The Examination Process Matthew R

CHAPTER 2 © sbayram/E+/Getty Images The Examination Process Matthew R. Kutz, PhD, ATC, CSCS

OVERVIEW LEARNING OBJECTIVES

This chapter focuses on the injury evaluation pro- After completing this chapter, the reader will be able to cess and how a proper evaluation contributes to do the following: the clinical diagnosis and patient’s plan of care. 1. Describe the injury evaluation process. Many nuances to the injury evaluation process 2. Understand the necessity of a systematic and contribute to the identification and classification organized approach to injury evaluation. of an injury. These nuances also affect which body 3. Articulate key questions to ask when taking a parts are evaluated relative to the primary injury, history. the treatment options, and the overall plan of care. 4. Understand the importance and necessity of It is impossible to identify and discuss every pos- inspections, palpitations, and special tests. sible nuance during an evaluation in a text such 5. Understand the difference between the HIPS injury as this. Therefore, the skilled clinician is required assessment and the SOAP note-taking format. to integrate and assess a very complex “web” of 6. Understand the difference between primary and information supplied by the patient, the clinician’s secondary evaluations. observation of the injury (if he or she was there), the patient’s presentation, the clinician’s experienc e, valid and reliable research evidence, and the FUN FACTS ABOUT INJURY experience and input from reliable stakeholders (eg, other health care providers and observations EVALUATION from witnesses). Sometimes, the information • Although all injury evaluations should be structured gathered from all of these different sources may and organized, they do not necessarily have to follow be contradictory, and so it must be carefully and a prescribed sequence. thoroughly scrutinized. • Injury evaluations should be divided into primary In this chapter, a common framework for and secondary assessments. Primary assessments gathering relevant information about a patient’s deal with life-threatening conditions and secondary injury and associated signs and symptoms, history, assessments deal with non–life-threatening inspection/observation, palpation, and special tests conditions. (known as HIPS, or HOPS by other clinicians), will be introduced. These are the four elements mini- mally required to gather enough information to form a clinical diagnosis. The ways in which that Introduction information is documented and recorded in a SOAP One of the key domains within athletic training is for (subjective, objective, assessment, and plan) note the athletic trainer to be proficient at examination, will be discussed; these four sections are necessary to provide enough information in the medical record assessment, and diagnosis. The examination process to ensure ongoing and adequate patient care.

© Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 18 Chapter 2 The Examination Process should be systematic and organized, and it should differential diagnosis requires that the clinician begin contribute to a valid clinical diagnosis and the patient’s to differentiate between two or more conditions that plan of care. However, the evaluation need not always share common signs or symptoms. Although signs follow a prescribed sequence. For example, there are and symptoms are sometimes used interchangeably, differences between a formal clinical evaluation (in a they have important differences: symptoms are gener- controlled environment) and an on-field evaluation ally subjective, whereas a sign is more objective. More (during competition or practice, usually in front of specifically, a sign is something that can be observed, spectators). In certain situations, the clinician may measured, and recorded by a health care professional, decide to abbreviate or reorder one aspect of the eval- and a symptom is something that the patient feels and uation to expedite the process or to accommodate a may or may not be able to explain or measure. For more emergent situation. There are also distinctions example, a patient with a fever may show a sign of a to be made between primary and secondary evalua- certain temperature, say 102°F, and the symptoms of tions. A primary evaluation assesses life-threatening headache and fatigue. Using the HIPS framework of conditions, whereas a secondary evaluation assesses injury evaluation, the clinician is better able to form non–life-threatening conditions. a differential diagnosis and determine between signs All injury evaluations, regardless of type, should and symptoms. Table 2.1 is a breakdown of the HIPS be structured and organized. The examination process framework used in a clinical examination. is generally structured according to history, inspec- An accurate history can be extremely revealing tion (or observation), palpations, and special tests. for the clinician and can help uncover many salient The acronym HIPS (or HOPS) is commonly used to issues. One of the most significant aspects that a good delineate this evaluation format. In the next sections, history contributes to is uncovering the mechanism the HIPS framework and each of these aspects will be of injury (MOI). Identifying the MOI often reveals the discussed. specific cause of or at least identifies the event that immediately preceded the injury as well as informs the clinician of any underlying medical conditions History that may contribute to or influence the current condi- Taking and recording a patient’s history is consid- tion and quality of life. Discovering the MOI is critical ered by many clinicians to be the most revealing por- to determining the forces that have been applied to tion of the evaluation process. An accurate history is the injured body structures. very important for determining a differential diag- The history-taking process requires active listen- nosis, which is a list of the possible diagnoses asso- ing, thorough note taking, and skills at framing open- ciated with a patient’s complaint. The process of a ended questions. Although a history usually occurs at

