MUSCULOSKELETAL SCREENING ASSESSMENT

TABLE 2: MYOTOMES C1, C2 Cervical flexion C3 C4 C5 C6 C7 C8 T1

L1, L2 Hip flexion L3 L4 L5 S1

S2

Cervical side flexion Scapula elevation Shoulder abduction

Elbow flexion and wrist extension Elbow extension and wrist flexion Thumb extension Finger abduction

Knee extension Ankle dorsiflexion Big toe extension Ankle plantiflexion Knee flexion

Lumbar spine Combine initial observation of the lumbar spine with that of the pelvis to distinguish whether the posture of the lumbar spine is related to the tilt of the pelvis. Note whether the spine has an increased lordosis or kyphosis along with the tilt of the pelvis. From the lateral view, the ideal posture is that the ear, shoulder, hip and anterior ankle joint should line up if you were to draw a line down them. From a posterior view, skin creases should be level and there should be no sway from right to left. Active movements that should be assessed are flexion, extension and side flexion, noting any rotational compensation due to tight hamstrings, quadratus lumborum and other soft- tissue restraints (4,6).

Neuromuscular assessment The neuromuscular assessment takes into consideration the fact that different spinal nerves innervate structures peripherally from the spinal column and can become irritated, causing pain and weakness. Each spinal level can be assessed

with different muscle contractions or sensation tests. This assessment should include a myotome (nerve supplying a muscle), a dermatome (nerve supplying the skin), reflexes and nerve tensioning assessment. The player should be dressed appropriately so that skin sensation can be tested without causing embarrassment (2). Table 1 shows the different dermatomal patterns. Assessment involves the

player closing their eyes and the practitioner lightly touching their skin. Ensure that you explain what is going to happen beforehand and obtain explicit consent from the player. Compare the right and left sides for different sensations – they should be equal.

The isometric contraction of various muscles will provide an indication of

weakness due to a nerve problem. Table 2 shows the muscles tested when assessing myotomal distribution. When assessing reflexes, again you are comparing right and left and ensuring that the reflex is not diminished or hypersensitive. Table 3 shows the reflexes tested.

Finally, a straight-leg raise, prone knee femoral nerve stretch, slump test and

upper-limb tensioning tests are performed to isolate tension on the main nerves from the spinal column (4).

TABLE 3: REFLEXES Bicep brachii tendon reflex Triceps brachii

Patella tendon reflex

Medial hamstring tendon Biceps femoris reflex

Sacro-illiac joint

The sacro-illiac joint (SIJ) is palpated medially to the posterior superior iliac spine to assess for a pain response (4). Performing an active straight-leg raise, with the perception that one side is harder to lift than the other, has also been elicited to indicate an SIJ problem (7).Other tests used are the FABERS test (passive flexion, abduction and external rotation at the hip) (8), hip thrust through the SIJ (the hip is flexed to 90° and pointing towards the contralateral shoulder and the practitioner compresses down the line of the femur) and kinetic tests looking at the movement of the SIJ during active movements at the hip (2). With all joint tests, compare the left and right sides.

C5 and C6 nerve root C6 and C7 nerve root L3

L5 – S1 S1, S2

while monitoring for excessive movements and pain (3,9). The apprehension test involves the athlete lying supine

and passively externally rotating a 90° abducted shoulder. Pain and apprehension are positive signs (2). This test is turned into the relocation test by adding a posterior–anterior force on the humeral head. Reduction in apprehension and an increase in external rotation are signs of a positive test (9).

Elbow complex To begin, observe the posture of the elbow. Men and women differ slightly, as women have developed a larger deviation at the elbow in a valgus direction. This angle is referred to as the carrying angle; typically, males have a carrying angle of about 5–10° while females have an angle of about 10–15°. Active and resisted movements of the elbow complex are flexion, extension, pronation and supination. Some of the wrist muscles attach around the epicondyles of the humerus, and so wrist actions may provide positive elbow signs on testing. To test the collateral ligaments around the elbow, bend

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the elbow slightly and add a varus force for the lateral ligament and a valgus force for the medial ligament (2).

Wrist and hand Always start with a close observation of both hands and wrists held side by side. Look for any bony deformity, swelling or muscle wasting (8). Active and resisted movements of the wrist are flexion, extension, and ulna and radial deviation. Ask the athlete to make the wrist movements with their fingers both flexed and extended, as many of the muscles pass over several joints and movement may be restricted in some positions (2); for example, ask the athlete to make a hook grasp with the fingers only, or to make a straight fist so that the fingers bend only at the proximal phalangeal and metacarpal–phalangeal joint. Check that the thumb can reach to all tips and pulps of all fingers (2).

If the athlete uses their hand and wrist continually or with fine control, then a more detailed assessment with further investigations may be required.

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