Location of Pain/Symptoms Where do you feel the pain/symptoms? Can you point with one finger to location of pain? Is the pain general or localized?

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1 Injury Evaluation History A complete and accurate medical history is one of the most important and useful parts of the clinical examination. A complete history consists of past history and a history of the present injury. Questions posed to the patient during the history taking process should be open-ended. Rather than asking a closed-ended question such as, "Does it hurt when you raise your arm?" which can be answered simply by "yes" or "no", an open-ended question such as "what movement causes you pain?" allows the athlete to describe in detail those motions causing discomfort. Past History All information collected should be synthesized in an attempt to identify the factors that contributed to the present injury. Information should include answers to the following questions for both the injured and non injured bilateral body part: 1) Previous injury to the body part or related structure. 2) Previous surgery 3) Pre-existing symptoms, including date of onset, anatomical location, and duration. Answers will help distinguish between chronic ligamentous laxity (pre-existing loose ligaments) and newly acquired instability (recent ligament Injury). Chronic inflammation or muscular strength imbalances may help explain the cause of acute muscle or tendon injuries. Present History Start your present history by having the patient describe in their own words "their problem". Their statement should be followed with specific questions to help you establish the Location, Type and Nature of the pain or symptoms, Relevant Sounds or Sensations at the time of injury, and the exact Mechanism of Injury. Location of Pain/Symptoms Where do you feel the pain/symptoms? Can you point with one finger to location of pain? Is the pain general or localized? Type of Pain/Symptoms How would you describe the pain? Is it sharp, dull, ache, gnaw, throb? Does the pain shoot, radiate? Do you have symptoms of paresthesia(numbness, burning)? Do you have a feeling of weakness? Nature of Pain/Symptoms What does the condition currently feel like? Identify which motions or positions cause and influence the symptoms? How easily are the symptoms evoked and how long do they last? What makes the pain feel better? Determine how severe or limiting the problem is? Determine behavior of pain, worst at night, morning, during activity, after activity?

2 Relevant Sounds or Sensations Did you experience any sensations? (click, pop, lock, grind, snap) Did you hear any sounds? (pop, snap, grind, crepitus) Mechanism of Injury Sources of information include: - Personal observation of trauma producing incident - The injured athlete - Other players or coaches, officials who witnessed the incident. Inspection Inspection is observation for local and generalized clinical signs. Inspection should be performed bilateral (right and left sides of the body) with comparison between the injured and non injured sides. Local Signs Swelling, discoloration, deformity, atrophy and asymmetry are inspected, at the sight of the injury. General Signs Evaluate patients response to activities of daily living, such as gait, ability to sit, stand. Is the affected part held stiffly to protect the painful area? Facial expressions are often a clue to severity of pain. Palpation Palpation should be performed thoroughly and systematically. It is often best to palpate the opposite, uninvolved body part first to identify pathological differences. The examination is enhanced by a sound knowledge of anatomy, which lets the examiner "visualize" the structures to be palpated. One of the most valuable uses of palpation is the identification of localized pain and point tenderness. With accurate identification you have a better understanding of specific lesions to ligaments, muscles, tendons, or bony structures involved. The patients reaction to a progressive increase in digital pressure may define the quality/severity of pain. A sense of touch can also reveal a temperature change(inflammation), abnormal gaps at joints, swelling, joint misalignment, abnormal protuberances, lumps, and muscle tension. The first step in the palpation sequence is to rule out a fracture. This is facilitated by early recognition of the following signs and symptoms of a fracture: Mechanism of injury that could cause a fracture Inspect for deformity - false joints - abnormal bumps Point specific tenderness Pain/Crepitus on bone movement - indirect pain - pain on percussion

