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- Examination of Musculoskeletal Injuries
Examination of Musculoskeletal Injuries
by Sandra J. Shultz, Peggy A. Houglum and David H. Perrin
688 Pages
Examination of Musculoskeletal Injuries, Fourth Edition With Web Resource, guides current and future athletic trainers and rehabilitation professionals through the examination and evaluation of musculoskeletal injuries both on and off the field. The text presents injury examination strategies in on-site, acute, and clinical settings and provides the information on mastering the skills needed for the Board of Certification examination for athletic trainers as determined by the sixth edition of Athletic Training Role Delineation Study/Practice Analysis for entry-level athletic trainers.
This updated fourth edition contains foundational information on a wide spectrum of injuries and the appropriate tests for examining and diagnosing them. Readers will learn to obtain an accurate injury history from the patient, inspect the injury and related areas, test motion control, palpate both bone and soft tissues, and examine function in order to gauge the player’s readiness to return to play. The fourth edition also includes the following enhancements:
• A new online video library contains more than 51 short video clips that correspond to and demonstrate evaluation techniques for various musculoskeletal disorders found throughout the text.
• Full-color photos and medical artwork have been added throughout the text to clarify testing techniques and enhance knowledge of relevant body structures.
• Substantial updates provide the most recent evidence-based clinical information.
• An expanded selection of special tests and injury-specific examinations are now presented in a more accessible format and include a photo or video, description of the purpose, patient and clinician positions for the test, procedures performed, and possible outcomes.
The content of Examination of Musculoskeletal Injuries, Fourth Edition With Web Resource, has been restructured and focused to provide applicable information in a straightforward manner. Part I is aimed at entry-level students and presents general and introductory skills for each component of injury examination, including basic terminology and a breakdown of the examination procedure. Each component is then explored in depth along with general purposes and techniques. Part I ends by incorporating the various components into a systematic strategy for examination based on severity of injury and environment. Part II then applies the principles learned in the previous chapters to the recognition and examination of injuries organized by specific regions of the body. Each chapter includes strategies for examination immediately after an injury as well as examinations seen later in a clinical setting.
To assist student comprehension and knowledge retention, key terms are in boldface throughout the text and are defined in the glossary. Symbols throughout the text alert students to essential procedures and highlight important information. The web resource houses printable tables of special tests, examination checklists and forms that students can use in laboratory work and review sessions, and a robust video library. To aid instructors, the text includes a suite of ancillary materials featuring a test package, instructor guide, and presentation package plus image bank.
Examination of Musculoskeletal Injuries, Fourth Edition With Web Resource, is an essential resource ffor students of athletic training and therapy as well as current practitioners in the field who wish to use evidence-based procedures in their clinical practice to ensure safe and accurate diagnoses of injuries.
Part I. Principles of Examination
Chapter 1. Anatomical Nomenclature and Injury Classifications
Anatomical Reference Terminology
Physical Maturity Classifications
Injury Classifications
Sign Versus Symptom
Acute Versus Chronic
Closed (Unexposed) Wounds
Closed Soft Tissue Injuries
Bone and Joint Articulations
Nerve Injuries
Open (Exposed) Wounds
Summary
Learning Aids
Chapter 2. Principles of Examination: An Overview
Proper Use of Terminology
Examination Components
Injury Survey
SINS
Subjective and Objective Segments
Testing During the Objective Segment
Determining an Appropriate Course of Action
Documenting the Examination
Standard Abbreviations
SOAP Notes
Summary
Learning Aids
Chapter 3. Taking a History
Information to Seek
Information Categories
Signs and Symptoms
Situation-Specific History and Depth of Inquiry
Essential History (Emergent Examination)
Focused History (On-Site Examination)
Detailed History
Summary
Learning Aids
Chapter 4. Observation
System of Observational Examination
Global Observation
Specific Observation
Details of Specific Observation
Examination of Posture
Examination of Gait
Specific Observation of the Injury
Summary
Learning Aids
Chapter 5. Palpation
General Principles
Foundational Skills
Palpation Technique
Structures to Palpate
Skin
Fascia
Myotendinous Unit
Bone
Joint Structures
Neurovascular Tissue
Lymph Nodes
Palpation Strategies
Summary
Learning Aids
Chapter 6. Examination of Joint Motion
Goals and Purposes
Normal Range of Motion
Prerequisites for Successful ROM Examination
Physiological Motion