Table 2.1 HIPS Framework Framework Elements Description Subjective Component History The clinician asks the patient about the onset and mechanism of the injury and associated signs and symptoms. Objective Components Inspection/Observation The clinician observes how the patient presents with the injury (gait, posture, etc) as well as any measurable factors, such as edema, ecchymosis, atrophy, range of motion, signs of infection, and other observable characteristics of the injury. Palpation The clinician begins to “feel and touch” the injured area to identify areas of point tenderness, swelling, pain, or discomfort and may also use it in conjunction with assessing range of motion in determining end feel. Special tests The clinician intentionally stresses the joint or injured body part to assess the integrity of the structures and soft tissue near and around the injury, which helps to determine extent and involvement of the injury. Other special tests include neurologic screening and muscle function tests (eg, break tests or manual muscle tests).

© Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. Inspection 19 the beginning of the evaluation, it is often necessary 3. When did the injury occur? to revisit it throughout the entire evaluation process. 4. What activities cause pain? A thorough history provides information about the 5. What activities reduce pain? activity that was being performed when the injury 6. Describe the type/sensation of pain (stabbing, occurred, the extent of the injury, the anatomic struc- aching, throbbing, radicular, radiating, etc). tures involved in the injury, and any limitations in 7. How did the injury occur/how did you do it? participation or desired activities that resulted from 8. If you landed awkwardly, how did you land? the injury. 9. What position was the joint in when you got hurt? Taking a history typically involves asking about 10. How long ago was the injury? past medical history as well as history of the current 11. Do you remember anything specific that hap- condition. Past medical history helps the clinician to pened immediately before or after the injury? establish any previous history that is relevant to the 12. Did you hear any noises (eg, click, pop, snap, or current condition (eg, any previous surgeries, previous crack) when the injury occurred? injuries, residual complaints, general health status, or It may also be beneficial to use a mnemonic to current medications). It is also important to identify help remember what questions should be asked. One any comorbidities. Comorbidity, or when a patient has one or more distinct conditions, is associated with such mnemonic that aids in the collection of a rele- worse health outcomes, more complex clinical man- vant history is OPQRST: agement, and increased cost of care.1 A thorough his- 1. O = Onset of the injury—What happened? tory includes asking questions about other medical 2. P = Provocation—What makes this problem feel conditions, including comorbidities. The history of the better or worse? current condition is to identify the cause of the cur- 3. Q = Quality of the pain—How would you describe rent complaint. It is necessary, at this point, to deter- the pain? mine current level of function, which is to determine 4. R = Region or radiation—Where is the pain? any restrictions to current activity and any limitations 5. S = Severity—How bad is the pain? the patient may be experiencing in any aspect of life. 6. T = Timing—How long has it been hurting? Did These limitations transcend sports participation and the symptoms change? include activities of daily living. A thorough history Asking questions such as these will help the cli- can also help determine any changes in activity that nician make an informed and accurate clinical diag- have occurred and, if activity is still possible, helps to nosis. The more specific the questions can be without identify if there any changes to activity patterns. badgering the patient, the more likely that meaningful and accurate information will be obtained. Gathering Information During Finally, it is also important that the clinician be a History aware of the patient’s level of frustration and anxiety When taking a history, it is necessary to help during the history, especially if it is a relatively acute the patient focus on his or her primary complaint. injury. Being aware of the patient’s demeanor during The primary complaint is the patient’s perception this portion of the examination is an important segue of the current injury. It may be necessary to gather to observation. information relative to past medical history, but the clinician should help the patient focus on the primary complaint first. It is also extremely important that Inspection the clinician learn to ask open-ended questions. Ask- Inspection (others may refer to this portion as ing questions that require only yes or no responses, observation) is the next aspect within the HIPS known as closed-ended questions, may not provide framework and includes observing how the patient enough information to make an accurate assessment. presents his or her signs and symptoms. In an ideal Open-ended questions require the patient to go into situation, the clinician observes the injury in real more detail and provide more information. Open- time. However, that is not always the case; most of ended questions about the primary complaint and the the time, the patient presents to the clinician after mechanism of injury include questions such as the the injury has occurred. Inspection includes obtain- following: ing a general overview of the appearance of the 1. What is the problem? injury and the patient, including the symmetry of 2. What hurts? the patient’s body; the patient’s posture, gait, and

© Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 20 Chapter 2 The Examination Process level of consciousness; and an observation of general Palpation motor function. Additionally, it is important to note any deformity, swelling, discoloration, scars, cuts or Palpation is the part of the examination where the abrasions, redness, ecchymosis, and any other skin clinician “touches and feels” the patient’s injury. It is abnormalities. important to obtain consent from any patient during Additionally, it may be important to note gen- a physical examination, but it is especially important, eral inspections, especially if the patient is unknown and should be done formally, when the patient is a to the clinician, of the patient’s well-being, willing- minor. Ask the patient whether he or she has a prefer- ness and ability to move, age, physical condition, ence regarding the sex of the clinician. If it is possible, and personal hygiene. Questions for the clinician to this preference should be accommodated. However, if consider during inspection of the patient include the it is not possible and the evaluation needs to continue, following: there should be a third party observing; it is best that the third party be another clinician or the patient’s 1. What is the patient’s level of consciousness/is the parent or guardian (if a minor). patient oriented to his or her surroundings? General rules of palpation include bilateral com- 2. What is the patient’s level of irritability? parison and feeling the temperature of the skin, feeling 3. Does the patient appear to be relatively healthy for any swelling, noting any areas of point tenderness, and practice good hygiene? identifying crepitus, feeling for deformity, noting end 4. Does the patient make good eye contact, and is he feel with passive range of motion (ROM), noting any or she able to articulate? muscle spasms, determining sensations on the skin, and 5. What are the general speech patterns of the assessing pulse and capillary refill. Bilateral comparison patient (slurred, hoarse, fast, etc)? means that it is necessary to palpate paired anatomic When visually scanning appearance, it is import- structures. For example, when assessing an injured ant to note symmetry of the patient’s body. For exam- right forearm, it is important to assess the left forearm to ple, are the shoulder heights relatively equal; posture establish a baseline. In addition to bilateral comparison, upright; spinal curves normal; and feet, knees, and palpation should begin with gentle pressure that grad- elbows “normal”? When observing, make note of pes ually increases. Palpation should always be initiated on planus, pes cavus, genu recurvatum, genu valgus, structures away from (distal) the most sensitive area and genu varus, and elbow carrying angle. move toward the injured area. Palpating the unaffected Further inspection of the injury site may include side first and waiting to palpate the most painful area a general or quick assessment of motor function. For until last helps to build rapport with the patient and example, is the patient able to bend over (flex); bend reduces residual pain for subsequent palpitations. to the side; rotate the head, neck, and spine; walk on As a precaution, it may be necessary that the clini- the heels and toes; and flex and extend the shoulders cian wears protective gloves, and the clinician should over and above the head? While the patient is per- always have clean, warm hands. To maximize palpa- forming these general motor tasks, it is important to tion, the clinician must have an accurate and proficient observe the ease or difficulty with which he or she knowledge of clinical anatomy. Knowledge of surface performs these tasks, making note of any intense pain anatomy, such as the bones, bony landmarks, origins or discomfort. If any inflammation or other changes and insertions of muscles, circulatory system, and loca- in the appearance of the joint are noted, the clinician tion of bursa, is necessary; without such knowledge, it must be able to determine whether these changes are may be difficult to form an accurate clinical diagnosis. edema or effusion. Edema, also known as swelling, is typically extra-articular (outside of the joint capsule), whereas effusion is usually intra-articular (inside the Special Tests joint capsule). It may be necessary for the clinician to After the history, inspection, and palpation have been perform special tests, such as a sweep test, to identify completed, it is important to perform special tests, effusion. When inflammation is suspected, but not which are necessary to assess the integrity of the readily obvious, it may be necessary for the clinician body’s tissues (eg, ligaments, tendons, muscles, carti- to record girth measurements. Girth measurements lage, bones). In most situations, special tests are per- generally require measuring the circumference of a formed last; however, it is not uncommon, especially body part where swelling is suspected. It is important in emergent, on-field, or follow-up situations, for to note nearby anatomic landmarks so that measure- these tests to come earlier in the assessment process. ments are more reliable. Regardless of the situation, special tests should not be

HIPS

Past Presentation Actual Healthy Injured MOI ROM MH of injury injury tissue tissue

RROM AROM PROM MMT

Special tests

Functional Joint Neuro tests

Figure 2.1 Concept map of HIPS framework. AROM, active range of motion; HIPS, history, inspection, palpation, special tests; MH, medical history; MMT, manual muscle testing; MOI, mechanism of injury; PMH, past medical history; PROM, passive range of motion; ROM, range of motion; RROM, resisted range of motion.

