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Examination of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
The Injury Examination Process
Chapter 1

Systematic Examination Technique
 Objective data
 Baseline measures
 Re-evaluations
 Rehabilitation and treatment protocols
 Documentation
 Medical records
 Legally required
 Communication tool

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?

Clinical Assessment
 Clinical assessment vs. acute evaluations
 What are the differences?
 Special considerations
 Discretion
 Religious considerations
 Informed consent
 Signed written statement
 Verbal
 Emergency medical care

History
 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

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?

Past 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

History 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

History of Present Condition
 Pain
 Location
 Type
 Referred
 Radicular
 Daily pain patterns
 Provocation and
alleviation patterns
 Other symptoms
 Treatment to date
 Affective traits
 Disability/limitations

Physical Examination
 Goals
 Rule out differential diagnosis
 Determine clinical diagnosis
 Identify impairments and functional limitations
 Standard precautions against bloodborne
pathogens (Box 1-5)

Inspection
Immediate 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

Inspection
 Functional assessment
 Perform functional tasks that were identified as
problematic.
 Impairments should be identified and measured.

Palpation
 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.

Palpation
 Point tenderness
 Trigger points
 Change in tissue density
 Crepitus
 Tissue temperature

 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
Assessment

Active 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

Manual 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)

Manual Muscle Testing

Passive 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

Joint 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

Stress
Testing

Joint 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

Special 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 (-)

Neurologic 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

Neurological Screening 1-1.
Lower Quarter Screen

Neurological Screening 1-2.
Upper Quarter Screen

Sensory 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

Motor 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.

Reflex 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

Table 1–10. Deep Tendon
Reflex Grading

Vascular Screening
Gross 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

 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
Examination Process

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