Accessory Motion
Examination of Physiological Range of Motion
Positioning
Patient Stabilization and Substitution
Measurement Technique
Examination of Accessory Motion
Joint Accessory Movement Rules
Joint Accessory Examination Technique
Recording Results
Examination of Ligament and Capsular Integrity
Indications for Ligament Stress Tests
Grading of Ligament Laxity
Stress Test Technique
Summary
Learning Aids
Chapter 7. Examination of Strength
Muscle Contraction
Functional Neuromuscular Anatomy
Review of Excitation–Contraction Coupling
Goals and Purposes
Manual Strength Examination
Break Tests
Manual Muscle Testing
Instrumented Strength Examination
Isometric Strength Examination
Isotonic Strength Examination
Isokinetic Strength Examination
Summary
Learning Aids
Chapter 8. Examination of Neurological Status
Functional Neuroanatomy
General Principles of the Neurological Exam
Goal and Purpose
Sensory Function Testing
Motor Function Testing
Reflex Testing
Region-Specific Neurological Examination
Cervical Plexus
Brachial Plexus
Lumbar and Sacral Plexuses
Summary
Learning Aids
Chapter 9. Examination of Cardiorespiratory Status
Functional Anatomy and Physiology
Lungs
Heart
Peripheral Circulation
Examination of Cardiorespiratory Status
Systemic Perfusion (Vital Signs)
Peripheral Circulation
Cardiovascular Compromise
Causes and Types of Cardiovascular Collapse (Shock)
Recognition of Shock
External Bleeding
Summary
Learning Aids
Chapter 10. Putting It All Together: General Examination Strategies
On-Site Examination
Goals and Purposes
On-Site Examination of the Unconscious Athlete
On-Site Examination of the Conscious Athlete
Communicating On-Site Examination Results
Acute Examination
Subjective Segment
Objective Segment
Clinical Examination
General Principles of the Clinical Examination
Subjective Segment
Objective Segment
Summary
Learning Aids
Part II. Region-Specific Examination Strategies
Chapter 11. Cervical and Upper Thoracic Spine
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 12. Shoulder and Arm
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 13. Elbow and Forearm
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 14. Wrist and Hand
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 15. Lower Thoracic and Lumbar Spine
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 16. Leg, Ankle, and Foot
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 17. Knee and Thigh
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 18. Hip, Pelvis, and Groin
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 19. Head and Face
Functional Anatomy
Regional Examination
Injury Recognition and Special Tests
Injury Examination Strategies
Summary
Learning Aids
Chapter 20. Thorax and Abdomen
Functional Anatomy
Thoracic Cavity
Abdominal Cavity
Regional Examination
Injury Examination Strategies
Summary
Learning Aids
Sandra J. Shultz, PhD, ATC, CSCS, is professor and chair in the department of kinesiology at the University of North Carolina at Greensboro. As a certified athletic trainer since 1984, Shultz has a broad clinical perspective having worked with athletes at the high school, collegiate, Olympic, and international levels.
Before coming to the University of North Carolina at Greensboro, Shultz taught and conducted clinical research in the sports medicine and athletic training program at the University of Virginia. She also served as associate director of athletic training and rehabilitative services at the University of California at Los Angeles, where two of her primary responsibilities were the direct health care of student-athletes and the education of athletic training students.
Shultz is a member of the National Athletic Trainers’ Association (NATA), the American College of Sports Medicine (ACSM), the National Strength and Conditioning Association (NSCA), and the Orthopaedic Research Society (ORS). She is a section editor for the Journal of Athletic Training. Previously she served on the NATA’s Entry-Level Education Committee, Pronouncements Committee, Convention Educational Program Committee, Appropriate Medical Coverage for Intercollegiate Athletics Task Force, and Research and Education Foundation Research Committee. She was also a site visitor for the Joint Review Committee on Educational Programs in Athletic Training (JRC-AT). As a researcher, Shultz focuses on the study of risk factors for anterior cruciate ligament injury in female athletes and has received grant funding from the National Federation of State High School Associations (NFHS), the NATA Research and Education Foundation, the National Football League Medical Charities, and the National Institutes of Health. She is the primary author of the NFHS Sports Medicine Handbook and the NATA Appropriate Medical Care for Intercollegiate Athletics.
Her awards from the NATA and NATA Foundation include the Freddie H. Fu, MD, New Investigator Award, the Most Distinguished Athletic Trainer Award, the Sayer “Bud” Miller Distinguished Educator Award, and the Medal for Distinguished Athletic Training Research.She was inducted into the NATA Hall of Fame. Shultz is a fellow of the NATA, the American College of Sports Medicine, and the National Academy of Kinesiology.
Shultz enjoys running, reading, and traveling. She resides in Greensboro, North Carolina.
