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Athletic Assessment

 

For an athlete to function optimally within his sport, full flexibility, balance, strength, conditioning and preparation are key to his success. Athletic trainers and strength and conditioning coaches have the overwhelming responsibility to assess large groups of athletes and prepare them for each game. This is very important in the area of college athletics, especially football.

Clinical skills vary among each healthcare provider. Basic skills need to be incorporated to determine best utilization of resources and time prior to the athletic event.

The following will be a basic assessment tool to give the athletic coach a direction of each athlete and his specific need.

We will start with the head and work distally into the feet in our assessment.

The cervical spine can be assessed by range of motion.  The range of motions that are functional are head forward flexion touching the chin to the sternum.  Extension is such that the chin should be at 45 degrees in relationship to the shoulders in extension.

Cervical or neck rotation should be within 10 degrees over the shoulder to each side. Lateral flexion should at least be obtained half the distance from erect posture to placing the ear towards the shoulder.

In the event that the cervical range of motion is less than 50% of the expected, one should refer the athlete for manual adjustment either through a chiropractor or an osteopathic physician.

Common problems that limit range of motion in the cervical spine are subluxations within the vertebrae or the uncovertebral joints. A quick adjustment by a chiropractor should correct the subluxation and restore full functional range.

The most common missed vertebral subluxation is the first thoracic--T-1.  These subluxations tighten the upper most fibers of the upper trapezial muscle limiting extension of the neck by 50%.

Strained muscles can cause nerve like pain syndromes as well as headaches.  The most common headaches are caused by the upper trapezial muscles.  These headaches start at the base of the skull and radiate around the top of the ear towards the orbits of the eyes.

Assessing the thoracic area can be accomplished by palpation of the vertebral spinous processes. There should be uniformity in their heights. Any elevation from baseline heights would suggest a posterior subluxation that also may need attention through the chiropractic or osteopathic manipulation specifically compression.

Symptoms arising from subluxations of the thoracic spine include difficulty taking a deep breath, pain with lying on the ribs or pain associated with coughing or sneezing in the ribcage.

The shoulders are a very complex structure composing of eleven muscles and multiple ligaments. The shoulder can be assessed by positioning the shoulder 20 degrees forward at horizontal and ranging the shoulder with the elbow at 90 degrees through internal and external rotation. 90 degrees in internal/external rotation is functional.

Individuals in athletics who have to use high speed throwing mechanisms overhand benefit from increased external rotation of approximately 120-160 degrees. The shoulder has two components, one being muscular, the other being ligamentous.

Muscular releases can be done through dynamic stretch techniques whereas ligamentous releases that are more capsular require manual retraction with assisted movements of internal and external rotation with the arm in the fully extended position at 20 degrees forward at the horizontal level of the shoulder.

A quick assessment of the latissimus dorsi can be done with the arm extended and thumb down, ranging it upward through a shoulder arc of 180 degrees such that the arm is fully abducted at the neck. Limitations or tightness of the latissimus dorsi will create decreased range of motion of the acromium joint.

To have a successful overhand throwing mechanism, the acromium must be opened up greater than 30 degrees to allow fluid movement of the rotator cuff muscles in order to avoid tendinopathy, secondary tightness that would lead to capsulitis as well as anterior labral tears.

Assessment of the upper extremities can be done primarily with the arm extended, elbow extended in a neutral position assessing pronation and supination movement, pronation of 90 degrees and supination of 90 degrees should be achieved.

Failure to get 90 degrees suggests shortening of the flexors or extensors of the forearm, which create medial and lateral elbow tendonitis. Distally the wrist can be assessed in flexion/extension movements where flexion is 90 degrees and extension is 80 degrees.

The lumbar spine needs to be assessed at the thoracic/lumbar junction as well as the lumbosacral junction. Palpation of the spine of the 12th thoracic vertebrae on to the first lumbar spine should be of equal height. Should there be a stepping down of the spinous processes, this subluxation may impede optimal respiratory function.

In the lumbosacral junction, there are many musculoskeletal/ligamentous attachments that stabilize the spine on to the pelvis. This is one of the most complex areas of the human body.

Should the initial inspection of the skin overlying the L5-S1 region show a patch of hair, this suggests clinically that the patient may have a silent spina bifida occulta. Spina bifida occulta is the lack of final embryologic maturation of vertebral fusion.  Even minimal spina bifida occulta predisposes to iliolumbar ligament sprains with rotational movements of the spine across the stationary pelvis.

The spine can be palpated in the lumbar area, notably at L4-5 and L5-S1. Should the spinous process and vertebral bodies shift anteriorly, this would lead the clinician to suspect spondylolisthesis. Spondylolisthesis is the anterior shifting of the vertebral bodies upon themselves creating increased tension in the lower spinal units.

Injuries from age eight to 15 are the usual causes of spondylolisthesis, as the spine ligaments have not reached full maturity. Spondylolisthesis will cause changes in the lumbosacral angles.

Normal angle on x-ray is 30 degrees, which adequately accommodates spinal weight distribution. A 10-degree increase in the lumbar/sacral spine angle increases the force along the spine by  50%.  A 20-degree increase in the lumbar/sacral spine angle increases the weight transmitted along the normal spinal angle by 75%.  Spondylolisthesis for athletes who partake in weightlifting, especially in the lift and jerk mechanism, predisposes to significant muscle spasm, and may aggravate the spondylolisthesis.

