Diagnoses for Common Combat Arts Injuries

Physical Exam

To examine tendon injuries, doctors will perform a physical exam. This includes a basic musculoskeletal evaluation and palpation of the involved tendon. Depending on the tendon involved, special tests and maneuvers are done to evaluate and isolate the tendon further. For example, Jobe’s test is done for rotator cuff tendons. 

The Yergason test is done for biceps tendonitis. In the above test, the martial artist places the arm at their side. The elbow is flexed at 90⁰ and supinated against resistance. The test is positive if there is referred pain to the bicipital groove.  Goniometers are used to check angles. Strength testing is undertaken. Tendinosis is often diagnosed after a history and a physical exam are performed. Injuries are further characterized by specialized further testing.

Imaging

Ultrasound is used frequently for tendon injuries. This is because several interventional procedures to treat tendinosis are done under sonographic guidance. Different frequencies are recommended for optimal visualization and this depends on which tendon is examined.

Common ultrasound findings in tendinosis reveal an increased spacing of the fibrillar lines, reduced echogenicity, thickening of the tendon, and formation of new blood vessels via color Doppler. The MRI is also used to evaluate tendinosis. On MRI, tendonitis may appear as thinning, with fluid, calcification, and muscle atrophy. The fibers may be interrupted, discontinuous, thickened, or lax. Tears are visible on MRI if present.

Lab Tests

To evaluate for tendinitis, C-reactive protein (CRP) and ESR are done. They are not very specific tests, but they indicate an inflammatory process in progress.

Physical Exam

The physical exam is important for nerve injuries. This is because most athletes with injuries to the nerves have a characteristic presentation. For example, a martial artist with a radial neuropathy will hold the affected arm with the normal hand. Often with nerve injuries, doctors examine for decreased or absent sensation on different sides of the extremity. 

They will also check the range of motion of all the joints. In the arm, this could involve testing the range of motion of wrist, thumb, and fingers. Supination and pronation are checked with and without the aid of gravity. They will text for function and strength. In the extremities, there could be wrist drop or foot drop, which signifies injury to the nerve.

The doctor will also check for other simultaneous injuries that accompany a nerve injury. This could include a dislocation, fractures, and other inflammatory conditions. Sometimes, on a physical exam, the only sign can be weakness, or numbness and tingling while the motor functions remain intact. In that case, a good physical exam is very important.

Imaging

Radiographs are usually adequate for identifying injuries. This is especially in the case of fractures. Occasionally, to rule out compressive neuropathies, MRI can further delineate the injury.

Electromyograms or nerve conduction studies (EMG/NCS) differentiate nerve versus muscle injury. They measure the speed at which the impulses travel along the nerve. They are also helpful for follow-up management via serial observations to assess the return of nerve function. Over 90% of nerve palsies resolve in 3 to 4 months spontaneously. 

Rapid ultrasound can also diagnose entrapment neuropathy at the spiral groove

Lab Tests

Blood tests are not necessary to diagnose nerve injuries.

Physical Exam

The doctor will examine the athlete for bruising and swelling in moderate to severe injuries. They will look for an area of point tenderness or localized tenderness. The proximal attachment to a bone or joint may be tender.  Athletes with muscular injuries may experience pain while a range of motion is done, adduction or abduction with or without resistance is tested.

They may also have pain with passive stretching.  Doctors will check all these movements and test the muscle strength. The strength or power of the muscle is reduced depending on the degree of injury. In muscle sprains and strains, loss of strength is due to pain.  In muscle or tendon rupture or avulsion injury, there may be a complete strength deficit. In the case of muscle rupture, the doctor will look for any visible deformity.

Imaging

X-rays are always used initially for all muscle strains. Anteroposterior views and lateral views are done. Special views are requested depending on the muscle. For example, for adductor strains, along with AP views of the pelvis, a frog leg view of the affected is advised. In most cases, X-rays are normal. Avulsion injuries are seen on Xrays. They can also reveal any stress fractures or other associated fractures.  

MRI is recommended as the next step. It is seen as muscle edema and hemorrhage at the site of injury. Any bone injuries will be further elucidated on the MRI.

Musculoskeletal ultrasound can visualize the tendon and muscle attachments to the bones, muscles, ligaments, and nerves. Ultrasound can identify the area and extent of an injury. It is also helpful for assessing the recovery from an injury.  