Peggy A. Houglum, PhD, is retired as an associate professor at the Rangos School of Health Sciences at Duquesne University in Pittsburgh. She has nearly 45 years of experience providing patient and athlete care in a variety of settings, including athletic training facilities, sports medicine clinics, rehabilitation hospitals, acute care hospitals, burn care facilities, workers’ compensation clinics, and extended care facilities. She has also been an athletic trainer with the United States Olympic Sports Festivals, Olympic Games, and World University Games.
Houglum’s extensive background as a certified athletic trainer, physical therapist, clinical and classroom educator, and program director gives her a unique perspective on the appropriate use of therapeutic exercise techniques in rehabilitation programs for treatment of athletic injuries. In 1991, Houglum created the NATA’s first formal continuing educatiion programming. Since that time Houglum has been chair of the NATA Continuing Education Committee and a member of the organization’s Education Council and the Council on Employment. She is a member of the NATA Hall of Fame and has received numerous awards, including the NATA’s Most Distinguished Athletic Trainer, NATA Continuing Education Award, NATA Board of Directors Recognition for Outstanding Contributions, and Therapy Times Most Influential Rehabilitation Professional in Physical Therapy.
Houglum is a member of the American Physical Therapy Association’s Sports Medicine Section. She is also a member of NATA and serves on the NATA Board of Certification Role Delineation #7 Committee. Houglum is associate editor for Sports Rehabilitation and serves on the editorial board of Physical Therapy and Rehabilitation.
Her professional writing career has focused on presenting complex concepts of health care to students at a level of understanding and appreciation that provides them with the conceptual and clinical core they need to become well-informed clinical professionals. She is author of Therapeutic Exercise for Musculoskeletal Injuries, lead author of Brunnstrom’s Clinical Kinesiology, Sixth Edition, and book chapters on sports medicine and rehabilitation.
Houglum enjoys spending time with family, reading, exercising, and painting. She resides in Cedar Grove, Wisconsin.
David H. Perrin, PhD, ATC, is dean and professor of exercise and sport science in the College of Health at the University of Utah. For 13 years Perrin was a member of the NATA Professional Education Committee, helping to write the guidelines for accreditation of both undergraduate and graduate athletic training education programs. For 15 years he directed the graduate programs in athletic training and sports medicine in the Curry School of Education at the University of Virginia. He was editor in chief of the Journal of Athletic Training from 1996 to 2004 and was the founding editor of the Journal of Sport Rehabilitation. He is author of Isokinetic Exercise and Assessment and Athletic Taping and Bracing, editor of the third edition of The Injured Athlete, and coauthor of Research Methods in Athletic Training.
Perrin’s research interests include injury risk factors of the anterior cruciate ligament in female athletes. His awards from the National Athletic Trainers’ Association include the Sayers “Bud” Miller Distinguished Educator Award, the Most Distinguished Athletic Trainer Award, and the William G. Clancy, Jr., MD, Medal for Distinguished Athletic Training Research. He was inducted into the NATA Hall of Fame. Perrin is a fellow of the National Athletic Trainers’ Association, American College of Sports Medicine, and National Academy of Kinesiology.
Perrin enjoys traveling, exercising, and vacationing at his lake cottage in Vermont.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
Measuring Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale.
Examination of Physiologic Range of Motion
Goniometry is the measurement of joint angles. The tool you will use to measure joints is a goniometer. There are many different types of goniometers on the market, but each has essentially the same structure: two arms (one stationary and one moveable) and an axis (fulcrum) that is surrounded by the body of the goniometer, which contains a measuring scale. The scale is usually similar to a protractor and calibrated in degrees. The scale can be either a 360° full-circle or a 180° half-circle. Goniometer arms range in length from 1 in. to 14 in. Use the long-armed goniometers to measure long bone joints such as the knee, and the short-arm goniometers to measure smaller joints such as the toe and finger interphalangeal joints. Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine (figure 6.2). Tape measures can also be used to identify lumbar range of motion if an inclinometer is not available (figure 6.3). Compare the measures found during the examination with previous measures or compare the left and right sides. Electric goniometers are also available but are usually reserved for research; they are more expensive and impractical for clinical use. Some of the more common goniometers are shown in figure 6.4. Calculate joint range of motion by measuring the angles between the beginning position and the ending position of available motion.
Goniometers similar to a carpenter level are called gravity-dependent goniometers, or inclinometers, and are used most often to measure motion in the spine.
Use of a tape measure to examine ROM of the spine. See chapter 11 for details on measurement technique.
Different types of goniometers used to measure range of motion.
