The Evaluation Process in Rehabilitation

Darin A. Padua, PhD, ATC Barnett Frank, PhD, ATC

Injury evaluation is the foundation of the rehabilitation process. To effectively coordinate the rehabilitation process, the athletic trainer must be able to perform a systematic differential evaluation and identify the pathological tissue. According to Cyriax,12 the injury evaluation process involves applying one’s knowledge of anatomy to differentiate between provoked and normal tissue:

Once the pathological tissue is identified, the athletic trainer must then consider the contraindications and determine the appropriate course of treatment:

The athletic trainer determines the appropriate rehabilitation goals and plan based on the information gathered from the evaluation. In designing the rehabilitation plan, the athletic trainer must consider the severity, irritability, nature, and stage of the injury.³¹ Throughout the rehabilitation process, the athletic trainer must continuously reevaluate the status of the pathological tissue to make appropriate adjustments to the rehabilitation goals and plan.

The athletic trainer might conduct multiple injury evaluations of the following kinds for varying purposes during the course of athletic injury management:

• On-site evaluation at the time of injury (on-field)
  
• On-site evaluation just following injury (sideline)
  
• Off-site evaluation that involves the injury assessment and rehabilitation plan
  
• Follow-up evaluation during the rehabilitation process to determine the patient’s progress
  
• Preparticipation physical evaluation (preseason screening)

All forms of injury evaluation will involve similar steps and procedures. However, it is important to note the difference between the on-site injury evaluation processes and the off-site evaluation performed when designing a rehabilitation program.

The goal of an on-site injury evaluation is to quickly, but thoroughly, evaluate the patient and determine the injury severity, whether immobilization is needed, whether medical referral is needed, and the manner of transportation from the field.

The off-site injury evaluation is more detailed and used to gain information to effectively design the rehabilitation program.

This chapter will focus on the steps and procedures involved during the off-site injury evaluation and incorporating this information into the rehabilitation plan.

THE SYSTEMATIC DIFFERENTIAL EVALUATION PROCESS

The key to a successful injury evaluation is to establish a sequential and systematic approach that is followed in every case. A systematic approach allows the athletic trainer to be confident that a thorough evaluation has been performed. However, the athletic trainer must keep in mind that each injury may be unique in some manner. Thus, the athletic trainer must maintain a systematic approach but not be inflexible during the evaluation process. The Injury Evaluation Checklist in Figure 3-1 is provided as an example of the steps and procedures that may be included in a sequential and systematic evaluation scheme.

The systematic differential evaluation process is composed of subjective and objective elements.³⁸ During the subjective evaluation the athletic trainer gathers information on the injury history and the symptoms experienced by the patient. This is performed through an initial interview with the patient. The athletic trainer attempts to relate information gathered during the subjective evaluation to observable signs and other quantitative findings obtained during the objective evaluation. The objective evaluation involves observation and inspection, acute injury palpation, range of motion (ROM) assessment (active and passive), muscle strength testing, special tests, neurological assessment, subacute or chronic injury palpation, and functional testing. After completing the subjective and objective evaluation, the athletic trainer will arrive at an assessment of the injury based on the information gathered.

When taking the patient’s history, the athletic trainer should initially use non-leading, open-ended questions. As the subjective evaluation progresses, the athletic trainer may move to more close-ended questions once a clear picture of the injury has been presented. Open-ended questions involve narrative information about the injury; close-ended questions ask for specific information.21

The history relies on the athletic trainer’s ability to clearly communicate with the injured patient. Thus, the athletic trainer should avoid the use of scientific and medical jargon and use simple terminology that is easy to understand. The use of simple terminology ensures that the patient will understand any close-ended questions the athletic trainer may ask.

PATIENT’S IMPRESSION

Allow the patient to describe in his or her own words how the injury occurred, where the injury is located, and how he or she feels. While listening to the patient, the athletic trainer should be generating close-ended questions. Once the patient has given his or her impression of the injury, the athletic trainer should ask more specific questions that fill in specific details.

SITE OF INJURY

Have the patient describe the general area where the injury occurred or pain is located. Further isolate the site of injury by having the patient point with one finger to the exact location of injury or pain. If the patient is able to locate a specific area of injury or pain, the athletic trainer should make note of the anatomic structures in the general area and consider this tissue as provoked tissue. A major purpose of the remaining evaluation phases is to further differentiate the identified provoked tissue from the normal tissue.⁹ Differentiating between provoked tissue and normal tissue allows the athletic trainer to identify the pathological tissue.¹² The athletic trainer must be able to identify the pathological tissue to develop an appropriate rehabilitation plan.