© Jones & Bartlett Learning completed until fractures, dislocations, and musculo- Later in the examination process, as the clinician reas- tendinous ruptures have been ruled out. Figure 2.1 is sesses the patient to determine how much progress has a concept map of the overall HIPS framework. been made, when to progress, or even to determine Special tests include a variety of interventions: return to play, it is likely that sport-specific functional 1. Functional tests (basic and sport specific) tests will be used. Sport-specific functionaltesting 2. ROM and end feel (Note: Some clinicians may includes running, jumping, diagonal movements, include ROM testing during the inspection por- changes of direction, balancing on unstable surfaces, tion of the assessment.) kicking or throwing, and any other movements that 3. Ligamentous stress test the sport requires. In both the basic and sport-specific 4. Neurologic tests versions, functional tests are used to determine the extent of the patient’s balance, coordination, agility, Each of these special tests, the S of HIPS, is briefly strength, endurance, and power, all of which are described in the next paragraphs. Specific special tests essential to performing a thorough evaluation. and related components are described in more detail in later chapters. ROM and End Feel Typically, ROM occurs during the special tests portion Functional Tests of the evaluation. However, some clinicians may pre- Functional testing takes two forms during the exam- fer to perform ROM testing earlier in the examination. ination process. The first is basic functional testing, Regardless of when it occurs, ROM is a must for a which includes tasks such as walking, standing up complete evaluation. It can be measured objectively from a chair, sitting down, opening a door, lifting, with a goniometer (Figure 2.2), and typical ranges for reaching, pushing, pulling, ascending and descend- selected joints are listed in Table 2.2. ing stairs, or other rudimentary functional activities Typically, ROM assessment occurs in the fol- (sometimes referred to as activities of daily living). lowing order: active range of motion (AROM), pas- Functional tests can be as simple as weight bearing sive range of motion (PROM), and resisted range of or balancing in an upright position. Obviously, these motion (RROM). If the patient is able to perform basic functional tests come early in the examination satisfactory AROM, then PROM and RROM can be and are used to determine a patient’s limitations and assessed. However, if the patient is unable to per- disability as well as the overall extent of the injury. form AROM, then RROM is either not necessary or

Table 2.2 Normal Ranges of Motion Joint Motion Range of Joint Motion Range of Motion Motion Cervical Flexion 0º–80° Digits 2 to 5 Extension 0º–70° MCP Flexion 0º–90° Lateral flexion 0º–45° PIP Extension 0º–45° Rotation 0º–80° DIP Abduction 0º–20° Flexion 0º–100° Flexion 0º–90° Lumbar Forward flexion 0º–60° Hip Flexion 0º–120° Extension 0º–35° Extension 0º–30° Lateral flexion 0º–20° Abduction 0º–40° Rotation 0º–50° Adduction 0º–30° Internal rotation 0º–40° External rotation 0º–50° Shoulder Flexion 0º–180° Knee Flexion 0º–135° Extension 0º–60° Extension 0º–15° Abduction 0º–180° Medial rotation 0°–25° Internal rotation 0º–70° with knee flexed External rotation 0º–90° Lateral rotation 0°–35° Horizontal abduction/adduction 0º–130° with knee flexed Elbow Flexion 0º–150° Ankle Dorsiflexion 0º–20° Extension 0º–10° Plantar flexion 0º–50° Pronation 0º–30° Supination 0º–50° Forearm Pronation 0º–80° Subtalar Inversion 0º–5° Supination 0º–80° Eversion 0º–5° Wrist Flexion 0º–80° Hallux Extension 0º–70° 1st MTP Flexion 0º–45° Ulnar deviation 0º–30° Extension 0º–75° Radial deviation 0º–20° 1st IP Flexion 0º–90° Thumb Toes 2 to 5 CMC Abduction 0º–70° MTP Flexion 0º–40° Flexion 0º–15° Extension 0º–40° Extension 0º–20° PIP Flexion 0º–35° Opposition Tip of thumb to DIP Flexion 0º–30° tip of fifth finger Extension 0º–60° MCP Flexion 0º–50° IP Flexion 0º–80°