3 Range of Motion Assessment of the patients functional status Active ROM Should always be evaluated first, as long as there is no immature fracture sites or recently repaired soft tissue. Athletes willingness and ability to move the body part through the ROM should be determined. Unwillingness to move could signify an extreme degree of pain, neurological deficit, or possible malingering. Any compensation or abnormal movement in the surrounding structures should be noted. Passive ROM By comparing the ROM obtained from Active ROM & Passive ROM you can evaluate the integrity of noncontractile tissue. Check for quantity of available movement. Check for Stage of Pathology. ACUTE: pain or muscle guarding experienced before the end feel SUBACUTE: pain or muscle guarding concurrent with the end feel CHRONIC: pain or muscle guarding after application of over pressure Check for Quality of End Feels. Normal End Feel Sensations Bone to bone This is a definite, abrupt end-feel when two bony surfaces approximate, or come in contact with each other, such as when the olecranon process of the elbow contacts the posterior humerus during elbow extension. Soft tissue approximation This indicates limited range of motion is due to normal extra-articular body tissue coming in contact with other tissue, such as when you bend your knee and the calf muscles meet the posterior thigh muscles. Tissue stretch A springy type of movement with a slight give that comes at the end of the range of motion. It is the most common type of normal end feel. Examples include hip extension and rotation at the shoulder.

4 Abnormal End Feel Sensations Muscle spasm This results in a rubber band twang when you reach the end of the range of motion. The muscle wants to contract to protect an acute injury. You may be able to palpate the muscle in spasm. Capsular This has a give to it similar to the tissue stretch but it does not occur where you would normally expect it. This indicates an injury to the joint capsule or synovial tissue. Bone-to-Bone This is similar to the normal bone-to-bone end feel but it occurs before the normal end of the range of motion, or where you might not expect it to occur. Empty end-feel The individual may stop you before you reach the end-feel because of excessive pain in an acute condition. Springy block This results in a rebound sensation which may be indicative of a loose bony fragment floating in the joint or damage to internal joint structures, such as a meniscus. Resisted ROM Can be performed through the joint's entire ROM, or more commonly tested isometrically through use of a "Break Test". Resistive testing is particularly useful in evaluation of contractile tissue. Functional ROM Functional movements are used to assess if recovery is complete and if the athlete is ready to return to full participation or activity. ROM TEST Break Test Strength is determined by trying to break the contraction exhibited by the athlete. Compression Joint Test Used to differentiate between pain caused by compressive force of muscle, or pain caused by muscle lesion. Approximate the joint surfaces (passively) and note if the pain increases or decreases. If pain increases, the compressive force of muscle contraction may also increase pain. The source of pain then is known to be some structure within the joint and not a muscle lesion.

5 Interpretation of ROM Have the athlete perfom AROM follow appropriate rubric: AROM (Pain /Limited) 1. AROM (Pain/Limited) + PROM (Normal) = Contractile Tissue 2. AROM (Pain/Limited) + PROM (Pain/Limited) RROM [mid-range isometric] (pain) + Compression Joint Test (Normal) Contractile Tissue 3. AROM (Pain/Limited) + PROM (Pain/Limited) RROM [mid-range isometric] (Pain) + Compression Joint Test (Pain) Suspect some structure within the joint being pinched 4. AROM (Pain/Limited) + PROM (Pain/Limited) RROM [mid-range isometric] (Normal) Non Contractile Tissue AROM (Normal, No limitations in ROM) 1. AROM (Normal) + PROM (Normal) RROM [mid-range isometric] (Normal) RROM [Break Test] (Pain / Weakness) Contractile Tissue 2. AROM (Normal) + * PROM (Pain/Limited) = Non Contractile Tissue * PROM outside traditional planes of movement Special Test Specific procedures applied to a joint or muscle in order to determine the presence of pathomechanics. - Ligamentous and Capsular Testing - Manual Muscle Test - Cartilage and Bone Neurological Test Neurological testing involves a screen of sensation, motor function, and deep tendon reflexes. Not required for all evaluations. - Cranial Nerves - Cervical Spine / Nerve Root - Level of Consciousness