All physical examinations in sports medicine start with the history. Exactly how one obtains the history has been debated for years and there is no consensus. Some follow an established set of questions covering predetermined content (1), while others follow a logical problem-solving approach (2). Other approaches fall in between, but there is no debate that the history is the most important part of the examination. It aids the sports medicine clinician in making the diagnosis, planning a therapeutic strategy, provides a basis for predicting the course of recovery, and establishes a baseline against which future progress is evaluated. Nowhere is the history taking more necessary than in the realm of athletic performance, where progress is assessed, qualified, and quantified with stunning swiftness and precision.

Gathering the history in athletics is different than in the office setting. Most athletes should already be assessed in the preseason during their pre-participation physical examinations. Any acute injury that occurs can be compared to a recent established baseline assessment of the athlete’s health, and further history taking can target more detail. However, many times a baseline examination was not done, and the clinician must work from the beginning.

Even when an athlete is acutely injured, for example, on the football field, the physician and trainer should always try to get an accurate history as quickly as possible, even if they witnessed the event. History gathering should be direct and specific to the injury, in order to recognize and expediently treat any severe injuries. For an athlete injured on the field, time should be taken from the competition to ascertain the level of severity. Only when the severity of the injury is established should the athlete be removed from the playing field. In many cases, the diagnosis can be made before the examination or reduced quickly to two or three possibilities. In most cases, the physical examination is limited without a thorough history of the athlete on record.

In the acute setting, the sideline evaluation may be done in many different environments—football fields, hockey arenas, basketball courts. The decision whether to examine the athlete on the field, on the sidelines, or in the locker room is based on several factors. If there is any question about instability, particularly of the spine, it is appropriate to complete the examination on the field until the athlete is appropriately
stabilized or transferred to a location where he or she can be stabilized.

The sports medicine clinician should seek out answers to the following questions in the acute setting:

The responses to these questions quickly indicate the severity of the injury and how aggressively the injury should be examined and treated. For example, a player is hit on the knee while falling down and cannot get up to return to play. During questioning, the athlete can quickly identify the trainer and physician, yells in pain when they talk with him, easily localizes the pain, and tells them about the injury. The athlete is barely able to lift the leg or bend the knee, and it hurts too much to walk.

In this example, the physician and trainer have quickly assessed that the athlete is stable, there are no obvious concussive effects from the trauma, but there is a significant knee injury that will limit participation in the event. From here, they can either examine the joint on the field or bring the athlete to the sideline for a more complete evaluation. In certain injuries, the immediate postinjury period is optimal for evaluation, such as in anterior cruciate ligament tears, so a physician may choose to perform an efficient knee examination on the field. Sometimes an athlete needs to be stabilized, and then fully evaluated later, after 12 to 24 hours of acute care depending on the situation. The initial examination should be efficient, but it must also help the clinician reach a decision quickly. A prolonged evaluation in the acute setting can affect outcome and morbidity. The examination should help establish a treatment plan, and appropriate follow-up is mandatory.

The athlete should disrobe to expose the injured body part, including its opposite joint. If the clinician is performing a complete physical, male athletes should just be in shorts, while female athletes should be in shorts and a sports bra. Missing a diagnosis because the athletes kept their clothes on is inexcusable.

When examining a specific joint, the uninjured joint should be examined first. This not only allows the examiner to feel an athlete’s normal variations in laxity and anatomy as a comparison, but it also puts the athlete at ease by showing that the examination will proceed without provoking pain.

Each physical examination chapter in this book is designed to follow a similar template. There are many ways to perform examinations with even more variations, so this template is not a consensus statement on physical examination. It does, however, offer the reader a comprehensive and systemic approach to the examination of the athlete that can be modeled as well as referenced. The template is relatively consistent from chapter to chapter. The basic components are as follows:

The neurologic examination is extremely important, as it can help a clinician hone in on a difficult diagnosis. The basic elements of the neurologic evaluation apply to each region of the body and are presented later in this section. Each specific chapter on physical examination discusses the specific neurology germane to that region, such as dermatomes and myotomes.

Testing for deep tendon reflexes rarely elicits an abnormal response, yet doing so helps make a diagnosis in many cases, for example, in herniated discs and cerebrovascular accidents. The tendon should be where the reflexes are elicited, and a proper reflex hammer should be used. A light tap on the tendon itself should be enough if the right location is struck. Tendon reflexes are graded according to the scale shown in Table 15.1.