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THE INJURY ASSESSMENT PROCESS

Note: The following sections are written from experiences and view points of the staff of this company. You may not find portions of the literature below in any textbooks or journals, however, the information is based on personal experiences.

Introduction

The injury assessment process is very important in athletics. Athletes will get injured and it is up to the athletic trainer, sports therapist, or physician to treat the injury. However, in order to treat an injury properly, the injury must be diagnosed correctly by the physician. In most athletic settings the athletic trainer will assess the injury as soon as it happens on the field. The athlete will be referred to a physician, and the physician will diagnosis the injury. Then the athlete will be referred to a surgeon, sports therapist, or athletic trainer for rehab.

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Athletic Trainer

Athletic trainers will supervise athletes during games and practices. They will
administer emergency care when needed and prevent and manage injuries. Athletic trainers will stay in close contact with the coaching staff, strength coach, athlete, parent, team nutritionist, equipment managers, and team physician to ensure the safety and management of the athlete. In addition, the athletic trainer can be a vast resource for the parent, coach, and athlete on directing them to the right sources of information for questions such as nutrition, sleep, workouts, rehab, equipment, and any other variable that can enhance or degrade performance.

An athletic trainer is certified by the National Athletic Trainers Association (NATA), and must have a degree in sports medicine or athletic training. Athletic trainers have a strong background in anatomy physiology, exercise physiology, biomechanics, psychology, health and nutrition, emergency medicine, injury prevention, injury assessment, organization and administration, kinesiology, and several other areas. In order to keep this certification, the athletic trainer must attend seminars, complete research, and continue his/her education on a regular basis. Athletic trainers often work under the direct supervision of a physician. Because of their broad background, they often are the mediator and heart of the medical team.

An athletic trainers primary responsibilities are to:

  • prevent injuries
  • recognize and evaluate injuries and illnesses
  • treat and manage injuries
  • provide emergency medical coverage
  • rehabilitate injuries
  • organization and administration of sports medicine issues
  • education and counseling of athlete, coaches, and parents
  • assess the quality and oversee management of the athletic equipment

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Athletic Trainers Role in the Injury Process

If an athlete is injured, the athletic trainer will examine the athlete. Then if needed, a referral will be written to the appropriate doctor, usually a sports medicine doctor. Once the doctor has seen the athlete, if surgery is not needed, then the athlete will be referred back to the athletic trainer for rehab and conditioning. The athletic trainer should meet with the coaching staff and parents to tell them how long the athlete will be out of practice and competition, and also what the athletes rehab goals will be. Towards the end of the rehabilitation process, the athletic trainer will start integrating the athlete slowly back into the sport. A meeting will be held with the coaching staff, to let them know what the athlete can and cannot do. The athlete will be monitored, evaluated, and tested to determine when the athlete can return to play without restrictions.

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Physicians

When an athlete goes to a doctor, that doctor has an enormous responsibility to correctly diagnose the athlete. An incorrect diagnosis could result in further harm to the athlete. Incorrect diagnosis’s happen all the time, therefore, having a good doctor is one of the keys to being a successful athlete. A good doctor will keep an athlete healthy and will help prevent injuries from reoccurring. If an athlete gets hurt, the doctor will be the one to head up the rehabilitation team that will get the athlete back on the field.

The purpose of an athlete to visit a doctor is to get a physical or to get diagnosed with an injury or illness. It is critical that doctors diagnose the primary injury and any secondary injuries. Athletes often have multiple injuries that stem from one injury, although it will be diagnosed as one injury. For instance, an athlete may have an ankle sprain (torn ligaments). The ankle sprain is the primary injury. However, it is very difficult to sprain the ankle without straining (tearing) certain muscles and tendons of the lower leg (secondary injury). Therefore, doctors must do a thorough assessment to pin point the primary injury and secondary injury (secondary injury sometimes goes unnoticed).

In contrast sometimes the primary injury goes unnoticed and the secondary injury gets diagnosed. Athletic injuries can get very complicated. If a doctor does a thorough exam he/she should be able to decipher between primary and secondary injuries and the doctor should not miss any other injuries. However, as complicated as athletic injuries can get, some athletic injuries can stump or slip by the best doctors.

