After the chief complaint, the next step of the history should be the history of the present illness. The purpose of the history of the present illness is to reconstruct the story of the chief complaint (from onset to present) so that the examiner has a clear understanding of how things started, what has been previously done, and the current state of the problem. The athlete may be unclear as to how or why symptoms started and may describe an insidious onset. When a single traumatic event is responsible for the injury, appropriate time spent on the mechanism, degree, and events surrounding the event provides reliable information. For example, in the patient whose chief complaint is that his shoulder "came out," appropriate questions might include those shown in Box 16-2.
The answers to these questions not only may establish the diagnosis but also may determine different courses of treatment. For example, an athlete who presents with a shoulder that came "partly" out of joint 1 week ago in a posterior direction, then spontaneously reduced, would be approached differently from the same athlete who complains of the shoulder coming "all the way" out of joint on the field. This short illustration demonstrates how similar chief complaints could result in entirely different management plans based on an appropriate history of present illness.
Once the circumstances surrounding the onset are established, the clinical course of the complaint is determined from its inception to the present. During this period, the effects and timing of various treatments are carefully considered. Any response to treatment, even if temporary, is important. For example, if a lidocaine and steroid injection was administered to the sub-acromial space for shoulder pain, it is important to note whether this was effective, even if only temporarily, as this will yield diagnostic as well as therapeutic information. One should evaluate other interventions such as the effect of antiinflammatories, modalities, and physical therapy. This information should lead the examiner to an understanding of what has already been done, and the progression of the treatment instituted. A patient who is improving after 6 weeks of physical therapy prescribed for impingement is a much different case from a patient who is getting worse with 6 months of the same therapy. It is important to realize that, while some athletes have the luxury of having highly trained therapists and athletic trainers who supervise their rehabilitation on a daily basis, others are often left on an independent, poorly guided therapy regimen that is often incomplete or even misdirected. It is not enough to ask whether "physical therapy" has been done. One must delve into the specifics of that therapy to make an accurate assessment of whether it was an adequate regimen that was correctly followed.
Current Status of the Problem and Degree of Disability
Finally, before leaving the clinical course section of the history, it is important to note the current status of the complaint. This current status should be understood in light of the athlete's current level of activity, where he or she is in relation to the season, and how long he or she has until the shoulder has to be in "playing condition." A college football quarterback who dislocates his shoulder for the first time early in his senior year might pursue a different treatment course from that of the same player who dislocates in the first week of the off-season after his junior year. Such an understanding requires thorough communication with the athlete and an understanding of his or her goals and guides the patient and the physician to the best choice for their desired outcome.
The final aspect to the current status of the problem is the degree of disability incurred by the athlete from his or her injury. Athletes, and patients in general, present with complaints on the spectrum from minimal annoyance with high-level sports to complete disability with activities of daily living. Understanding where the patient is on this spectrum greatly aids in guiding how aggressive the diagnostic workup and how invasive the treatment plan should be. It is important to note that an accurate assessment of the degree of disability may require communication with the athletic trainer and/or physical therapist, as some athletes may attempt to "play through" injuries that render them ineffective and put themselves in danger of further injury. These are sometimes difficult decisions for an athlete to make, and often a trainer's input is very valuable in defining the degree of disability.
Although we should be confident with a solid differential diagnosis at this point, and although athletes are among the healthiest patients in our population, questions about medical history should not be neglected. These include questions about medications, allergies, and congenital or other medical problems. Finding out that a swimmer with shoulder pain has Ehlers-Danlos syndrome might not only point to multidirectional instability (MDI) as a diagnosis but might also influence the treatment of such a shoulder. Although often negative, a review of systems and queries regarding medical history can avoid missing key aspects affecting the diagnosis and eventual treatment of the athlete.
• Did the shoulder "come out" because of a significant injury?
• What position was the arm in when it "came out?"
• Could you move the shoulder after the injury?
• Did it "slide out of joint" or did it "pop?"
• Did the shoulder feel like it came all the way out of joint?
• Did you feel any numbness or tingling in the arm or hand?
• Did you have to go to the hospital or have something else done to have it "put back in?"
• Did you have radiographs?
• Has this ever happened to your shoulder before?
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