Table of Contents

 

 

 

SECTION 1

FOUNDATIONS OF EXAMINATION

1

Chapter 1

The Injury Examination Process

1

 

Systematic Examination Technique

1

 

Description of the Examination Model

2

 

The Role of the Uninjured Paired Structure

2

 

Clinical Assessment

2

 

History

4

 

Physical Examination

13

 

Inspection

14

 

Palpation

16

 

Joint and Muscle Function Assessment

17

 

Special Tests

25

 

Neurological Screening

25

 

Vascular Screening

29

 

The Role of Evidence in the Examination Process

29

Chapter 2

Examination and Management of Acute Pathologies

33

 

Emergency Planning

34

 

Sport-Specific Rules

34

 

Critical Findings

34

 

The On-Field Examination

34

 

Equipment Considerations

37

 

Primary Survey

37

 

Secondary Survey

37

 

On-Field History

38

 

On-Field Inspection

39

 

On-Field Palpation

39

 

On-Field Joint and Muscle Function Assessment

40

 

On-Field Joint Stability Tests

40

 

On-Field Neurologic Testing

40

 

On-Field Vascular Assessment

40

 

Immediate Management

40

 

Splinting

41

 

Transportation

41

 

Disposition

41

 

Return to Activity Decision Making

43

Chapter 3

Evidence-Based Practice in the Diagnostic Process

45

 

The Role of Evidence-Based Practice in Orthopedic Examination and Diagnosis

47

 

Fundamentals of Interpreting Research

47

 

Reliability

47

 

Diagnostic Accuracy

48

 

Diagnostic Gold Standard

49

 

Diagnostic Predictive Value

49

 

Sensitivity and Specificity

50

 

Likelihood Ratios

51

 

Positive Likelihood Ratio

52

 

Negative Likelihood Ratio

52

 

Interpreting Likelihood Ratios

52

 

Clinical Decision Rules

54

 

Use of Evidence in this Text

54

 

Incorporating Evidence-Based Practice into Clinical Diagnosis

55

Chapter 4

Injury Pathology Nomenclature

57

 

Tissue Response to Stress

57

 

Stress-Strain Relationships

57

 

Mechanisms of Injury

58

 

Tensile Forces

58

 

Compression Forces

58

 

Shear Forces

58

 

Torsion Forces

59

 

Direct Blow

59

 

Soft Tissue Pathology

59

 

Musculotendinous Injuries

59

 

Joint Structure Pathology

65

 

Articular Surface Pathology

71

 

Bony Pathology

73

 

Exostosis

74

 

Apophysitis

75

 

Fractures

75

 

Neurovascular Pathologies

80

 

Peripheral Nerve Injury

80

 

Complex Regional Pain Syndrome

81

Chapter 5

Musculoskeletal Diagnostic Techniques

83

 

Imaging Techniques

84

 

Radiography

85

 

Computed Tomography Scan

86

 

Magnetic Resonance Imaging

87

 

Bone Scan

90

 

Diagnostic Ultrasound

90

 

Nerve Conduction Study/Electromyography

92

Chapter 6

Assessment of Posture

95

 

Clinical Anatomy

95

 

The Kinetic Chain

95

 

Muscular Function

97

 

Muscular Length-Tension Relationships

97

 

Agonist and Antagonist Relationships

98

 

Muscle Imbalances

99

 

Noncontractile Soft Tissue Influences

100

 

Clinical Examination of Posture

100

 

History

101

 

Inspection

102

 

Views of Postural Inspection

102

 

Palpation

109

 

Muscle Length Assessment

116

 

Assessing for Shortness of the Lower Extremity Muscles

116

 

Assessing for Shortness of the Upper Extremity Muscles

116

 

Common Postural Deviations

116

 

Foot and Ankle

118

 

The Knee

120

 

Spinal Column

124

 

Shoulder and Scapula

125

 

Head and Cervical Spine

128

 

Interrelationship Between Regions

129

 

Documentation of Postural Assessment

132

Chapter 7

Evaluation of Gait   Monique Mokha, PhD, ATC

137

 

Gait Terminology

137

 

Walking Gait Phases

139

 

Stance Phase

139

 

Swing Phase

140

 

Muscle Activity During Gait

141

 

Hip

141

 

Knee

141

 

Foot and Ankle

146

 

Running Gait Cycle

146

 

Stance Phase

146

 

Swing Phase

147

 

Observational Gait Analysis

147

 