MECHANISM OF INJURY

Musculoskeletal injury results from forces acting on the anatomic structures and ultimately results in tissue failure. Thus, it is imperative to identify the nature of the forces acting on the body and relate these to the anatomic function of the underlying anatomic structures. The athletic trainer should determine whether the injury was caused by a single traumatic force (macrotrauma) or resulted from the accumulation of repeated forces (microtrauma). In dealing with an acute injury, it is important to identify the body position at time of injury, the direction of applied force, the magnitude of applied force, and the point of application of the applied force. The athletic trainer must then apply knowledge of anatomy, biomechanics, and tissue mechanics to determine which tissues may have been injured. When dealing with recurrent or chronic injuries, it is important to establish what factors influence the patient’s symptoms, such as changes in training, routine, equipment use, and posture. The accumulation of this information should be used to further identify the pathological tissue. Any sound or sensation noted at the moment of or immediately after injury is also important information to gather. The athletic trainer may be able to relate certain sounds and sensations with possible injuries, hence identifying pathological tissue:

During the second phase of the subjective evaluation, the athletic trainer explores specific details of the symptoms discovered during the history. Again, this should be performed in a systematic and sequential process. Moore22 describes the PQRST mnemonic to guide this phase of the subjective evaluation (P = provocation or cause of symptoms; Q = quality or description of symptoms; R = region of symptoms; S = severity of symptoms; T = time symptoms occur or recur).

PROVOCATION OF SYMPTOMS

This information is primarily gathered through a detailed mechanism-of-injury description by the patient. Additional information may be gathered by asking the patient if they are able to recreate their symptoms by performing certain movements. However, the athletic trainer should not have the patient recreate these movements at this phase of the evaluation. This will be performed during ROM assessment in the objective evaluation. Typically, musculoskeletal pain is worse with movement and better with rest. Symptoms caused by excessive inflammation may be constant and not alleviated with rest. Symptoms associated with prolonged postures may be indicative of prolonged stress being placed on the surrounding soft tissue structures, which ultimately causes breakdown.

QUALITY OF SYMPTOMS

The patient should be asked to describe the quality of his or her symptoms. The patient might describe his or her pain as being sharp, dull, aching, burning, or tingling. The athletic trainer should attempt to relate the patient description of the quality of symptoms to possible pathological tissue. Magee²¹ describes different descriptions of the quality of symptoms as being associated with different anatomic structures:

• Nerve pain: Sharp, bright, shooting (tingling), along line of nerve distribution
  
• Bone pain: Deep, nagging, dull, localized
  
• Vascular pain: Diffuse, aching, throbbing, poorly localized, may be referred
  
• Muscular pain: Hard to localize, dull, aching, may be referred

REGION OF SYMPTOMS

The majority of this information is given during the patient’s description of the site of injury. The region of symptoms might correlate with underlying injured or pathological tissue. However, the athletic trainer must be aware of possible referred pain patterns and not assume that the pathological tissue is located directly within the region of symptoms. Once the region of symptoms has been identified, there are several other items that should be noted. Do the symptoms stay localized, or do they spread to peripheral areas? Do the symptoms feel deep or superficial? Do the symptoms seem to be located within the joint or in the surrounding area? Pain that radiates to other areas may be due to pressure on the nerve or from active trigger points in the myofascial tissue. Symptoms that are well localized in a small area might indicate minor injury or chronic injury. Symptoms that are diffuse in nature may be indicative of more severe injury.

Duration and frequency of symptoms may be used to determine whether the injury is progressing or worsening. An improvement in symptoms is demonstrated by reductions in their duration and frequency. The opposite may be reported in the situation of a worsening injury. Response of symptoms to activity or rest may also be used to identify the nature of the injury. Magee21 describes several injury classifications that may be related to the response of symptoms to activity or rest:

• Joint adhesion: Pain during activity that decreases with rest
  
• Chronic inflammation and edema: Initial morning pain and stiffness that is reduced with activity
  
• Joint congestion: Pain or aching that progressively worsens throughout the day with activity
  
• Acute inflammation: Pain at rest and pain that is worse at the beginning of activity in comparison to the end of activity
  
• Bone pain or organic/systemic disorders: Pain that is not influenced by either rest or activity
  
• Peripheral nerve entrapment: Pain that tends to worsen at night
  
• Intervertebral disc involvement: Pain that increases with forward or lateral trunk bending

The athletic trainer should plan the objective evaluation.22 After completing the subjective evaluation, the athletic trainer should create a mental list of specific procedures and tests to perform during the objective evaluation. At this point the athletic trainer may expect to get specific findings during the objective evaluation. However, the athletic trainer is reminded to stay open-minded and not become too focused during this stage of the evaluation.

