIMB -EMS!!

What is Irregular pulse rate?

-Early, late or missed beat -Rapid Pulse = short intervals -Slow pulse = longer intervals -EMS

What is Decerebrate?

-Extention of LE & UE -Injury to the brain stem

What condition causes Weak & Slow?

-Head Injury

How do we open an Airway?

-Head Tilt (if no suspected C-spine) -Jaw Thrust Maneuver (if C-Spine injury)

What is HIPS?

-History -Inspection -Palpation -Special Tests

What is HOPS?

-History -Observation -Palpation -Special Tests

What is the Primary Survey?

-Immediately life threatening problems

What is Respiratory Distress?

-Inability to speak fluently

What is Labored Breathing?

-Increase effort -use of Accessory Muscles -Gasping -Flared Nostrils

What is Noisy Breathing?

-Increased sounds -Wheezing -Gurgling -Grunting -Stridor

What is Observation/Inspection?

-Is the objective information that you gain primarily throughb visual cues

What is an On-Field assessment used for?

-Is this life or limb-threatening

What are 3 things to look for with ABC's?

-Look -Listen -Feel

What are things to look for in establishing if airway is open?

-Look for chest rise -Listen for breathing, talking -Feel for chest rise & breath on face

What is Unconscious person?

-May faint, but ABC's will be there -Or may not have all ABC's functioning

What is the Secondary Survey?

-Non-immediately life threatening problem

If all fails, what do you do?

-Oxygen tank

What is Palpation?

-Palpation is the process of putting your hands on someone and gaining information through touch

If more than 2 seconds for Capillary Refill?

-Poor Peripheral circulation

What does PEARL stand for?

-Pupils -Equal -and -Reactive to -Lightly

How to check breathing once established?

-Rate -Quality -Rhythm -Depth -Effort -Noises

What should the strength of the pulse rate be?

-Regular -Bounding =stronger than normal -Weak/thready = difficult to feel

What is P?

-Responsive to pain -appropriare vs inappropriate

What is V?

-Responsive to verbal stimulus -Aroused & responds by opening eyes, moaning, speaking, or moving -Normal voice vs yelling

What are s/s of shock?

-Restless / anxious -Weal & rapid pulse -Cold & clammy skin -Profuse sweating -Pale fascial color (grayish in dark skinned -Respirations (shallow, labored, rapid, irregular, gasping) -Dilated pupils -Thirst -Nausea, vomiting -Loss of conscious- usually if rapid onset -Decrease blood pressure (systolic < 100)

What noises should be present in normal breathing?

-Silent

What is looking for substantial injuries 1st?

-Spinal cord, fractures, dislocations, major soft-tissue injuries -Continue to be aware of potential life threatening injuries

What is Irregular Rhythm?

-Varied timing of respirations

What is a Clinical Secondary Assessment?

-Very Detailed

What does it mean when someone says they are Either A or Unconscious

: Awake and alert is the only criteria where the person is awake. Therefore, if not awake, they must go under V,P, or U

What is Confused? (L.O.C)

: Disoriented and does not know the person, place, nor time. : Short Attention span :Difficulty following conversation/commands

What is Alert? (L.O.C)

: Normal Conversation without delay . : Oriented and knows the person, place, and time

What does the Presence of CSF or blood (ears/nose) mean?

: Skull fracture (Halo Sign)

What is Dyspnea?

Difficulty/labored breathing

What is tachycardia?

Pulse rate above 100

What is bradycardia?

Pulse rate below 60

What temperature should the skin be?

Warm