CMC, carpometacarpal; DIP, distal interphalangeal; IP, interphalangeal; MCP, metacarpophalangeal; MTP, metatarsophalangeal; PIP, posterior interphalangeal. contraindicated (PROM can still be assessed in the assessment includes determining specific ranges absence of AROM). Figure 2.3 shows the use of a (Table 2.2) as well as noting the patient’s willing- goniometer. ness to move and the ease of that movement. During AROM is a joint motion performed voluntarily an AROM assessment, the clinician must note the by the patient via muscular contraction. Unless con- point during the range where pain begins, the pain- traindicated, AROM should be performed before ful arc (the presence of pain at specific joint angles), PROM. AROM is an indication that the patient is and the type of pain associated with the complaint. willing and able to move the injured joint and con- If the patient suspects that a particular movement tract the associated muscles. When the patient is not will be painful and exhibits apprehension, it should able to perform AROM, it is typically an indication be performed last or terminated if apprehension is of a neuromuscular injury. An accurate AROM noticed.

results from soft-tissue stretch (eg, muscular, capsular, ligamentous). An example of a firm end feel is when the end range of a muscle begins to feel tight during flexibility testing. A hard end feel results from bone- to-bone contact. An example would be elbow extension during which the olecranon process fits into the olecranon fossa. Abnormal end feels occur when any of the normal end feels occur out of place (eg, if the clinician recog- nizes a hard end feel when there should be a soft end feel, or a firm end feel when there should be a hard end feel). In addition to these three abnormal end feels, there is an empty end feel, which is the absence Figure 2.2 An example of a goniometer. of any sensation at all. This is when, at the end range,

© Jones & Bartlett Learning the clinician does not notice any tissue resistance and the patient does not have any pain. RROM is motion during which the clinician resists the patient’s voluntary movement. Some clinicians refer to this as manual muscle testing or break testing. RROM/manual muscle testing is a way to evaluate voluntary muscle contraction by asking the patient to perform movements of the joint against gravity or manual resistance. It can also be described as gentle to moderate resistance applied by the clinician throughout the patient’s available ROM. Figure 2.4 shows examples of selected manual muscle tests. Break tests are when overload is applied to a patient when holding a static (isometric) position. The intent is for the patient to hold a static position (isometric contraction), for example, elbow flexion at 90°, while the clinician tries to gently, Figure 2.3 Example of a goniometric measurement. but forcefully, move the forearm and consequently the © ESB Professional/Shutterstock elbow back to neutral or into extension. Table 2.3 is the typical scale used to grade manual muscle tests. PROM is motion where the clinician “moves” During RROM testing, muscle strength is graded the patient’s injured body part without any assis- on a six-point numeric scale. Some clinicians use tance from the patient. Positioning the patient for plusses and minuses within this scale. For example, PROM is important. The patient should be relaxed if the clinician estimates that a patient’s strength is and in a non–weight-bearing position. The rationale approximately 90%, the rating would be 4+ (fall- to performing PROM is that it distinguishes between ing between 4 and 5). A plus and minus system can contractile and noncontractile tissue. Typically, if be added for any number between 1 and 4 on the there is pain with PROM, it is an indication that the strength scale to add further specificity and detail to injury is to noncontractile tissue; if there is no pain the medical record. with PROM, but pain is present with AROM, it is RROM is necessary because it will help detect an indication of injury to contractile tissue. Another neuromuscular involvement in any injury. The pres- important component of PROM is gentle overpres- ence of pain during RROM testing should be noted, sure. Typically, PROM will show greater ranges than and the test may need to be repeated before pain or AROM because the clinician will apply gentle over- weakness is noted. pressure to determine end feel. Normal end feels include soft, firm, and hard. Soft end feels result from tissue approximation, which is Ligamentous Stress Test when two body parts touch. An example of a soft end After ROM testing is complete, it is necessary to feel as a result of tissue approximation is elbow flexion perform a series of tests that assess the integrity when the forearm and bicep touch. A firm end feel of the joint and its associated structures. Joint