Sometimes the primary mechanism of injury can be missed and the athlete will keep re-injuring themselves. The doctor may treat the injury and not look for the mechanism that caused the injury. This is bad, because the doctor needs to counsel the athlete on how to keep the injury from reoccurring. For instance, athletes will complain of back and knee pain. Often doctors will treat the symptoms with medication and rehabilitation. Therefore, the symptoms subside. However, the athlete returns back to the doctors office complaining of the same symptoms as before (back and knee pain). The cycle will repeat itself until a sports medicine professional can locate the mechanism of injury. In this case the mechanism may be a leg length discrepancy. This can be treated with special shoes or orthotics (shoe inserts). The downfall is the athlete has endured months of pain and months of decreased performance. This is not to mention, the long term damage he/she has caused to the effected joints. Therefore, a doctor’s diagnosis is critical to the rehab program and to make sure the injury does not happen again.

The Team Physician is responsible for:

  • Administering and reviewing pre participation physical exams
  • Assess the quality and manage the athletic equipment
  • Dispense medications
  • Educate the athletic staff on emergency policies and procedures, health care insurance policies, and legal liability
  • Review of all medical forms
  • Policies and procedures to ensure compliance with all school and athletic association guidelines.
  • Provide education counseling to athletes, parents, coaches, and administration.

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A Physician’s Examination

The following is the scenario that should happen when you visit your doctor:

  • The doctor will collect a history of the illness or injury. The history is the who, what, when, where, and how did happen. It is very important that the athlete describe the history as best as possible. In this portion of the exam, athletes will need to be very descriptive and explain exactly what happen so the doctor can get a visual image of what the mechanism of injury might have been. To the layman it may look like a swollen knee. To the sports medicine doctor it looks like a swollen knee with hundreds of possible injuries, and hundreds of injury mechanisms. Diagnosing an athletic injury is far more complicated than one may think. Therefore it is very important to get a history of the injury.
  • The doctor will then visually observe the area injured for any abnormalities. Since the body is symmetrical the doctor will compare the injured vs. non injured side. The doctor will also inspect areas surrounding the injury and far away from the injury. There are injuries that occur, that can refer pain to other regions of the body. For instance, the spleen can refer pain to the shoulder. Your shoulder is not injured but it will feel like it is. Therefore, don’t think your doctor is incompetent, if he is assessing other areas of the body.
  • Next the doctor will physically inspect and palpate (feel) the areas around the injury and then will palpate the injury site. He/she will apply force to stress joints, muscles, tendons, ligaments, and such. Sometimes in order to inspect an injury, they may have to cause the athlete great pain. Don’t think the doctor is being rough with you. It is just part of the assessment process. Anytime injured tissues are stressed, it will be painful. There is no easy or non-painful way to asses these tissues. This part of the exam will hurt and pain should be expected.
  • The doctor will order diagnostic testing if he thinks it is needed. There is not a doctor alive that will not order x-rays for an injured bone or ligament. Some may even order an x-ray for an injured muscle. This is normal because muscles can detach from bones and they will tear off a piece of bone with them. It is a misconception that doctors are trying to dig into your wallet. Most are not, they need to use another means of diagnosing the injury, because they may not be able to diagnose just on palpation and history. In sports medicine, x-rays, MRIs, and blood samples are all normal ways to assess injuries and illnesses.
  • Next the doctor will do one of three things, he will diagnose the injury, refer the athlete to another doctor, or order more test to further explore the injured area. The latter issue is not uncommon, especially if you are seeing a non specializing sports medicine doctor. Athletes sustain very unique injuries and if one does not understand them, then it is hard to diagnose those injuries.
  • Finally, if a diagnosis has been reached the doctor will prescribe medications, and therapy. Follow his directions to the letter. Ask him questions at this time. If the doctor prescribes surgery get a second opinion.