Observation and Inspection

The beginning of the objective evaluation consists of a visual inspection of the injured patient as he or she enters the medical facility. The athletic trainer focuses on the patient’s overall appearance and specific body regions that were identified during the subjective evaluation as being a potential site of provoked tissue. For example, if the lower extremity is identified as a potential area of injury, the athletic trainer will pay close attention to the patient’s gait patterns. If an upper extremity injury is suspected, the carrying position of the injured extremity and movement patterns when removing an item of clothing would be noted. In observing the patient’s movement patterns, the athletic trainer should be looking for compensatory patterns, muscle guarding, antalgic movements, and facial expressions. All observations should be made with a bilateral comparison of the uninvolved side.

POSTURAL ALIGNMENT

Overall postural alignment should be assessed during the observation, especially in patients suffering from chronic or overuse-type injuries.^18,21,32 Many chronic and overuse injuries are due to postural malalignments that create repeated stress on a specific tissue. Over time the repeatedly loaded tissue may become pathological or lead to additional postural alignment alterations as compensatory mechanisms to reduce tissue stress. In addition, postural alignment can influence muscle function.

If postural malalignments are present, the athletic trainer should consider the patterns of muscle tightness and weakness that would correspond to such a postural malalignment. Altered postural alignment can be caused by muscle imbalances, not just bony deformity.^7,8 It is important that the athletic trainer determine whether postural malalignments are due to muscle imbalances or bony deformity, as this might influence the rehabilitation options. Postural malalignments that are due to muscle imbalances may be addressed through physical rehabilitation using appropriate muscle flexibility and strengthening techniques to restore muscle balance, hence improving normal postural alignment.

There are many elements involved with a detailed postural alignment assessment. The athletic trainer may consider using a checklist approach to ensure that all elements are covered. It is important that the patient be viewed in a weightbearing position (standing) from multiple vantage points (anterior, posterior, medial, lateral). In general, the athletic trainer should be checking for neutral alignment, symmetry, balanced muscle tone, and specific postural deformities (genu valgum, genu varum, etc.). A detailed checklist for postural alignment is provided as an example in Figure 3-2.

SIGNS OF TRAUMA

During the postural alignment assessment, the athletic trainer should also check for signs of trauma. In acute injuries, observing for signs of trauma might be the primary purpose of the observation (Figure 3-3). Gross deformity along the bone’s long axis or joint line may be present in cases of fractures of joint dislocations. Visible swelling, bleeding, or signs of infection at the injury site should also be noted, as should the nature of its onset.

Atrophy of the surrounding muscles may be present in the case of chronic injury. Skin color and texture should also be assessed. The patient’s skin might have red (inflammation), blue (cyanosis, indicating vascular compromise), or black-blue (contusion) coloration. If the skin appears to be shiny, to have lost elasticity, or to have lost overlying hair, or if there is skin breakdown, there might be a peripheral nerve lesion.

The question of when palpation should be performed during the objective evaluation is debatable. Some feel that palpation should be performed immediately following the observation; others feel that palpation should be performed later during the objective evaluation. If an acute injury is being evaluated, palpation may be appropriate immediately following observation to detect any obvious, but not visible, soft tissue or bony deformities.22 Such findings may warrant termination of the evaluation and immediate referral to a physician. However, if the injury is subacute or chronic in nature, palpation may be performed later in the objective evaluation. The disadvantage of performing palpation early in the objective evaluation is that such manual probing can elicit a pain response that will distract from findings during the later subphases of the objective evaluation (ROM, strength, and special tests).¹¹

Regardless of when palpation is performed, the primary purpose of palpation is to localize as closely as possible the potential pathological tissues involved (Figure 3-4). To gain the patient’s confidence, palpation should start with a gentle and assuring touch and the trainer should frequently communicate with the patient. Palpation should be performed in a sequential manner and include the anatomic and joint structures that are above and below the site of the injury. Palpation should begin on the uninjured side so that the patient knows what to expect and the examiner knows what is “normal” and has an objective comparison when palpating the injured side. Palpation of the injured side begins with the anatomic structures distal to the site of pain and then progressively works toward the potential pathological tissues. To systematically palpate all possible tissues, it may be helpful to develop a specific sequencing of tissues to palpate.³² For example, the athletic trainer might first palpate all bones, then ligaments and tendons, and then the muscles and corresponding tendons. Consideration should be given to positioning of the patient as one develops the sequencing of tissues to palpate. Minimizing patient movement is important, as excessive motion can cause the patient’s symptoms to worsen. Thus, the athletic trainer should palpate all possible anatomic structures in a given position prior to repositioning the patient.