Observational Gait Analysis Findings

150

SECTION 2

REGIONAL EXAMINATION

157

Chapter 8

Foot and Toe Pathologies

157

 

Clinical Anatomy

157

 

Rearfoot

158

 

Midfoot

158

 

Forefoot and Toes

158

 

Articulations and Ligamentous Support

159

 

Muscles Acting on the Foot and Toes

161

 

Arches of the Foot

164

 

Neurologic Anatomy

166

 

Vascular Anatomy

166

 

Clinical Examination of Foot and Toe Injuries

167

 

History

168

 

Inspection

170

 

Joint and Muscle Function Assessment

181

 

Joint Stability Tests

190

 

Neurologic Examination

190

 

Vascular Examination

190

 

Pathologies of the Foot and Toes and Related Special Tests

192

 

Influence of Foot Structure on Pathology

193

 

Plantar Fasciitis

198

 

Tarsal Coalition

201

 

Tarsal Tunnel Syndrome

202

 

Metatarsal Fractures

204

 

Lisfranc Injuries

208

 

Phalangeal Fractures

210

 

Intermetatarsal Neuromas

210

 

Hallux Rigidus

211

 

Hallux Valgus

214

 

First Metatarsophalangeal Joint Sprains

214

 

Sesamoiditis

214

 

On-Field Evaluation of Foot Injuries

217

 

Equipment Considerations

217

 

On-Field History

217

 

On-Field Inspection

217

 

On-Field Palpation

217

 

On-Field Range-of-Motion Tests

217

 

On-Field Management of Foot Injuries

217

 

Plantar Fascia Ruptures

218

 

Fractures and Dislocations

218

Chapter 9

Ankle and Leg Pathologies

221

 

Clinical Anatomy

221

 

Related Bony Structures

222

 

Articulations and Ligamentous Support

223

 

Muscles of the Leg and Ankle

225

 

Bursae

229

 

Neurologic Anatomy

229

 

Vascular Anatomy

230

 

Clinical Examination of the Ankle and Leg

230

 

History

230

 

Past Medical History

230

 

History of the Present Condition

230

 

Inspection

233

 

Inspection of the Anterior Structures

234

 

Inspection of the Posterior Structures

235

 

Joint and Muscle Function Assessment

239

 

Joint Stability Tests

243

 

Neurologic Testing

250

 

Vascular Assessment

251

 

Pathologies and Related Special Tests

251

 

Ankle Sprains

252

 

Ankle and Leg Fractures

260

 

Os Trigonum Injury

264

 

Achilles Tendon Pathology

266

 

Peroneal Tendon Pathology

270

 

Medial Tibial Stress Syndrome

273

 

Stress Fractures

273

 

Compartment Syndromes

277

 

Deep Vein Thrombosis

281

 

On-Field Examination of Leg and Ankle Injuries

281

 

Equipment Considerations

281

 

On-Field History

282

 

On-Field Inspection

282

 

On-Field Palpation

282

 

On-Field Range of Motion Tests

283

 

Initial Management of On-Field Injuries

283

 

Ankle Dislocations

283

 

Compartment Syndrome

284

Chapter 10

Knee Pathologies

289

 

Clinical Anatomy

289

 

Articulations and Ligamentous Support

290

 

The Menisci

293

 

Muscles Acting on the Knee

295

 

Neurologic Anatomy

299

 

Vascular Anatomy

299

 

Clinical Examination of Knee Injuries

299

 

History

299

 

Past Medical History

299

 

History of the Present Condition

299

 

Inspection

302

 

Determination of Intracapsular versus Extracapsular Swelling

309

 

Joint and Muscle Function Assessment

311

 

Joint Stability Tests

313

 

Neurologic Testing

320

 

Vascular Testing

321

 

Pathologies of the Knee and Related Special Tests

325

 

Uniplanar Knee Sprains

325

 

Rotational Knee Instabilities

332

 

Meniscal Tears

340

 

Osteochondral Lesions

344

 

Iliotibial Band Friction Syndrome

347

 

Popliteus Tendinopathy

357

 

Tibiofemoral Joint Dislocations

360

 

On-Field Evaluation of Knee Injuries

364

 

Equipment Considerations

364

 

On-Field History

364

 

On-Field Inspection

365

 

On-Field Palpation

365

 

On-Field Range of Motion Tests

365

 

On-Field Ligamentous Tests

365

 

On-Field Management of Knee Injuries

366

 

Tibiofemoral Joint Dislocations

366

 