Lab Tests

Blood tests are not required to diagnose muscle injuries. However, if an athlete develops repeated muscle injury or diffuse muscle pain, CRP, ESR, and CK are tested.

Physical Exam

On physical exam, doctors will look for pain in the joint and where it radiates to. They will test if the pain is worse on movement or improves with rest. They will look for swelling, bruising, any deformity of the joint, and tenderness. 

The doctors will test for active and passive range of motion. Specific to the joint are various tests where the doctor looks for specific signs. For example, the piano key sign is seen, while the clavicle is elevated and rebounds after inferior compression in the case of distal radioulnar joint injury. All the contributing bones of the joint are evaluated for a possible fracture.  A full neurovascular examination is done to test the nerves and vessels.

Imaging

Standard x-rays are done to diagnose joint injuries.  Anteroposterior and lateral views of both sides are advised. Additional views are done depending on the joint involved. For example, in the case of shoulder injuries or injuries to the acromioclavicular joint, the Zanca view is done. 

This is an AP view done by tilting the beam 10 to 15⁰ cranially. The opposite joint is always visualized as it is necessary to compare the injured joint to the normal joint. Stress views are used to evaluate displacement of the joint if the diagnosis is unclear with a standard AP view.

For more clarity, an ultrasound or MRI is done for further evaluation.

Usually, with the help of imaging, joint injuries are classified. The classification determines the treatment. In the case of the acromioclavicular joint, the Rockwood Staging System is outlined to guide further treatment.

Lab Tests

In the case of joint injuries, blood tests are not needed for diagnosis unless surgery is planned. If a joint is suspected of infection then a CBC, ESR, and basal metabolic panel are done to rule out sepsis. If the joint is considered septic, an arthrocentesis may be done to aspirate joint fluid and test it for microbes.

Physical Exam

Doctors will first palpate the bursa to look for pain and tenderness. They will also test the range of motion of the involved joint. They will specially test for active motion since, in many athletes, the bursa may not be painful when the muscles are at rest without activation, especially if they’re not compressing the bursa. In many cases, pain occurs during flexion and not on extension. So, a full range of motion is tested to check the biomechanics involving the bones, muscles, and tissues around the bursa.

Imaging

Bursitis is typically diagnosed clinically. Imaging is necessary for the diagnosis and management of bursitis. Imaging is helpful when the precise cause is unknown. Plain film imaging of the affected joint or bursa is done in all athletes with trauma or fracture with swelling or pain. MRI is used to evaluate the deeper bursa. It can also be visualized via ultrasound. 

The benefit of the ultrasound is that it shows real-time images of a joint and the area surrounding the bursa. This provides the opportunity to see changes with active and passive motion.

Ultrasound can also see the cobblestone appearance of the fat overlying a bursa. This is helpful as it differentiates cellulitis from infectious bursitis. Color Doppler can show signs of infection, which look like hyperemia of the bursa and the surrounding tissues.

Lab Tests

Blood tests are not diagnostic of bursitis unless an infectious cause is sought. In that case, CBC and ESR are done. The inflamed bursa is aspirated if septic bursitis or crystalline disease complicates the injury. The aspirated fluid is sent for cell count, Gram stain, culture, glucose, and analysis for crystals.

Physical Exam

The physical examination of abrasions is important for treatment. Doctors look for the type, size, shape, color, location, size, depth, other associated injuries as well as the presence of extraneous material. Based on this the treatment and medication change.

Imaging

These are diagnosed clinically and do not require imaging. Unless there is associated nerve, bone, muscle, or vascular injury, abrasions limited to the epidermis, they do not require imaging. If the injury is deeper and muscle, tendon, bone injuries are suspected then X-rays are ordered.

Lab Tests

Blood tests are not required to diagnose abrasions. However, if there is deeper injury and delayed healing, CBC and ESR may be done. In some cases, doctors may swab the injury and send it for culture and sensitivity tests just to prescribe the right antibiotics.

Physical Exam

Doctors will look for weakness, instability, or clicking. Certain cartilage injuries are very common with individual sports and so many athletes can have certain common movements that injure the cartilage characteristically. The heavy load placed on the wrist during a swinging action can cause triangular fibrocartilage complex (TFCC) injuries.