Measuring ROM accurately requires precision, and precision is achieved through practice and skillful observation. In addition to thoroughly mastering the material presented in this chapter, you must be able to position and stabilize the patient and segment to be measured, appropriately determine the end range of motion, identify and palpate the correct landmarks, apply the goniometer in the proper position, and read the goniometer correctly.
Positioning
Position involves four factors: the patient, the joint, the goniometer, and yourself. Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. You should position the patient so the joint to be measured can move through its ROM freely, without obstruction, and so you can easily observe the joint. The patient should be comfortable. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. For example, you should measure all motions with the patient in prone before moving the patient to another position.
You must also carefully consider the position of the segment to be measured, particularly when measuring active motion. A segment that must lift against gravity may give a false active motion measurement if its muscles are not sufficiently strong enough to lift through the range of motion. When measuring passive ROM, performing too many activities at the same time such as stabilizing the part, holding the extremity against gravity, and aligning the goniometer may lead to a gross error of measurement. You should document the segment's position during ROM testing when recording the measurement.
Positioning the goniometer correctly is crucial; if the arms of the goniometer are not aligned properly, the measure will be inaccurate. Likewise, moving the axis of the goniometer off the joint line will yield an incorrect measurement. The correct technique for goniometer alignment is discussed under Measurement Technique.
Finally, your position is just as important as the other factors in ROM measurements. Once you have placed the goniometer and ensured proper alignment, you must read the goniometer at eye level for an accurate reading. For example, if you measure hip flexion and read the goniometer in an erect standing position, the results could differ by several degrees from the reading you would obtain if you knelt down to read the goniometer at eye level.
Please refer to "Prerequisite Knowledge for Measuring ROM" and "Prerequisite Skills for Measuring ROM" for a summary of the prerequisite skills.
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Patient Stabilization and Substitution
Stabilization is isolating the motion of the joint while eliminating unwanted motion from adjacent structures. You must stabilize the patient before measuring ROM or examining end feel to assure reliable results. Most often, you will stabilize the proximal joint segment and move the distal segment. You must isolate a joint motion to examine it accurately. If you allow both joint segments to move, true joint end feel may be inaccurate.
Moreover, if you do not stabilize the proximal segment, motion of other joints may contribute additional motion gains, exaggerating the joint's true motion and resulting in substitution. For example, if you measure shoulder flexion without appropriately stabilizing the shoulder, the patient can hyperextend the spine and falsely appear to have greater shoulder motion. Your knowledge of possible substitutions and an awareness of the patient's movement will assist in recognizing substitution patterns. Stabilization during ROM examination ensures a truer execution of the test and a more accurate result.
Occasionally the patient's body weight may prevent unwanted motion. Most motions, however, require manual stabilization of the proximal segment to prevent unwanted motion. You must know how to stabilize the proximal segment while simultaneously using a goniometer to measure joint motion.
Measurement Technique
Goniometric measurement requires proper alignment of the stationary and moveable arms and the goniometer's axis (figure 6.5). Use bony landmarks to properly place these elements. Place the stationary arm along the longitudinal axis of the stabilized joint segment and the moveable arm parallel to the longitudinal axis of the moving joint segment. When using a 180°-scale goniometer, you may need to reverse the stationary and moving arms before the moveable arm will register on the scale. Align the goniometer's axis with the joint's axis of motion. If the goniometer arms are accurately placed, the fulcrum will be positioned correctly.
The axis is placed at the joint, the stationary arm is along the longitudinal aspect of the stabilized segment, and the moveable arm is placed in alignment with the moving segment.
Visit the web resource, video 6.2, for the range of motion measurement technique.
To correctly align the goniometer arms, position yourself so your line of vision is at the same level as the goniometer. Checking both arms more than once before reading the scale also assures correct alignment. Often, you will align the stationary arm and then unwittingly move it again when adjusting the moveable arm; even highly experienced clinicians make a habit of checking and rechecking the goniometric arm and axis positions before reading the measurement.
Before measuring range of motion, you should explain to the patient what you will do. Take measurements at the start and end positions of the joint motion. If you are only interested in the end of the ROM, it is assumed that the start position is 0° and has been verified by visual determination. ROM examination is usually performed on the uninvolved extremity before the injured extremity. Performing the examination in this sequence provides you with an idea of what to expect when you examine ROM of the injured segment.
The final factor in ROM measurement is recording the measure. Some facilities use forms listing normal ranges of motion and you can simply fill in the blanks with the patient's measurements. If such a form is not available, you should record the date, the patient's position (seated, prone), the type of motion (active or passive), and the side of the body and joint measured. Note any pain or other abnormal reactions that occur during the examination. If the patient lacks full motion, record the degrees as a range. For example, if a patient lacks 20° of knee extension and has full knee flexion motion, record ROM as 20-145°. If the patient has excessive motion, or hypermobility, use a minus to indicate excessive mobility. For example, if the patient has 15° of hyperextension of the knee and normal flexion motion, record -15-145°.