Collateral and Cruciate Ligament Sprains

366

 

Meniscal Tears

366

Chapter 11

Patellofemoral Articulation Pathologies

371

 

Clinical Anatomy

371

 

Articulations and Ligamentous Support

371

 

Muscular Anatomy and Related Soft Tissues

372

 

Bursa of the Extensor Mechanism

373

 

Clinical Examination of the Patellofemoral Joint

373

 

History

373

 

History of the Present Condition

375

 

Inspection

376

 

Joint and Muscle Function Assessment

384

 

Joint Stability Tests

385

 

Neurologic and Vascular Testing

385

 

Pathologies and Related Special Tests

385

 

Patellofemoral Pain with Malalignment

388

 

Patellofemoral Instability

391

 

Patellofemoral Pain without Malalignment

392

 

Traumatic Conditions

402

 

On-Field Evaluation of Patellofemoral Injuries

405

 

Equipment Considerations

405

 

On-Field History

405

 

On-Field Palpation

405

 

On-Field Functional Assessment

405

 

Initial Management of On-Field Injuries

407

 

Patellar Tendon Rupture and Patellar Fracture

407

 

Patella r Dislocation

407

Chapter 12

Pelvis and Thigh Pathologies

411

 

Clinical Anatomy

411

 

Articulations and Ligamentous Support

412

 

Muscular Anatomy

413

 

Bursae

417

 

Neurologic Anatomy

418

 

Vascular Anatomy

418

 

Clinical Examination of the Pelvis and Thigh

418

 

History

418

 

Past Medical History

420

 

History of the Present Condition

420

 

Inspection

420

 

Joint and Muscle Function Assessment

426

 

Joint Stability Tests

429

 

Neurologic Testing

431

 

Pathologies and Related Special Tests

438

 

Iliac Crest Contusion

438

 

Muscle Strains

438

 

Quadriceps Contusion

440

 

Slipped Capital Femoral Epiphysis

441

 

Legg-Calvé-Perthes Disease

442

 

Femoral Neck Stress Fracture

443

 

Degenerative Hip Changes

443

 

Labral Tears

445

 

Athletic Pubalgia

446

 

Piriformis Syndrome

447

 

Snapping Hip Syndrome (Coxa Saltans)

449

 

Bursitis

450

 

Ischial Bursitis

452

 

On-Field Evaluation of Pelvis and Thigh Injuries

452

 

Initial Evaluation and Management of On-Field Injuries

452

Chapter 13

Thoracic and Lumbar Spine Pathologies

457

 

Clinical Anatomy

458

 

Bony Anatomy

458

 

Intervertebral Disks

460

 

Articulations and Ligamentous Anatomy

461

 

Neurologic Anatomy

462

 

Muscular Anatomy

463

 

Clinical Examination of the Thoracic and Lumbar Spine

467

 

History

467

 

Past Medical History

468

 

History of the Present Condition

468

 

Nonorganic Origin of Pain

469

 

Inspection

469

 

Joint and Muscle Function Assessment

475

 

Joint Stability Tests

482

 

Special Tests

482

 

Neurologic Testing

488

 

Pathologies and Related Special Tests

495

 

Spinal Stenosis

495

 

Segmental Instability

499

 

Spondylopathies

501

 

Sacroiliac Dysfunction

504

 

Thoracic Spine

504

 

On-Field Evaluation of Thoracic and Lumbar Spine Injuries

508

 

On-Field History

508

 

On-Field Inspection

511

 

On-Field Neurologic Tests

511

 

On-Field Palpation

511

 

On-Field Management of Thoracic and Lumbar Spine Injuries

511

 

Thoracic Spine

511

 

Lumbar Spine

511

Chapter 14

Cervical Spine Pathologies

515

 

Clinical Anatomy

515

 

Intervertebral Disks

516

 

Ligamentous Anatomy

516

 

Neurological Anatomy

517

 

Muscular Anatomy

518

 

Clinical Examination of the Cervical Spine

519

 

History

519

 

Inspection

525

 

Joint and Muscle Function Assessment

527

 

Joint Stability Tests

538

 

Neurologic Testing

538

 

Pathologies and Related Special Tests

540

 

Cervical Radiculopathy

540

 

Clinical Cervical Instability

553

 

Facet Joint Dysfunction

553

 

Brachial Plexus Pathology

553

 

Thoracic Outlet Syndrome

555

 

On-Field Evaluation and Management of Cervical Spine Injuries

560

 