So, doctors will test the joint with a range of motion tests. In the wrist, this will include pronation and supination. They could do additional tests that are specific to that cartilage. For example, in TFCC, a TFCC compression test is done. Here, the forearm is in the neutral position and ulnar deviation reproduces symptoms.

The TFCC stress test where a force is applied across the ulna and the wrist is in ulnar deviation causes symptoms. Another test is the Press test where the athlete lifts themselves out of a chair by using the extended wrists. Pain indicates a positive test.

Additionally, there’s the supination test, the piano key test, and the grind test. The supination test identifies a tear where the athlete grabs the underside of a table with the forearms supinated. The piano key test suggests distal radioulnar joint instability. The Grind test indicates a degenerative process where the athlete rotates the forearm and has pain. These are specific tests for the TFCC. Similarly, there are specific tests for various cartilaginous injuries.  

Imaging

The initial imaging is always a radiograph to evaluate for fracture. An MRI follows with or without an arthrogram. An arthrogram shows the communication of contrast and directly visualizes a tear. If MRI is contraindicated, a CT is done. Arthroscopy is the most accurate way to diagnose certain cartilage injuries.

Lab Tests

Blood tests are not necessary to diagnose cartilage injuries.

Physical Exam

Doctors will carefully assess athletes with acute blunt trauma. This is to make sure serious injuries are not missed.  This assessment is done in the form of primary, secondary, and tertiary surveys with appropriate intervention and resuscitation as required. They will inspect, palpate and percuss as needed.

Since blunt impact injuries are not always visible, especially deeper-seated injuries, the doctors will examine adjacent or underlying subcutaneous soft tissues. This will identify a hemorrhage due to ruptured blood vessels.

Imaging

Depending on the location of blunt impact, X rays are done initially. This will reveal any air in the abdomen or chest, which is a sign of a ruptured organ. However, CT is done to evaluate hemorrhage and damage to the organs. An MRI provides even better visualization of soft tissues and can demonstrate tears, edema, disruption, and contusions.

Lab Tests

A battery of blood tests is done to evaluate the state of function of the organs and metabolic functions. These include complete blood count (CBC), serum chemistries, glucose, serum amylase, urinalysis, coagulation studies, blood typing and cross-matching in preparation for surgery, and arterial blood gases (ABGs) among others.

Physical Exam

The physical examination involves assessing the tooth socket for foreign material, tooth fragments, and lacerations. It's necessary to evaluate these as they determine tooth replantation. The clinician will also evaluate the surrounding structures for other associated injuries such as lacerations, fractures, and ecchymoses.

Imaging

Imaging usually includes extra and intraoral radiographs. In some cases, CT scans evaluate for alveolar and surrounding fractures. CT is also used to verify that the tooth is not intruded if it’s not found intraorally. This can delay tooth replantation.

Lab Tests

Blood tests are not done to diagnose dental injuries as imaging is diagnostic. However, if an infection is suspected, then a CBC may be done.

Physical Exam

The physical exam is very important. For all bleeds, irrespective of size, the advanced trauma life support (ATLS) protocol is done. Doctors look for hard signs and soft signs, especially for bleeding in the extremities. The Western Trauma Association (WTA) defines hard signs as expanding hematoma, bruit, thrill, external bleeding, pulselessness, pallor, paresthesia, paralysis, or pain.

Soft signs are a history of arterial bleeding at the scene or en route, neurological deficit occurring in a nerve next to an artery, and a small non-pulsatile hematoma over an artery.

Doctors assess circulation by palpating pulses in the extremities. Obvious vascular injuries like active bleeding will require immediate treatment. If no hard signs are present in the primary survey then doctors look for soft signs for vascular injuries.

Imaging

In athletes who have small vascular injuries and among those who are stable but have abnormal physical exam arteriography, CT arteriography, or duplex ultrasound is ordered.

CT arteriography (CTA) is very sensitive and specific for arterial injuries, especially in the extremities. Standard arteriography is a more invasive study. Duplex ultrasound is an option to evaluate vascular injuries.

Lab Tests

Standard trauma labs include (CBC), electrolytes, BUN, creatinine, amylase, PT, prothrombin time (PTT), blood type and screen (T&S), or type and crossmatch (T&C), urinalysis (UA), and arterial blood gases and lactate are ordered.