Avoid using a visual estimate to determine range of motion. The visual estimate may be off and can easily vary among clinicians, and it is not an objective measure. Especially avoid estimating if you use the measurement to identify a deficiency, record progress, or determine a patient's readiness to return to normal activity levels.
See "Range of Motion Measurement Technique" for a summary.
Injury Recognition: Ankle Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region.
Injury Recognition and Special Tests
The majority of active people experience leg and foot problems sometime in their lives. Tremendous forces, both compressive and rotational, are transmitted through the weight-bearing structures of the foot, ankle, and leg. Consequently, both traumatic and chronic injuries frequent this region. Even seemingly minor injuries can be debilitating given the foot and ankle's need for strength and stability in daily weight-bearing activities, let alone sport activities. Additionally, leg and foot problems can alter gait or lower-body mechanics, increasing stress and compensatory problems up the kinetic chain in the knee, hip, or low back.
Acute Soft Tissue Injuries
The leg complex relies on the integrity of active and passive soft tissue structures for both stability and propulsion. Dynamic sport activity places tremendous loads and demands on the foot and ankle. Soft tissue injuries commonly occur as a result of direct contact and intrinsic or extrinsic forces acting on the foot, ankle, and leg.
Contusions
Making contact with the ground or an opponent, kicking an unyielding object, being hit in the shin by a baseball, and being stepped on or kicked by another player are all common injury mechanisms for soft tissue and periosteal contusions. Signs and symptoms include pain, swelling, and discoloration. Direct contact to the superficial and unprotected anterior medial border of the tibia can result in localized inflammation (periostitis) and hematoma formation under the periosteum, which can take considerable time for the body to absorb. Disability and function loss are usually more severe with muscle contusions as a result of tenderness, swelling, and spasm within the muscle tissue. Decreased range of motion and strength also occurs and varies according to the degree of tissue injury. Although muscle contusions rarely result in serious injury, complications can arise from severe contusions and excessive bleeding within the enclosed anterior tibial compartment of the leg (see the discussion of anterior compartment syndrome earlier in this chapter). You should closely monitor contusions that result in severe swelling of a muscular compartment for neurovascular compromise.
You should closely monitor severe contusions to a muscular compartment for excessive swelling and neurovascular compromise.
A heel contusion, or stone bruise, can be particularly problematic. A heel bruise can result from landing hard on the heel during jumping activities or stepping on an uneven surface or a stone at heel strike with little or no footwear protection. A contusion to the fat pad of the heel can cause considerable pain and point tenderness, making it difficult to bear weight or walk with a normal gait. Discoloration and swelling may or may not be evident, depending on severity.
Sprains
The foot and ankle include multiple joints and ligaments that stabilize the body during weight-bearing activities. Given the tremendous forces exerted on these structures during landing, cutting, and running, the ligaments are prone to injury when these forces extend the joint beyond its normal ROM. Sprains occur most often at the hindfoot, which is composed of the inferior tibiofibular (syndesmosis), talocrural (tibia, fibula, and talus), and subtalar (talus, calcaneus, navicular) joints. Ligamentous support is essential for stabilizing the hindfoot, particularly when the ankle plantar flexes. Stability is provided medially by the deltoid ligament complex (refer to figure 16.2) and laterally by the anterior talofibular, calcaneofibular, and posterior talofibular ligaments (refer to figure 16.3). The distal tibiofibular joint is stabilized by the interosseous membrane and the anterior and posterior tibiofibular ligaments. Although sprains occur most often at the hindfoot, sprains in the midfoot (talocalcaneonavicular, cuneonavicular, intercuneiform, and calcaneocuboid joints) and forefoot(tarsometatarsal, intermetatarsal, metatarsophalangeal, and interphalangeal joints) are not uncommon. The injury mechanism determines which joint structures are involved.
