BOX 1: TYPICAL CONSIDERATIONS OF A ‘SURGICAL SIEVE’

1. Does the patient have a congenital disorder?

2. Does the patient have an acquired disorder? If so, is it: n Neoplastic n Metabolic

n Infective

n Traumatic n Autoimmune n Vascular n Inflammatory n Degenerative n Idiopathic

investigations. Many primary field- side practitioners depend on the first two. The history is vital. Consider the following: n Get the patient to talk you slowly through what happened – not what they think is injured or what someone else told them! n If you know the sport, talk in their sporting terms. Talk about what eases the problem, and what exacerbates it. Even day-to-day activities can reveal the diagnosis. n What treatment or treatments have they used? Have they seen another practitioner? Get straight in your mind what

your examination should be proving before you touch the patient. Ask him or her to demonstrate where the pain is – “Show me where” is a very useful statement. The following steps (summarised in Table 1) are important in every examination.

1. Look – Look for clues such as swelling, signs of inflammation, infection, or scars. 2. Move – Before you touch the patient, ask them to move to check their range of movement (ROM). The physical therapist logic is that if it hurts and your feeling examination (below) exacerbates the pain, then the full range of movement (FROM) may not be achieved. Ask the patient to move the joint both actively and passively, or with assistance from you. FROM may be achieved with assistance – not forcing the joint but instead using trick movements such as getting a patient with a painful shoulder to bend at the waist, to allow gravity to help achieve full flexion assisted, rather than opposing the rotator cuff and causing a painful block. The painful ROM can also be examined on the way down (painful arc).

3. Feel – Finally you can feel the patient. Check for heat and stability, end-point feel (this is covered more in the individual articles on each joint), and the type of swelling and tenderness. Tenderness occurs most commonly in

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tissues that are injured locally, but don’t forget muscles acting over a joint some way from the joint, because of tender points or trigger points in muscles. For most field-side injuries, primary

care treatment can begin because the diagnosis is straightforward. This probably covers 80–90% of all injuries such as sprains, strains and muscle and joint contusions. Deeper injuries or more severe injuries will need further investigation and that will depend on what is available to the primary care physician. We will discuss each joint separately in subsequent articles but first aid in the form of PRICE (Box 3), and general treatment are covered below.

OVERUSE INJURY This is not usually obvious because, the history is less clear in the patients mind. A more detective-type approach is needed. Usually something has changed! The diagnosis is as for acute injury, but in overuse injury the history is of paramount importance. If you know about the patient’s particular sport, talk in their language. If you can’t do this, then get them to talk you, especially about any changes or new techniques in training or coaching. n What about the duration and intensity of training? n Are they using new or worn sportswear or protection? n Are they playing on a different surface?

Go and watch the kind of training

they undertake, or their sport being played – the answer may be obvious to a fresh eye! Learn what forces the

STATEMENT

n Swelling n Signs of inflammation

n Infection n Scars

“SHOW ME WHERE” IS A VERY USEFUL

TABLE 1: APPROACH TO EXAMINATION OF THE PATIENT 1. LOOK

2. MOVE

n Range of motion (ROM)

n Full range of motion (FROM)

n Active/passive movements (or assisted)

n Painful arc 3. FEEL

n Heat and stability n End-point feel n Type of swelling n Tenderness

players are subjected to. Consider, for example, the forces going up a runner’s leg at heel strike, or the forces exerted on a front-row’s spine and back during a scrum in rugby (which may be repeated 50 times in 30 minutes during training). Whatever you discover, this is only half the battle – the patient may yet need some convincing that a change has caused their injury! Examination may be fruitless in a static situation – out of context of the sport itself. Perhaps you can observe the patient in action at their sport, while he or she is actually wearing the appropriate sports-wear. Often the difference between average, good or great sports practitioners relates to “getting your hands dirty” – in other words, putting in the time and energy to see the action live and from the players’ point of view. It seems to be widely

acknowledged that most injured sports people “cheat”. What does this mean? They want to get back to their sport because it makes them feel good. So they do exercises or train in a way that will allow them to achieve what they need in the quickest possible time, whether it is muscle or strength gain, or technique or recovery. However, it is possible that they have unwittingly or unknowingly modified a technique or recovery exercise that is the very cause of their current problem. You should determine whether they have “cheated” like this. Often giving them an explanation of what the problem is works wonders. Advising them to change back to the original conditions and therapeutic trial may be the best solution.

DYSBALANCE

This leads nicely to the concept of dysbalance. One definition of dysbalance is “the injury of other tissues secondary to the original injury or action”. Classically, muscles work in opposition and with other muscles (e.g. the biceps contracting as the triceps relaxes). But the situation isn’t that simple; the relaxing muscle may actually be contracting – albeit eccentrically (i.e. contraction as the muscle lengthens).

If the eccentrically contracting

muscle is weak, it may allow the concentrically contracting (shortening) muscle to work excessively or without

sportEX medicine 2010;43(Jan):17-21