integrity is generally maintained by noncontractile tissues called ligaments and joint capsules; sometimes, other intra-articular structures, such as car- tilage, are present. Stress tests are performed in a single plane of motion and graded on a three-point scale for severity. Injuries to ligamentous tissue are A referred to as sprains. Instability, which is the failure of the ligament to sustain the joint’s normal function under stress, is generally the result of ligamentous injury and can be functional or dynamic. Ligamen- tous tests should always be performed bilaterally and compared to baseline metrics. Positioning of the patient’s joint and the clinician’s hands is of utmost importance to ensure proper angle during ligamen- B tous testing. Generally, when examining for joint laxity and ligamentous injury, the proximal segment of the joint is stabilized, and the distal segment is moved. Failure to properly position the patient’s joint may result in false-positive or false-negative findings. A false-positive ligamentous test result is when a joint or ligament is not injured, but testing appears to indicate an injury; a false-negative C ligamentous test result is when a joint or ligament Figure 2.4 Examples of manual muscle testing. A. The is actually injured, but testing does not reveal the elbow. B. The knee. C. The shoulder. injury. Typically, false-negative test results are a con- A. © Jones & Bartlett Learning; B. Used with permission from http://at.uwa.edu/mmt/knee.htm; C. © Jones & Bartlett Learning sequence of muscle guarding or faulty joint positioning during testing. Table 2.3 Manual Muscle Testing Scale The three-point scale for ligamentous sprains is as follows: Numeric Grade Clinical Value Name Percentage Description • Grade 1 has a normal ligamentous end feel and is described as a minor stretching of the ligament 0 Zero 0% No muscle contraction with little or no tearing of the fibers. Pain is present, but stability is comparable upon bilateral 1 Trace 5% Evidence of comparison. muscular Grade 2 has a soft or abnormal end feel and is contraction, no • joint movement described as partial tearing of the fiber. There is moderate instability when compared bilaterally. 2 Poor 20% Complete range • Grade 3 has an empty end feel and is described as of motion with a complete tearing of the ligament. some assistance or gravity eliminated In addition to ligamentous stress tests, there are other tests that have been developed by clinicians that 3 Fair 50% Complete range of motion against target specific body parts (eg, bones, muscle, or ten- gravity don). Generally speaking, these tests are more detailed than ligamentous tests; they often occur across mul- 4 Good 80% Complete range tiple planes of motion and are not generally graded of motion against gravity and some on severity (except for strains, which are injuries to resistance muscles and tendons that are also graded on a three- point scale). In many cases, special tests are reported 5 Normal 100% Complete range as positive or negative. An example of a special test of motion against gravity with would be the Yergason test, which is a technique negative break test used to assess pathology to the bicipital tendon at the bicipital groove.

© Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. Special Tests 25 Neurologic Tests The motor component of neurologic testing requires assessing myotomes. Myotomes are the nerve Neurologic testing is very complex, so it will be dis- roots that innervate specific muscles or muscle groups. cussed only briefly here. Basic neurologic testing Table 2.4 identifies the myotomes and their associated includes dermatomes, myotomes, and reflexes. neuromuscular motions. When performing a myotome The sensory component of a neurologic test assessment, the clinician instructs the patient to demon- requires assessing dermatomes. Figure 2.5 identi- strate specific movements or motions, which the clini- fies the possible dermatomes that should be assessed cian evaluates for the quality and strength of a given during injury evaluation. Dermatomes can be assessed muscular contraction and the coordination of associated by using different pressures and sensations on the sur- muscular contractions. Weakness in a myotome may face of the skin. For example, a patient should be able indicate possible injury to the nerve or nerve root. to distinguish between a cotton ball, pinprick, and Reflexes should also be assessed during neurologic feather, and between light pressure versus deep pres- testing. Assessing reflexes can indicate damage to the sure. When performing a dermatome assessment, the central nervous system; reflexes, and specifically deep clinician should ask the patient about the sensations tendon reflexes, may be diminished or even absent if and whether or not the sensations are similar when the nerve root is injured. Abnormal reflexes should be compared bilaterally. considered relevant only in conjunction with sensory or

