EVALUATION OF SPORTS INJURIES

Injury evaluation is an essential part of athletic training. Each examiner must develop his or her own systematic approach to injury evaluation. Three distinct evaluations are commonly conducted: the primary, or on-site, injury inspection and evaluation; the secondary, or off-site, injury evaluation; and the evaluation for determining the progress of a specific treatment regimen.

Primary Assessment or Survey

The primary assessment or survey, as discussed in Chapter 8, involves the determination of serious, life-threatening injuries and the proper disposition of the injured athlete.

The secondary assessment or survey concerns the detailed sequence of evaluative procedures that determine specifically the nature, site, and severity of injury.

• A secondary assessment is done on the field immediately after injury to rule out those injuries that may potentially become life-threatening, to assess musculoskeletal injuries, and to determine how the athlete should be transported from the field.

Once the athlete is off the field, a more detailed secondary evaluation is performed according to the procedures described in this chapter.

Secondary Assessment

A secondary evaluation is more thoroughly performed once the athlete has been removed from the site of initial injury to a place of comfort and safety. This detailed assessment may be performed on the sidelines, in an emergency room, in the training room, or in a sports medicine clinic. Further inspection and evaluation may be performed when the injury is still in an acute phase or has become chronic or recurrent. The evaluation scheme is divided into three broad categories: history, general observation, and physical examination (see the Focus box, opposite). There are numerous special tests that provide additional information about the extent of injuries. The following discussion provides the student with a brief overview of some of the steps and techniques that can be used in a secondary evaluation.

History

Obtaining as much information as possible about the injury is of major importance to the examiner. Understanding how the injury may have occurred and listening to the complaints of the athlete and how key questions are answered can provide important clues to the exact nature of the injury.  From the history, the examiner develops strategies for further examination and possible immediate and follow-up management.

When obtaining a history, the examiner should do the following:

1. Be calm and reassuring.
2. Express questions that are simple, not leading.
3. Listen carefully to the athlete's complaints.
4. Maintain eye contact to try and see what the athlete is feeling.
5. Record exactly what the athlete said without interpretation.

Questions might be stated under specific headings in an attempt to get as complete a historical picture as possible. In many cases, a history becomes clear cut because the mechanism, trauma, and pathology are obvious; in other situations, symptoms and signs may be obscured.

Primary complaint

If conscious and coherent, the athlete is encouraged to describe the injury in detail. If the athletic trainer or coach did not see the injury happen, try to get the athlete to describe in detail the mechanism of the injury.

1. What is the problem?

2. How did it occur?

3. Did you fall?

4. How did you land?

5. Which direction did your joint move?

6. When did it occur?

7. Has this happened before? If so, when?

8. Was something heard or felt when it occurred?

If the athlete is unable to describe accurately how the injury occurred, perhaps a teammate or someone who observed the event can do so.

Injury location

1. Ask the athlete to locate the area of complaint by pointing to it with one finger only.

2. If the athlete can point to a specific pain site, it is probably a localized injury.

3. If the exact pain site cannot be indicated, the injury may be generalized and nonspecific.

Pain characteristics

1. What type of pain is it?

2. Nerve pain is sharp, bright, or burning.

3. Bone pain tends to be localized and piercing.

4. Pain in the vascular system tends to be poorly localized, aching, and referred from another area.

5. Muscle pain is often dull, aching, and referred to another area.

•  Does the pain change at different times?

1. Pain that subsides during activity usually indicates a chronic inflammation.

2. Pain that increases in a joint throughout the day indicates a progressive increase in edema.

• Does the athlete feel sensations other than pain?

1. Pressure on nerve roots can produce pain or a sensation of "pins and needles" (paresthesia).

2. What movement, if any, causes pain or other sensations?

   Joint responses

1. If. the injury is related to a joint, is there instability?

2. Does the joint feel as though it will give way?

3. Does the joint lock and unlock?

4. Positive responses may indicate that the joint has a loose body that is catching or that is inhibiting the normal muscular support in the area.

Determining whether the injury is acute or chronic

• Ask the athlete how long he or she has had the symptoms and how frequently they appear.

Observation

Along with gaining knowledge and understanding of the athlete's major complaint from a history, general observation is also performed, often at the same time the history is taken (see the Focus box below). What is observed is commonly modified by the athlete's major complaints. The following are suggested as specific points to observe:

1. How does the athlete move? Is there a limp? Are movements abnormally slow, jerky, and asynchronous? Is movement not possible in a body part?

2. Is the body held stiffly to protect against pain?

3. Does the athlete's facial expression indicate pain or lack of sleep?

4. Are there any obvious body asymmetries?

5. Is there an obvious deformity?

6. Does soft tissue appear swollen or wasted as a result of atrophy?

7. Are there unnatural protrusions or lumps such as occur with a dislocation or fracture?

8. Is there a postural malalignment?

9. Are there abnormal sounds such as crepitus when the athlete moves?

10. Does a body area appear inflamed? Are there swelling, heat, and redness?

Palpation

The two areas of palpation are bony and soft tissue. As with all examination procedures, palpation must be performed systematically, starting with very light pressure followed by gradually deeper pressure, usually beginning away from the site of complaint and then gradually moving toward it.

Bony palpation

• Both the injured and non-injured sites should be palpated and compared.

• The sense of touch might reveal an abnormal gap at a joint, swelling on a bone, joints that are misaligned, or abnormal protuberances associated with a joint or a bone.

Soft tissue palpation

• Like bony palpation, soft-tissue palpation must be performed on both sides of the body for comparison.

• Tissue deviations such as swellings, lumps, gaps, and abnormal muscle tensions and temperature variations can be detected.

• The palpation of soft tissue can detect where ligaments or tendons have torn.

• Variations in the shape of structures, differences in tissue tightness and textures, differentiation of tissue that is pliable and soft from tissue that is more resilient, and pulsations, tremors, and other involuntary muscle twitching can be discerned.

• Excessive skin dryness and moisture can also be noted.

• Abnormal skin sensations such as diminished sensation (dysesthesia), numbness (anesthesia), or increased sensation (hyperesthesia) can be noted.