Lateral Ankle Sprains
The most common mechanism of ankle injury involving the lateral ligament complex is inversion with or without plantar flexion. In typical scenarios, a basketball player comes down on an opponent's foot or lands awkwardly on the outside of his own foot, causing the ankle to turn in (inversion mechanism). The athlete complains of immediate pain upon injury and may hear a pop. Injury almost always involves the anterior talofibular ligament (figure 16.22). The calcaneofibular and, less often, the posterior talofibular ligaments are also involved. Signs and symptoms are consistent with first- through third-degree ligament sprains. However, remember that the amount of swelling is a poor indicator of injury severity with lateral ankle sprains because even minor sprains can result in considerable joint swelling. With second- and third-degree sprains, there may also be injury to the medial structures of the ankle as a result of compression from the inversion force. Dislocation of the ankle mortise rarely results with third-degree ligament injuries, but associated avulsion or push-off fractures of the lateral and medial malleolus, respectively, are not uncommon with more severe ankle sprains. Because of this, you must be able to distinguish between soft tissue and bony tenderness during palpation. To test the integrity of the lateral ligament complex, use the anterior drawer test to examine both the anterior talofibular and calcaneofibular ligaments, and the medial talar tilt (inversion stress) testto primarily test the calcaneofibular ligament. An alternative testing position for the anterior drawer test is with the patient prone and the foot hanging off the edge of the table. Place one hand under the distal anterior surface of the tibia and apply an anteriorly directed force to the calcaneus.
Injury to the lateral ligaments of the ankle.
Anterior Drawer Test
Other names for test
None
Used to assess
Integrity of anterior talofibular ligament and calcaneofibular ligament
Patient position
Either long-sitting or supine, knee slightly flexed to relax the gastrocnemius, and ankle in 20° plantar flexion
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing distal tibia and fibula just above malleoli
Clinician's test hand position
Grasping calcaneus posteriorly
Action performed
Pull calcaneus forward on talus.
Positive result
Pain and laxity; laxity is greater when both ligaments are torn.
Accuracy
- SN = .58-.83 SP = .38-1.0 +LR = 1.2-2.2 - LR = 0.39-0.70
Croy et al. 2013; Raatikain, Putkonen, and Puranen 1992; Van Dijk et al. 1996.
Medial Talar Tilt Test
Other names for test
Inversion (varus) stress test
Used to assess
Integrity of calcaneofibular ligament
Patient position
Either long-sitting or supine
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing medial distal leg just above medial malleolus
Clinician's test hand position
Grasping lateral foot along calcaneus to hold ankle in anatomical neutral position
Action performed
Adduct and invert calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = .50 SP = .88 +LR = 4.00 - LR = 0.57
Hertel et al. 1999; Schwieterman et al. 2013.
Medial Ankle Sprains
Medial ankle sprains resulting from eversion forces are considerably less common, primarily because of the greater stability of the medial ankle, a consequence of the thickness and strength of the deltoid ligament complex as well as the longer lateral malleolus, which prevents excessive eversion (figure 16.23). Palpate the distal fibula for possible fracture with severe eversion injuries. Signs and symptoms are consistent with first-, second-, and third-degree sprains. To test deltoid ligament integrity, use the lateral talar tilt (eversion stress) test and Kleiger (lateral rotation) testto determine the degree of instability. Disability and recovery may be prolonged with medial ankle sprains; given the support the deltoid ligament provides to the medial longitudinal arch of the foot, even simple weight-bearing stresses the injured structures. Furthermore, pes planus and excessive pronation may result from chronic medial instability.
Injury to medial ligaments of the ankle. Carefully palpate the distal fibula for possible fracture with all serious eversion injuries.
Lateral Talar Tilt Test
Other name for test
Eversion (valgus) stress test
Used to assess
Integrity of deltoid ligament
Patient position
Either long-sitting or supine
Clinician position
End of table, facing patient
Clinician's stabilizing hand position
Stabilizing lateral distal leg with hand over lateral leg proximal to lateral malleolus
Clinician's test hand position
Grasping medial calcaneus and positioning ankle in neutral
Action performed
Abduct and evert the calcaneus.
Positive result
Pain and laxity
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Kleiger Test
Other name for test
Lateral rotation test
Used to assess
Integrity of deltoid ligament
Patient position
Sitting, knee flexed to 90° and foot relaxed
Clinician position
Standing at foot of table
Clinician's stabilizing hand position
Stabilizing leg by grasping distal tibia and fibula
Clinician's test hand position
Grasping top of metatarsal region of foot
Action performed
Rotate the foot laterally.
Positive result
Medial ankle pain with or without laxity (talar displacement)
Accuracy
- SN = N/A SP = N/A +LR = N/A - LR = N/A
Examining Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures.
Examination of Posture
Examine posture with the patient in a static position and in as few clothes as possible to allow an unobstructed view of all postural elements. (See the posture examination checklist later in this chapter.) Correct posture minimizes stress on muscles, bones, and joints while incorrect posture places abnormal stress on these structures. The more posture deviates from the correct position, the greater the stress placed on the structures that work to maintain it.