Brachial Plexus Injury

562

Chapter 15

Thoracic, Abdominal, and Cardiopulmonary Pathologies

565

 

Clinical Anatomy

565

 

Muscular Anatomy

566

 

Respiratory Tract

566

 

Cardiovascular Anatomy

567

 

Digestive Tract

568

 

Lymphatic Organ

568

 

Urinary Tract

569

 

Reproductive Tract

569

 

Clinical Examination of Thoracic, Abdominal, and Cardiopulmonary Pathologies

570

 

History

570

 

Inspection

573

 

Review of Systems

575

 

Pathologies of the Thoracic and Abdominal Regions and Related Special Tests

588

 

Injuries to the Thorax

588

 

Pathologies of the Abdominal and Urinary Organs

593

 

Kidney Pathologies

593

 

Appendicitis and Appendix Rupture

596

 

Hollow Organ Rupture

598

 

Pathology of the Reproductive Organs

598

 

Cardiopulmonary Pathologies

600

 

Respiratory Pathologies

605

 

On-Field Examination of Thoracic, Abdominal, and Cardiopulmonary Pathologies

607

 

Examination of the Unconscious Athlete

607

 

Inspection and Palpation of the Conscious Athlete

609

 

On-Field Management of Thoracic, Abdominal, and Cardiopulmonary Pathologies

609

 

Rib Fractures

610

 

Pneumothorax and Hemothorax

610

 

Open Pneumothorax

610

 

Hollow Organ Injuries

610

 

Solar Plexus Injury

610

 

Asthma

611

 

Hyperventilation

611

 

Sudden Cardiac Arrest

612

Chapter 16

Shoulder and Upper Arm Pathologies

615

 

Clinical Anatomy

615

 

Bony Anatomy

615

 

Joints of the Shoulder Complex

617

 

Muscles of the Shoulder Complex

620

 

Scapulothoracic Rhythm

627

 

Bursa of the Shoulder Complex

627

 

Clinical Examination of Shoulder Injuries

627

 

History

629

 

Inspection

629

 

Joint and Muscle Function Assessment

637

 

Joint Stability Tests

660

 

Neurologic Testing

664

 

Pathologies of the Shoulder and Related Special Tests

664

 

Sternoclavicular Joint Sprains

664

 

Acromioclavicular Joint Pathology

666

 

Glenohumeral Instability

670

 

Rotator Cuff Pathology

680

 

Biceps Tendon Pathology

683

 

On-Field Examination of Shoulder Injuries

699

 

Equipment Considerations

699

 

On-Field History

699

 

On-Field Inspection

699

 

On-Field Palpation

701

 

On-Field Neurologic Tests

701

 

Additional On-Field Tests

701

 

Initial Management of On-Field Shoulder Injuries

701

 

Scapular Fractures

701

 

Clavicular Injuries

701

Chapter 17

Elbow and Forearm Pathologies

707

 

Clinical Anatomy

707

 

Articulations and Ligamentous Anatomy

708

 

Muscular Anatomy

710

 

Nerves

711

 

Bursae

711

 

Clinical Examination of the Elbow and Forearm

711

 

History

715

 

Inspection

716

 

Joint and Muscle Function Assessment

720

 

Active Range of Motion

721

 

Manual Muscle Testing

721

 

Passive Range of Motion

725

 

Joint Stability Tests

725

 

Neurologic Testing

725

 

Pathologies and Related Special Tests

727

 

Elbow Dislocations

727

 

Fracture About the Elbow

727

 

Elbow Sprains

733

 

Epicondylalgia

737

 

Distal Biceps Tendon Rupture

739

 

Osteochondritrs Dissecans of the Capitellum

742

 

Nerve Pathology

742

 

On-Field Evaluation of Elbow and Forearm Injuries

747

 

On-Field History

747

 

On-Field Inspection

747

 

On-Field Palpation

747

 

On-Field Joint and Muscle Function Tests

747

 

On-Field Neurologic Tests

748

 

On-Field Management of Elbow and Forearm Injuries

748

 

Elbow Dislocations

748

 

Fracture About the Elbow

748

Chapter 18

Wrist, Hand, and Finger Pathologies

751

 

Clinical Anatomy

751

 

Articulations and Ligamentous Support

752

 

Muscular Anatomy

754

 

Nerves

761

 

The Carpal Tunnel

761

 

Clinical Examination of Injuries to the Wrist, Hand, and Fingers

761

 

History

763

 

Inspection

764

 