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Questions You Should Ask Your Doctor

  • What is the primary injury?
  • Are there any secondary injuries?
  • What was the mechanism of injury?
  • Can this injury be prevented from reoccurring, if so what can be done?
  • Can the athlete compete? If not, what is going to be the rehab goals?
  • What can be done at home to further aid the athlete’s recovery?
  • What can be done to make the athlete more comfortable?
  • Are the drugs you are prescribing going to affect the athletes performance? Drugs can have physical and mental side affects that will decrease performance such as increase/decrease heart rate/blood pressure, some drugs may dehydrate an athlete, and some drugs can alter an athlete’s mental state. While all these and many more drugs can affect performance, some can cause harm to the athlete in extreme situations. Talk to your doctor and pharmacist about the side affects of the drugs.
  • How often should the athlete be checked? Often with head trauma, athletes should be closely monitored for a week or longer.
  • How long should it take before the athlete is able to play again?
  • What factors will play a role in his/her recovery time?
  • Are there any signs or symptoms that should be noticed during the athlete’s recovery? Some injuries such as, injuries in the lower leg and in the brain, can be further aggravated after they happen. These are compartment type injuries. The blood vessels may dilate or rupture spilling blood into the brain cavity or one of the four compartments in the lower leg. Bleeding in the brain can cause death or serious harm. In this case, your doctor will probably brief you for a while to be sure you understand just how important it is to monitor an athlete after head trauma. In the lower leg, it is called Compartment Syndrome. Bleeding in this area can cause the blood and nerve supply to be shut off to every thing below the bleeding site. In this case, the tissues do not get oxygen and the tissues die. These injuries may happen and can happen, when there is a communication gap between doctors and patients.
  • Are there any specialist you recommend the athlete should go to?

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Surgery

When a doctor tells you that he wants to do surgery, always get a second opinion. Surgery can be taking an enormous risk to an athlete’s career, if it is not done properly. It may be in your best interest to spend the extra money and have the surgery done by a specialist, especially if it will affect performance. If you can afford it and the athlete has to have surgery, check around town and find the best surgeon. If an athlete has a shot at the pros or college scholarship, you want the surgery done by the best possible surgeon.

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Malingering

Freshman college and rookie professional athletes during preseason training are put under grueling stress. The athletes are usually out of shape and some may not even be acclimated to the region. These problems when combined with very rigorous training and environmental factors can apply great psychological stress to an athlete. The athlete under pressure from the coach, teammates, family, and commitment to the university may look for an alternative means to lessen the stress. The means usually sought out is to malinger. Taber's Medical Dictionary explains malingering as “to fake injury, to arouse sympathy, and to escape work.”

A combination of the athlete missing their family, sleep deprivation, digestive problems/inadequate nutrition, and extreme heat, cold, or altitude adjustments can lead to malingering. The coach’s expectations may be very high and the athlete may not perform up to those expectations (if the athlete knows this), this will lead to psychological stress and possibly malingering. Other teammates may have to carry the freshman’s weight in practice, if the athlete is not up to par, which could be another reason to malinger.

The athlete’s advantage to malinger is to escape from the stress. All the factors playing against the athlete can soon be alleviated by just faking an injury. This will earn the athlete sympathy from the athletic training staff, a cool or warm training room, and something to drink. Most importantly the negative coach and teammates, the heat/cold, and total exhaustion will stop. Coaches and trainers sometimes use six ways to deter this type of behavior, they are as follows:

  • To make all rehabilitation workouts harder than practice work outs (a down fall to this would be it may motivate athletes who are injured to not come forth and present the injury in fear of the difficulty in the rehab workout, thus causing the injury to become worse)
  • To encourage coaches to allow athletes (who are not from the region) to come to school ten days prior to preseason to allow for the acclimatization process to take place
  • To encourage coaches to positively reinforce athletes through praise and constructive criticism, and to not negatively talk down to the athlete when the athlete is not performing up to par
  • To encourage coaches to require a nightly bed time during preseason training to avoid sleep deprivation
  • To encourage family to stay in close contact with the athlete and positively reinforce them during preseason
  • To encourage the cafeteria manager to offer a wide variety of food. Athletes are used to 18 years of moms home cooking; they may not adjust easily to not having her cooking anymore.

When these factors are implemented, then the battle against malingering can be won, but it takes the combined effort of the various staffs, family members, and the individual. The end result should be a happy, healthy young athlete that will become successful in his/her sport, through the help of family and the university staff. Remember team means Together Everyone Achieves More, and together they will.

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