Incorrect posture usually develops with gradual changes in muscle, tendon, or fascial support. Children under the age of four generally have good posture and mechanics. As early as elementary school, children develop poor sitting and standing habits, and abnormal posture becomes apparent. By the time an individual becomes a teenager or young adult, abnormal postural habits are entrenched. Poor posture becomes more exaggerated as people age and develop progressively greater tightness and weakness in already shortened or lengthened soft tissue structures, resulting in changes in bone alignment and stress distribution.
Incorrect posture can also occur rapidly following an acute injury if the athlete alters position to reduce pain, functions with altered ability, or protects an injury. For example, a patient who experiences excessive swelling around the knee following an injury may not be able to stand with the knee fully extended, or a person suffering a cervical sprain may stand with the head thrust forward to relieve pain.
Sometimes an individual acquires an incorrect alignment because genetically determined joint or soft tissue characteristics cause the deformity over time, or the deformity present from birth becomes more apparent as the person ages.
You should include posture when examining any injury in the athletic training clinic. Posture can either result from injury or contribute to injury and should not be overlooked if you are to provide appropriate care. Examine posture by inspecting the anterior, lateral, and posterior views of the patient in the frontal and sagittal planes (figure 4.2).
Correct standing alignment: (a) anterior, (b) lateral, and (c) posterior views.
Examination Procedure
A plumb line is often used as a reference of alignment for the body when examining posture. A plumb lineis a string suspended overhead with a small weight, or plumb bob, attached at the end near the floor. Position the patient behind the line so you can see the body bisected by the plumb line.
- Anterior view. The patient faces you with the plumb line dividing his body into right and left halves. Use the checklist for the anterior view to identify any deviations from normal.
- Lateral view. Observe the lateral view from both the left and right sides so you can see any imbalances between the two. Use the checklist for the lateral view to identify any deviations from normal.
- Posterior view. This view includes some of the same items observed in the anterior view but should not be eliminated since it also reveals other factors such as foot arch positions, knee fossa alignment, scoliosis, and scapula height. The plumb line bisects the body as indicated in the posterior view checklist. Again, use the checklist to identify any deviations from normal.
Postural Deviations
You should record postural deviations during the examination, ranking them as mild, moderate, or severe. Occasionally, a position may be considered normal, hyper-, or hypo-, while other postural deviations may be identified with names that define the abnormality but may not indicate severity. For example, genu recurvatum indicates hyperextension of the knee joint without relating the severity of the hyperextension. Placing a descriptor such as mild in front of these names can further qualify or quantify the deviation.
The examination process always includes comparison of left and right corresponding segments, because "normal" is often solely determined by comparison to the contralateral side. Normal for one person may not be normal for another person. For example, a gymnast will have much greater excursion in a straight leg raise than a baseball player, and a pitcher will have more glenohumeral lateral rotation than a first baseman. Each athlete must be compared only to herself and not to others.
Postural deviations cannot be recognized as abnormal unless normal posture is identified. You must know what is normal, or expected, in postural examination from all views. In part II, where the body regions and their associated injuries are discussed, postural deviations unique to those regions are presented. How to identify, treat, or modify the deviations, as well as the consequences of the deviations, are also discussed.
Examination of Sense: Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Examination of Vision, Smell, and Hearing
Unique to this region of the body is the examination of the sensory organs for sight, smell, and hearing. This includes a close inspection of eye and ear structures using an ophthalmoscope and otoscope, respectively, and testing for visual, smell, and hearing acuity.
Interior Eye Examination Using an Ophthalmoscope
An ophthalmoscope(figure 19.8) is an instrument used in a routine eye exam to detect injury or disease in the interior structures of the eye. It consists of a light source combined with a set of lenses of graded focal lengths designed to inspect the structures of the eyeball. The lenses are calibrated so that shorter (black scale, positive values from 0 to +16) and longer focal lengths (red scale, negative values) can be used to isolate the structures by moving them in and out of focus. With experience, you will become familiar with the scale settings and which focal length best visualizes each structure. In general, shorter focal lengths focus on structures in the anterior globe (e.g., lens and cornea), whereas longer focal lengths examine the internal structures (e.g., retina and optic nerve). There are two types of ophthalmoscopes, direct and indirect. In the clinical setting, you will more commonly use the direct ophthalmoscope, a handheld instrument with a battery-powered light source.
Eye examination using an ophthalmoscope.
Visit the web resource, video 19.1, for a demonstration of using an ophthalmoscope.