During palpation, the athletic trainer should take note of point tenderness, trigger points, tissue quality, crepitus, temperature, and symmetry.16,21,22,27,30,32 Point tenderness is noted by indications of pain over the area being palpated. If point tenderness is noted, the patient should be asked to rate his or her point tenderness on a scale of 0 to 10, where 0 is no pain (normal) and 10 is the worst pain imaginable. Similar to rating one’s symptoms, this does not provide an objective assessment. Rather, this information will be used to make relative comparisons of the patient’s progress during rehabilitation. Trigger points may be located in the muscle and feel like a small nodule or muscle spasm. The trigger point may be identified as an area that upon palpation refers pain to another body area. Increased tissue temperature may be present if infection or inflammation is present. Calcification or change in tissue density may be present in a poorly managed hematoma formation, or might indicate effusion or hemarthrosis of the joint. Crepitus is a crunching or crackling sensation along the tendon, bone, or joint. Crepitus along the length of a tendon can indicate tenosynovitis or tendinitis. The presence of crepitus along the bone or joint may indicate damage to the bone (fracture), cartilage, bursa, or joint capsule. Rupture of a muscle or tendon may present as a gap at the point of separation.

All information gathered during palpation should be used to further confirm the findings of the initial evaluation steps. At this point the athletic trainer should be further able to differentiate between the normal and provoked tissue. Before beginning the next subphase of the objective evaluation, the athletic trainer should review the findings and further organize the remainder of the objective evaluation.

Special Tests

Range of Motion

ROM assessment involves determining the patient’s ability to move a limb through a specific pattern of motion. There are several general principles that should be applied during ROM testing. Motions will be performed passively, actively, and against resistance to fully quantify the patient’s status.^22,32 Testing should first be performed on the patient’s uninjured limb through each of the joint’s cardinal planes of motion and the quantity of motion available should be recorded. Then ROM testing is repeated on the injured limb. The athletic trainer can then compare the ROM of the injured limb to that of the uninjured limb and/or against established normative data.²⁴ In addition, ROM records will serve an important role in tracking the patient’s progress during rehabilitation. Active ROM testing should be performed first, followed by passive, then resistive, ROM assessment.^22,32 If possible, the athletic trainer should perform movement patterns that facilitate pain at the end to prevent a carryover effect to following movement patterns. This should be evident based on the previous steps performed during the evaluation process. ROM assessment should also be performed at the joints proximal and distal to the involved area for a comprehensive evaluation.³² These general guidelines allow the athletic trainer to efficiently assess ROM.

One of the primary goals of ROM testing is to assess the integrity of the inert and contractile tissue components of the joint complex. Inert tissues are sometimes referred to as anatomic joint structures and include bone, ligament, capsule, bursae, periosteum, cartilage, and fascia.¹² The contractile tissues, also referred to as physiological joint structures, include muscle, tendon, and nerve structures.¹² Cyriax developed a method to differentiate between inert and contractile pathological tissues as part of the ROM assessment.¹² Differentiating between inert or contractile tissue pathology is performed by selectively applying passive and active tension to joint structures and making note of where pain is located.¹² The ability to differentiate between inert and contractile tissue pathology is an important step in setting up the rehabilitation plan and identifying the appropriate tissue to treat.

Inert tissue pathology is indicated when the patient reports pain occurring during both active and passive ROM in the same direction of movement.¹² Typically, pain due to inert tissue pathology will occur near the end of the ROM as the tissue becomes compressed between the bony segments. Example: The patient reports pain in the anterior shoulder region when actively and passively moving the humerus into the end range of shoulder flexion. Because pain was present in the same direction of motion (direction of shoulder flexion = anterior shoulder) during active and passive movements, pathology of an inert tissue structure of the shoulder would be indicated.