Spinal Peripheral nerves Spinal dermatomes dermatomes C2 Divisions of trigeminal 1 Opthalmic C2 2 Maxillary C3 C4 3 Mandibular C5 C3 Posterior cervical rami C6 C7 C4 Branches from cervical plexus C8 C5 T1 T1 Anterior thoracic rami T2 T2 T3 T4 T3 Posterior thoracic rami T5 T4 Axillary T6 T5 T7 Lateral thoracic rami T8 T6 Branches from medial T9 T7 T10 cord of brachial plexus T11 T8 T12 L1 T9 Radial L2 L3 T10 Posterior lumbar rami L4 L5 T11 S1 Lateral antebrachial cutaneous S2 T12 S3 L1 Median antebrachial cutaneous S4 C6 S5 C8 S3 Radial Co C7 L2 Ulnar Median L3 Posterior sacral rami L1 Iliohypogastric L2 Ilioinguinal L3 L4 Posterior femoral cutaneous Lateral femoral cutaneous Obturator

L5 Anterior femoral cutaneous Common peroneal Saphenous L4

S1 Superficial peroneal

Deep peroneal L5

Figure 2.5 Anatomic drawing identifying the dermatomes.

progress notes. These progress notes are essential to Table 2.4 Common Myotomes ensuring and maintaining proper patient care. The Nerve Root Motion standard format for notes documenting the patient’s C1, C2 Cervical flexion progress is referred to as SOAP notes. Health care professionals in a variety of disciplines use this SOAP C3 Cervical side flexion format. C4 Scapula elevation The subjective aspect of the report refers to the current feelings of the patient. These feelings cannot be C5 Shoulder abduction validated via objective measurements; they are simply C6 Elbow flexion and wrist extension how the patient reports feeling that day and are an indi- C7 Elbow extension and wrist flexion cator of the ongoing status of the patient’s recovery. The objective aspect of the report refers to any objective mea- C8 Thumb extension sures that can be reported; these may include follow-up T1 Finger abduction special tests, ROM, strength measurements, girth measurements, or other measurable outcomes. It is not L1, L2 Hip flexion necessary to repeat the entire initial evaluation when L3 Knee extension recording objective notes, but they should be thorough and address any changes from previous measurements. L4 Ankle dorsiflexion The assessment aspect is where the clinician assesses the L5 Big toe extension patient’s prognosis and may confirm or reiterate a clin- S1 Ankle plantar flexion ical diagnosis. The assessment primarily addresses two questions: how is the patient progressing and is he or S2 Knee flexion she on track? It is in the assessment portion where both short-term and long-term goals are indicated as well as motor abnormalities, as it is not uncommon to find an progress toward those goals and any setbacks. The final abnormal reflex without sensory or motor involvement. section of the SOAP record is the plan. The plan is where Pathologic reflexes can indicate motor neural lesions any interventions are noted. Interventions can include and serve as an indication of a pathologic condition. therapeutic modalities, remedial or advanced exercises, Examples of pathologic reflexes include the following: consultations, and functional activities. These are all outlined in this section for the patient and clinicians to The Babinski reflex, which is elicited by stroking • follow and use as a reference for the current prognosis. the lateral aspect of the sole of the foot, can indi- A thorough plan should include the following: cate a pyramidal tract lesion if the big toe extends. • The Oppenheim reflex is elicited by stroking the 1. Immediate treatment goals anterior medial portion of the tibia and may also 2. Long-term treatment goals indicate pyramid tract lesion. 3. Frequency and duration of treatments (for thera- • A positive Brudzinski reflex is elicited by passively peutic modalities and therapeutic exercises) flexing the lower limb and with the opposite limb 4. Evaluation standards and outcomes also moving; it may indicate meningitis. 5. Required patient education 6. Requirements for discharge from care Finally, peripheral nerve testing includes motor function of peripheral nerves and is assessed during In many clinical settings, SOAP notes are ROM testing. There are several peripheral nerves close considered a basic standard of care; they serve as an to the surface of the skin, which can be tested via Tinel important aspect of providing care and document- sign; this is performed by light pressure or tapping of ing the services provided and associated outcomes. the skin directly over a superficial nerve. A positive Tinel Table 2.5 is a sample SOAP note. sign indicates irritation or compression of the nerve. On-Field and Emergency Record-Keeping Format Evaluations (SOAP Notes) When assessing an injury in an emergency, and after Another critical component to a thorough evalua- ruling out life-threatening conditions, the typical tion is accurate records. After documenting the initial HIPS framework still applies, but can be imple- injury, it is important to keep up-to-date and accurate mented with greater flexibility. However, regardless

