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Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
The Injury Examination ProcessThe Injury Examination Process
Chapter 1
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Systematic Examination TechniqueSystematic Examination Technique Objective data
Baseline measures Re-evaluations Rehabilitation and treatment protocols
Documentation Medical records
Legally required Communication tool
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Table 1.1. Role of the Noninjured Limb in the Examination Process
Table 1.1. Role of the Noninjured Limb in the Examination Process
Evaluation Strategies
1. Perform each task on uninjured limb first.
2. Perform each task on injured limb first.
Increase or decrease apprehension and muscle guarding?
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Clinical AssessmentClinical Assessment Clinical assessment vs. acute evaluations
What are the differences? Special considerations
Discretion Religious considerations Informed consent
Signed written statement Verbal Emergency medical care
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
HistoryHistory Identifies
Mechanism of injury Past medical history Underlying pathology Impact injury may have on patient’s life
Communication skills Open-ended questions
Avoid “yes” or “no” questions unless critical
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Past Medical History Past Medical History Past medical history
Non-acute examinations (physicals) Health conditions Previous injuries Predisposing factors NCAA Guideline 1B: Medical
Evaluations, Immunizations, and Records (Box 1-3)
Previous history questions
Is there a history of injury to the body area? On either side? Describe and compare
current injury Do the current symptoms
duplicate the old symptoms?
Are there any possible sources of weakness from a previous injury?
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Past Medical HealthPast Medical Health General medical health
Current health status? Comorbidities present?
Relevant illness and lab work Note during exam if they may
affect injury management or the healing process.
Medications What medications are they
currently taking? What interactions or effect
may they have on healing, treatments, etc.?
Smoking Decrease exercise tolerance Increased risk for CV disease May delay fracture and
wound healing
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
History of Present ConditionHistory of Present Condition Mechanism of injury
(MOI) How did the injury
occur? Macrotrauma Microtrauma
Identifies structures involved
Relevant sounds or sensations
Onset and duration of symptoms Acute Chronic
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
History of Present ConditionHistory of Present Condition Pain
Location Type Referred Radicular Daily pain patterns Provocation and
alleviation patterns
Other symptoms Treatment to date Affective traits Disability/limitations
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Physical ExaminationPhysical Examination Goals
Rule out differential diagnosis Determine clinical diagnosis Identify impairments and functional limitations
Standard precautions against bloodborne pathogens (Box 1-5)
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
InspectionInspectionImmediate observations
Physical examination observations (bilateral) Deformity
Subtle or gross? Swelling
Hemarthrosis Edema
Girth measurements (Special Test 1-1)
Skin Redness Ecchymosis
Infection signs
As soon as patient enters facility observe Gait Posture Function Guarding Splinting
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
InspectionInspection Functional assessment
Perform functional tasks that were identified as problematic.
Impairments should be identified and measured.
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
PalpationPalpation Bilaterally performed in specific sequence Sequencing strategy #1
Bones Ligaments Muscles and tendons
Sequencing strategy #2 Palpate all structures Begin away from pain site and progress toward
suspected injury.
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
PalpationPalpation Point tenderness Trigger points Change in tissue density Crepitus Tissue temperature
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Perform bilaterally Involves
Active range of motion (AROM) Manual muscle testing (MMT) Passive range of motion (PROM) Joint stability tests Stress testing Joint play
Joint and Muscle Function Joint and Muscle Function AssessmentAssessmentJoint and Muscle Function Joint and Muscle Function AssessmentAssessment
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Active ROMActive ROM Joint motion produced by the patient
contracting the muscles Evaluated first (unless contraindicated) Note
Ease of movement Range of motion achieved
Painful arc Compensation
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Manual Muscle TestingManual Muscle Testing Assesses strength and provocation of pain by
relatively isolating the muscle Resisted range of motion (RROM) assesses
strength throughout the muscle’s entire ROM Procedure
Stabilize limb proximally Apply resistance distal to muscle attachment, not
joint Grade accordingly (Table 1-6)
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Manual Muscle TestingManual Muscle Testing
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Passive ROMPassive ROM Clinician moves the joint through the ROM Identifies the available movement and pain
patterns Apply over-pressure to determine end-feel Findings
PROM > AROM — suspect muscular weakness or tissue lesion
PROM = AROM and are deficient — suspect capsular adhesions or joint tightness
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Joint Stability TestsJoint Stability Tests Procedure
Apply specific stress to non-contractile tissue
Hypermobile — more laxity than normal
Hypomobile — below normal laxity
Laxity — clinical sign of the amount of “give” within a joint; identified by stress testing
Instability — joint’s inability to function under the stresses of function activity
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Stress TestingStress Testing
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Joint PlayJoint Play Accessory/arthrokinematic motion
Rolling Spinning Gliding
Procedure Patient relaxed in loose-pack position Gliding or distracting stress is applied Degree of movement assessed Compare bilaterally
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Special TestsSpecial Tests Specific procedures applied to selected tissues Unique to each structure Results are compared
Side to side Cause provocation Cause alleviation
Reported as positive (+) or negative (-)
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Neurologic ScreeningNeurologic Screening Upper and lower quarter
screen Evaluate
Sensation Motor function Deep tendon reflexes
Identify Nerve root impingement Peripheral nerve damage CNS trauma Disease
Indicated by Numbness Paresthesia Muscular weakness Pain of unexplained origin Injury to cervical or lumbar
spine
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Neurological Screening 1-1.Neurological Screening 1-1.Lower Quarter ScreenLower Quarter ScreenNeurological Screening 1-1.Neurological Screening 1-1.Lower Quarter ScreenLower Quarter Screen
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Neurological Screening 1-2.Neurological Screening 1-2.Upper Quarter ScreenUpper Quarter ScreenNeurological Screening 1-2.Neurological Screening 1-2.Upper Quarter ScreenUpper Quarter Screen
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Sensory TestingSensory Testing Dermatome — area of skin innervated by a
spinal nerve root Bilaterally performed Patient position
Eyes closed and head turned away Discrimination tests
Light touch discrimination Sharp and dull discrimination Two-point discrimination
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Motor TestingMotor Testing If muscle weakness is noted during
neurological screening, test another muscle innervated by the same nerve root. If one muscle is weak, suspect muscle pathology
or peripheral nerve patholgy. If both muscles are weak, suspect nerve root or
peripheral nerve pathology.
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Reflex TestingReflex Testing Increased response upper motor
neuron lesion Decreased response lower motor
neuron lesion Deep tendon reflex (DTR)
Muscle stretched and relaxed Patient should look away Strike tendon with reflex hammer Jendrassik maneuver for difficult patients
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Table 1–10. Deep Tendon Table 1–10. Deep Tendon Reflex Grading Reflex Grading Table 1–10. Deep Tendon Table 1–10. Deep Tendon Reflex Grading Reflex Grading
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Vascular ScreeningVascular ScreeningGross assessment of blood flow to and from the extremities Capillary refill
Nail beds Pulses
Lower extremity Femoral Posterior tibial Dorsal pedal
Upper extremity Brachial Radial Ulnar
Systemic Carotid
Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Results from the history and functional assessment can reduce the number of tests to be performed. Example
Symptoms: Gradual onset No need to perform acute fracture special tests
Use best evidence Efficient
Eliminate time wasted performing unnecessary special tests Makes examine more accurate
Eliminate false positives
The Role of Evidence in the The Role of Evidence in the Examination ProcessExamination ProcessThe Role of Evidence in the The Role of Evidence in the Examination ProcessExamination Process