To examine the internal structures of the eye, hold the instrument in one hand, keeping the index finger free to manipulate the focal length, beginning with the lens setting at zero. To examine the right eye, sit on the right side of the patient and use one hand to stabilize the forehead and the other to hold the instrument. The room should be dimly lit during the examination, and the ophthalmoscope should be approximately 3 in. (7.6 cm) from the eye surface. Resting your hand on the patient's cheek may help you maintain a steady hand and the correct distance from the eye surface. With the patient holding her gaze at a stationary point on the far wall, view the retina through the pupil using your right eye. A minor adjustment in the focal length should bring the retina into focus. A nearsighted patient requires a more negative setting to focus deeper into the elongated globe; the opposite is true for a farsighted patient (Munger and Baird 1980). The optic disc, retina, and blood vessels should all appear normal. Understanding the appearance of normal is best accomplished through practice with a trained professional.
To examine structures in the anterior globe, increase the setting to approximately +6 to bring the lens into focus, and progressively increase magnification to +15 to view structures through the anterior chamber, including the cornea (Munger and Baird 1980). Note any inconsistencies or evidence of debris. As with the internal structures, practice with a trained professional will develop your examination skills.
Inner Ear Examination Using an Otoscope
An otoscope(figure 19.9) is a light source combined with a magnifying lens and specula used to examine the inner ear. The specula are usually disposable for hygienic purposes and adjustable in size to accommodate adults and children. The examiner holds the otoscope with the hand corresponding with the ear to be examined.
Ear examination using an otoscope.
Visit the web resource, video 19.2, for a demonstration of using an otoscope.
First inspect the outer ear for swelling and other abnormalities. Use your free hand to grasp the outer aspect of the ear, gently pulling it upward, backward, and outward to allow you to view the canal and eardrum. Be careful to introduce the speculum gently into the canal to avoid friction or pressure because the canal is very sensitive and rough insertion may cause pain or a gag or cough reflex. Note the condition of the skin, evidence of foreign bodies, redness, or swelling in the canal. If the canal is clear, you can observe the tympanic membrane (eardrum) as a pale or grayish structure deep in the canal that is pulled inward at its center by the malleus. Inspect the membrane for evidence of scarring, which appears as a white, thickened area, or signs of erythema, a pattern of small blood vessels that indicates inflammation (Munger and Baird 1980).
As with use of the ophthalmoscope, considerable practice is required to distinguish normal from abnormal findings. Refer patients if you note swelling, redness or disruption of the external canal and eardrum, excessive wax occluding the canal, or excessive swelling trapped in the external ear (pinna).
Visual Acuity Testing
A Snellen eye chart, named after Dutch ophthalmologist Herman Snellen, is relatively inexpensive and simple to use. It displays 11 lines of letters in decreasing size from top to bottom (figure 19.10). Modified charts may use numbers or a tumbling E chart for which patients must identify the direction that the E faces (up, down, right, or left). To test visual acuity, position the patient 20 ft (6 m) in front of the Snellen eye chart. Test each eye individually by covering the other, and also test both eyes together. Each line represents an acuity fraction typically ranging from 20/20 to 20/200, and the patient is scored based on the lowest line he can clearly read from 20 ft away. Normal vision is considered 20/20. A visual acuity of 20/50 indicates that the patient can read from 20 ft what a person with normal acuity (20/20 vision) can read from 50 ft. Immediately refer any patient showing a loss of visual acuity or blurred or double vision to an ophthalmologist for further examination.
Snellen eye chart.
If a Snellen chart is not available, you can grossly examine visual acuity by having the patient read the scoreboard for distance vision. You can test near vision acuity by having the patient identify the number of fingers you hold in front of her or by reading text on a page.
Smell and Breathing Testing
Loss of smell or difficulty breathing can occur with epistaxis and nasal fractures, but smell and breathing should return to normal once bleeding and swelling subside. Loss of smell can also result from injury to the first cranial nerve (olfactory) and may be evidence of brain trauma. To determine the presence of smell, have the patient close both eyes and describe or identify a particular scent that you wave under the nose. The scent should be one that the patient is familiar with and able to identify under normal circumstances.
Hearing Acuity Testing
Transient hearing loss is common with blows to the head or ear, but hearing should return to normal shortly following injury. Sustained hearing loss may indicate a rupture of the tympanic membrane, infection, swelling, or impacted cerumen. You can examine diminished or loss of hearing bilaterally by rubbing two fingers together or by snapping your fingers beside the patient's ear. Patients with lost or diminished hearing in one ear may turn their head while you speak to align the good ear with the direction of the sound. Whenever loss of hearing persists or is profound, you should refer the patient to a physician for further examination.
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