Joint and Muscle Function Assessment

772

 

Joint Stability Tests

781

 

Neurologic Testing

784

 

Pathologies of the Wrist, Hand, and Fingers and Related Special Tests

794

 

Wrist Pathology

794

 

Hand Pathology

805

 

Finger Pathology

808

 

Thumb Pathology

810

 

On-Field Evaluation and Management of Wrist, Hand, and Finger Injuries

813

 

Wrist Fractures and Dislocations

813

 

Interphalangeal Joint Dislocations

814

 

Hand and Finger Fractures

814

 

Lacerations

815

Chapter 19

Eye Pathologies

817

 

Clinical Anatomy

817

 

Eye Structures

818

 

Muscular Anatomy

818

 

Visual Acuity

818

 

Clinical Examination of Eye Injuries

818

 

History

819

 

Inspection

821

 

Functional Assessment

824

 

Neurologic Testing

825

 

Eye Pathologies and Related Special Tests

825

 

Orbital Fractures

825

 

Corneal Abrasions

828

 

Corneal Lacerations

828

 

Iritis

828

 

Hyphema

828

 

Retinal Detachment

828

 

Ruptured Globe

828

 

Conjunctivitis

832

 

Foreign Bodies

832

 

On-Field Evaluation and Management of Eye Injuries

835

 

Contact Lens Removal

835

 

Orbital Fractures

835

 

Penetrating Eye Injuries

836

 

Chemical Burns

836

Chapter 20

Face and Related Structure Pathologies

837

 

Clinical Anatomy

837

 

Temporomandibular Joint Anatomy

838

 

The Ear

838

 

The Nose

839

 

The Throat

840

 

The Mouth

840

 

The Teeth

840

 

Muscular Anatomy

841

 

Clinical Examination of Facial Injuries

841

 

History

843

 

Inspection

844

 

Functional Assessment

850

 

Neurologic Testing

850

 

Facial Pathologies and Related Special Tests

850

 

Ear Pathology

851

 

Nasal Injuries

854

 

Throat Injury

854

 

Facial Fractures

856

 

Dental Conditions

856

 

Temporomandibular Joint Dysfunction

861

 

On-Field Examination and Management of Injuries to the Face and Related Areas

863

 

Lacerations

863

 

Laryngeal Injuries

863

 

Facial Fractures

863

 

Temporomandibular Joint Injuries

863

 

Nasal Fracture and Epistaxis

863

 

Dental Injuries

864

Chapter 21

Head and Cervical Spine Pathologies

867

 

Clinical Anatomy

867

 

The Brain

868

 

The Meninges

869

 

Cerebrospinal Fluid

869

 

Blood Circulation in the Brain

870

 

Examination of Head and Cervical Spine Injuries

870

 

Evaluation Scenarios

871

 

Evaluation of the Athlete’s Position

872

 

Determination of Consciousness

872

 

History

873

 

Inspection

875

 

Functional Assessment

876

 

Neurologic Assessment

882

 

Head and Cervical Spine Pathologies and Related Special Tests

886

 

Head Trauma

886

 

Cervical Spinal Cord Trauma

895

 

On-Field Examination and Management of Head and Cervical Spine Injuries

899

 

Equipment Considerations

899

 

Initial Inspection

901

 

Initial Action

902

 

History

907

 

Inspection

908

 

Palpation

908

 

Neurologic Testing

908

 

Removing the Athlete from the Field

908

 

Home Instructions

910

Chapter 22

Environment-Related Conditions

915

 

Clinical Anatomy and Physiology

915

 

Heat Transfer

915

 

Blood Flow and Heat Exchange

916

 

Sweating Mechanism

917

 

Heat Conservation

917

 

Ambient Temperature Influence

917

 

Clinical Examination of Environmental Conditions

918

 

History

918

 

Inspection

918

 

Palpation

919

 

Review of Systems

919

 

Environmental Pathologies and Related Special Tests

919

 

Heat Illnesses

919

 

Prevention of Heat Illness

922

 

On-Field Examination and Management of Heat Illnesses

925

 

Heat Cramps

925

 

Heat Exhaustion and Heat Stroke

925

 

Cold Injuries

926

 

Hypothermia

926

 

Frostbite

926

 

Prevention of Cold Injuries

927

 

On-Field Examination and Management of Cold Injuries

927

 

Hypothermia

927

 

Frostbite

928

Appendix A

Reflex Testing

931

Appendix B

Lower Extremity Functional Testing

937

 

Index

941