There are many structures that attach in the lumbar spine which connect with the lower thoracic vertebrae such, when these muscles spasm, they may also precipitate respiratory difficulties and ribcage pain.

The pelvis is not one unit, but actually consists of five bones that are held together with fibrous tissue.  In athletics, the pelvis is subjected to extreme forces, especially when the individual is thrown to the ground.  With enough force to the pelvis, the ileum bone will shift or sublux against the sacrum, leading to pain and secondary gluteal muscle tightness.  The consequences of a subluxed sacral-iliac may lead to secondary muscle strains in addition to the gluteals and commonly involve the erectors of the lumbar spine, multifidus, piriformis and hamstring muscles.

Assessing subluxations of the sacroiliac junctions can be made by having the athlete lie supine with his legs extended. Visual inspection should assess for symmetry of the feet as well as functional leg length. If there is shortening of a leg length, that may indicate that there is pelvic asymmetry. Most athletes will experience a functional leg length discrepancy rather than a true leg length discrepancy, which is based on anatomical length differences.

Functional assessment of the sacroiliac subluxation is done by passively assessing the patient’s internal/external rotation of the hip in the supine position. Limitations of 50% of external rotation and 50% of internal rotation should lead the clinician to assess for subluxations and correct the subluxations. It appears through clinical experience that internal rotation is much more limited than external rotation in the subluxations. Subluxations that occur closer to the sacroiliac joint have a referred pain pattern from the sacrum into the groin area and occasionally into the testicles.

Subluxations for the sacroiliac junctions are best done by chiropractic or osteopathic manipulation, and once the manipulation is successful, functional range of motion of the gluteal and lumbar muscles can be restored quickly through various myofascial release techniques.

In the lower extremities, assessing quadriceps flexibility can be achieved by having the athlete in a side lying position where the head, shoulders and knee are in a straight line. The non-treated quadriceps muscle will be placed in a position with the knee bent at 90 degrees toward the chest to stabilize the pelvis.

The affected quadriceps will be placed in a shoulder position in a straight line, and through active assisted technique of bringing the heel to the buttocks with the assistance of the clinician, a gentle force is placed at end range to help promote the functional recovery of putting the heel into the gluteal muscles.

Two other positions of the quadriceps are then utilized in that the lower extremity.  The next position is to place the proximal leg into a 45-degree abducted position with the athlete actively trying to bring the heel into the buttocks, and at end range, the clinician assisting to promote that full flexibility. The final position is to bring the knee down toward the table, having it contact the table, while the athlete is again actively assisting by bringing the heel to the buttocks.

Extreme caution should be approached with an athlete who has had any knee surgery. Should the patient have had any reconstructive surgery for anterior cruciate ligament bone grafting or tendon grafting, this technique is to be avoided and contraindicated.

Assessment of the extensors is done by having the patient in the supine position on his back with the unaffected legs knee up 45 degrees and heel to the ground while the other hamstring is being assessed through a straight leg raise movement.

Functional is 90 degrees of range; however, anything greater than 70 degrees may be adequate for the athlete unless it is specifically needed for highly competitive activities such as gymnastics or track and field events.

In the lower extremities, the gastrocnemius/soleus complex can be assessed with the knee extended and the knee bent. Bending the knee inactivates the gastrocnemius and allows for assessment of soleus function. Soleus function should allow for dorsi and plantar flexion as well as the gastrocnemius.

It is important to initiate with the soleus muscle first as it is the deeper muscle and then progress to the gastrocnemius muscle as it is the more dominating muscle. Dorsi flexion should be 30 degrees. Plantar flexion should be 45 degrees or more.  Athletes who have worn shoes or boots such as in figure skating or skiing will show significantly limited range of motions and just obtaining neutral dorsi flexion may be functional for those individuals.

Difficulty of having restricted range of motion in the ankles is that, should the support within the boot not be present, they are more susceptible to ankle fractures when their ankle becomes twisted.

Next is an important stretch as most athletes are noted to have tight internal hip flexors iliopsoas.  The iliopsoas muscles are deep hip flexors attaching from T12-L3 transversing through the pelvis, attaching to the anterior femur.  These muscles cannot be stretched effectively by the athlete alone and requires the assistance from a clinician who is trained in stretching this muscle dynamically.  This stretch of the iliopsoas improves the spring, takeoff and increases stride length.

Finally, assessment of the wrist carpal bones needs to be done.  Any carpal bone shift or subluxation disrupts the proper muscle tendon movement, and affects the athletes finger and wrist flexibility, strength and dexterity.  This assessment and release technique can be reviewed in another article of wrist assessments and my Web page.

The wrist and fingers are very important for golfers, baseball pitchers, football quarterbacks, wide receivers, gymnasts, basketball players, boxers and hockey players.  The wrist carpal bone release needs to be instructed by a person who has knowledge and experience in these techniques.  Attempting to do them through reading only may cause more harm than benefit to the athlete.

 

Should you have any further questions regarding this article, please direct your questions or comments to "Ask the Doctor" section.

 

Copyright © 2004 - 2012Taras V. Kochno, M.D.  All Rights Reserved
Board Certified in Physical Medicine and Rehabilitation

 

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