Table 2.5 Sample SOAP Note Section Sample Subjective Patient reports feeling “better” today. Reported sleeping well last night despite some “minor throbbing” in the left ankle. Patient reported walking yesterday with virtually no pain. Objective Yesterday’s radiograph ruled out fracture. Patient reports pain is 2/10. Ranges of motion for dorsiflexion, plantar flexion, inversion, and eversion are within normal limits; manual muscle tests for both dorsiflexion and plantar flexion are 4/5. Negative talar tilt test; negative anterior drawer test; patient indicates a small amount of pain with Kleiger test. Assessment Patient continues to present with symptoms indicating grade 1 syndesmosis sprain of left ankle. Patient should be able to increase tolerance of current exercise program. Continue weight- bearing exercises and add 10 lb to stationary calf press. Plan All exercises should be completed with brace or tape. Continue current exercise regimen and add 3 × 10 bodyweight lunge walks and 3 × 10 lateral skipping. of the level of urgency, the clinician should at least Decerebrate rigidity (abnormal extensor response) take a modified history and determine the location of the pain, presence of any neurologic signs and symptoms, the mechanism of injury, and associated sounds (crack or pop associated with the injury). Occasionally, multiple patients are injured at the same time, in which case the clinician should perform triage. Triage is the rapid assessment of all injured parties to determine who has the most seri- ous injuries. After a modified history has been performed, on-field or emergent inspection/observation would include checking the surrounding environment for Decorticate rigidity (abnormal flexor response) additional dangerous conditions or clues about the MOI. The clinician should note body position of the patient (eg, supine, prone, or sideline) and note any gross deformity or posture. For example, is the patient found in extension of all four extremities (eg, decerebrate rigidity), or extension of the legs and flexion of the upper extremities, including wrists and fingers (eg, decorticate rigidity)? Figure 2.6 is an example of the types of rigidity. Additional observation would include how the patient presents the injury—is he or Hemiplegia (early) she protecting a limb or limping? Note the patient’s level of responsiveness and any associated signs of head trauma. On-site and emergent palpation should include bony palpitations for possible fractures as well as for gross deformity, specific deformity, skin temperature, and any swelling. On-site and emergency special testing can include quick assessments of ROM and weight bearing as well as any specialized joint integrity tests. On-site neurologic testing can include cutaneous sensation (dermatomes) and gross motor function. Finally, the clinician should inspect any damaged Figure 2.6 Abdominal postures showing rigidity in equipment and use safe and appropriate techniques comatose patients. to remove any equipment that hinders the patient’s © Jones & Bartlett Learning

© Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 28 Chapter 2 The Examination Process immediate well-being. The injured patient should be typically follows the HIPS framework. Evaluating an moved only when deemed safe to do so. Under no injured patient can be extremely complex and require circumstances should coaches, players, officials, or integrating and assimilating information from multi- other bystanders prematurely move the patient, nor ple sources, including the history, inspection, palpa- should the clinician allow any bystanders to pressure tion, and special tests. The clinician should take care or expedite moving a patient before it is deemed safe. to thoughtfully and thoroughly report initial findings as well as follow-up findings in a SOAP format. Using Summary the HIPS framework and the SOAP format increases the likelihood of an accurate clinical diagnosis and Performing a thorough evaluation of an injured patient allows the clinician to develop a well-informed plan should be structured and organized. That structure of care.

WRAP-UP

Critical Thinking Questions 1. When assessing range of motion (ROM), what 3. How is an on-site or emergent assessment/ might differences between deficits in passive evaluation different from a clinical evaluation? range of motion and active range of motion 4. Describe the difference between a false-positive indicate? and a false-negative test result. 2. Discuss the importance of performing all 5. What is the value of end feel during a clinical assessments bilaterally. musculoskeletal/orthopedic evaluation and helping to reach a clinical diagnosis?

Pearls and Pitfalls • Unless in an emergency situation, evaluations • Clinician positioning is just as important as should be systematic and follow a structured patient positioning in order to perform special sequence. tests correctly. • Active ROM testing can be an early myotome • Functional tests are both general and specific. screen. Used early in an evaluation, they can indicate • HIPS and SOAP are not the same types of evalu- basic activities of daily living—for example, ation. HIPS format is used for initial evaluations; standing, bending, walking, and sitting—and, SOAP notes are for follow-up evaluations. later in the evaluation, they can be sport-specific • Special tests include several types or categories of activities (eg, running, jumping, and cutting). tests (eg, neurologic, vascular, ROM) and not only joint laxity or structural assessments.

Reference 1. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M: Defining comorbidity: implications for understanding health and health services. Ann Fam Med 2009;7(4): 357-363.