Contractile tissue pathology is indicated when the patient reports pain in the same direction of motion during active ROM, then reports pain in the opposite direction of motion during passive ROM.12 Contractile tissue pain occurs due to increased tension placed on the tissue. However, the cause of contractile tissue tension differs between active and passive ROM testing. During active ROM, contractile tissue tension increases due to the voluntary agonist muscle contraction generated to move the limb. In contrast, passive ROM increases contractile tissue tension as the muscle is stretched by the athletic trainer. Example: The patient reports anterior shoulder pain when actively bringing the humerus into shoulder flexion (pain in same direction as motion) and when passively bringing the humerus into shoulder extension as it is stretched by the athletic trainer (pain in opposite direction as motion). It is not possible to determine the specific location of either inert or contractile tissue pathology through ROM assessment. This is accomplished by incorporating manual muscle and special tests to locate the exact location of pathology.

MEASURING JOINT RANGE OF MOTION

Both active and passive joint range of motion can be measured using goniometry. (Figure 3-5A) When measuring joint range of motion, the goniometer should generally be placed along the lateral surface of the extremity being measured. The 0, or starting, position for any movement is identical to the standard anatomical position. The patient should move the joint either actively or passively through the available range to the endpoint. The stationary arm of the goniometer should be placed parallel with the longitudinal axis of the fixed reference part. The movable arm should be placed along the longitudinal axis of the movable segment. (note: The axis of rotation will change throughout the range as movement occurs. Thus, the axis of rotation is located at the intersection of the stationary and movable arms.) A reading in degrees of motion should be taken and recorded as either active or passive range of motion for that movement.

Like a goniometer, a digital inclinometer may be used for measuring range of motion digitally (Figure 3-5B). It provides accuracy, repeatability, and objective documentation of range of motion measurements.

Having the patient “actively” contract his or her muscles as he or she takes his or her limb through the desired cardinal plane of motion assesses active ROM, location of pain, and painful arcs.27 A painful arc is pain that occurs at some point during the ROM but later disappears as the limb moves past this point in either direction.^27,32 Typically, a painful arc is present due to impingement of tissue between bony surfaces. Painful arcs may be present during either active or passive ROM testing. Overpressure may be applied at the end ROM to assess end-point feels, if active ROM is full and pain-free.²² Pain or limited ROM prohibits applying overpressure during active ROM assessment and may indicate waiting until the passive ROM testing. If ROM is limited or elicits pain, the athletic trainer should consider the cause of these findings, as this will have direct implications on the rehabilitation plan. Limited ROM can be caused by several factors, including swelling, joint capsule tightness, agonist muscle weakness/inhibition, or antagonist muscle tightness/contracture.¹⁵

PASSIVE RANGE OF MOTION

When passive ROM is assessed, the patient should be positioned so that the contractile tissues are relaxed and do not influence the findings due to active muscle contraction. The athletic trainer then takes the limb through the desired passive movement pattern until the point of pain or end ROM.

A number of recent studies have shown the importance of using passive ROM goniometric assessments to identify individuals at risk for injury to the lower extremity. For example, multiple studies have demonstrated that restriction in hip rotation has been associated with increased risk of ACL injury.^2,20,33,34 Wahlstedt has shown that limited ankle dorsiflexion is also predictive of potential ACL injury.³⁵ Winkelmann found that increased ankle plantar flexion and greater hip external rotation were in part predictive of medial tibial stress syndrome in physically active individuals.³⁷

Upon reaching the end ROM, gentle overpressure should be applied and particular attention should be directed toward the sensation of the end-point feel.

The end-point feel encountered at the end ROM has been given several normal and abnormal classification schemes.⁹ End-point feel assessment may be useful in helping determine the type of pathological tissue¹² (Table 3-1). The athletic trainer should determine whether differences exist between the ranges of motion available during active and passive testing. Reduced ROM during active compared to passive testing may indicate deficiency in the contractile tissue. Contractile tissue deficiencies may be caused by muscle spasm or contracture, muscle weakness, neurological deficit, or muscle pain.32 Such deficiencies should be addressed during the rehabilitation plan to restore normal ROM. The presence of crepitus or clicking is also of significance during passive ROM testing.²¹ Crepitus or clicking along the joint line or between 2 bones may indicate damage to the articular cartilage or a possible loose body in the joint. Similar sensations along the muscle or tendon may indicate adhesion formation or tendon subluxation.

Related posts:

Maintaining Cardiorespiratory Fitness During Rehabilitation Restoring Range of Motion and Improving Flexibility Regaining Muscular Strength, Endurance, and Power Rehabilitation of Lower Leg Injuries Rehabilitation of Injuries to the Spine Rehabilitation of Ankle and Foot Injuries

Stay updated, free articles. Join our Telegram channel

Join