5.1 Patient History & Interview Techniques

5.1 Patient History & Interview Techniques

Practice Analysis 8th Edition (PA8) Domain II (Assessment, Evaluation and Diagnosis, 25.6% of scored items) opens with task 0201: obtain a thorough, individualized history. Task 0202 (physical examination) is useless if you never learned how the tissue was loaded, what the athlete cannot do, and whether this is even a musculoskeletal problem. Magee's Orthopedic Physical Assessment and Starkey's Examination of Orthopedic and Athletic Injuries both treat history as the highest-yield part of the evaluation. Most diagnoses are generated from the story and then confirmed or refuted by a short, targeted exam. The Board of Certification (BOC) item is rarely "which special test is positive." It is "what do you ask first, what must you not miss, and when do you stop the orthopedic battery and activate emergency care?"

This chapter is the system. Region-specific special tests live in Chapters 6–8. If you skip mechanism of injury (MOI) and reach for a Lachman test, you are practicing backwards.

Observation Begins Before You Touch

History and observation overlap. The evaluation starts when the athlete enters your visual field, not when your hands land on a joint.

Watch, from a distance:

• Gait and willingness to load: antalgic limp, inability to plantarflex off the toe-off, stiff-knee gait, or a teammate carrying the athlete.
• Posture and guarding: how they sit in the waiting chair, remove a shoe, or protect an arm in a sling position without a sling.
• Facial expression and distress: pallor, diaphoresis, and reluctance to talk are medical data, not personality.
• Equipment and surface: worn lateral heel, broken cleat, extra-long soccer studs on dry turf, a helmet still on after a collision.
• On-field scene: position found, motionless versus moving, obvious deformity, hemorrhage, and whether the athlete got up and then collapsed.

If the athlete is down, primary survey first (airway, breathing, circulation, disability, exposure, and cervical-spine control). A complete OPQRST never precedes an unresponsive or deteriorating athlete. Domain III owns the emergency algorithms; Domain II still requires you to recognize that this is no longer a clinic history.

Sideline trap: An athlete jogs off saying "it's just my knee." You still watch the last ten yards. A quadriceps-avoidance gait plus an immediate tense effusion is a different pretest probability than a delayed ache after practice.

OPQRST: The Clinic Skeleton

Use a consistent pain and symptom framework so you do not leave holes that a focused testlet will punish.

Ask what they cannot do in sport and in life: squat to lift a child, sit through class, raise the arm to dress, plant and cut. Function is the outcome that later judges your plan of care (task 0204), so it belongs in the first interview.

SAMPLE and Mechanism of Injury

SAMPLE is the emergency-medicine overlay that still belongs in athletic training, especially on the field and in acute clinic visits:

• Signs and symptoms (what you see plus what they report)
• Allergies (drugs, latex, stinging insects — anaphylaxis changes the whole encounter)
• Medications (prescription, over-the-counter, supplements)
• Past medical and surgical history, including prior injury to this and adjacent regions
• Last oral intake (relevant if you may need sedation, surgery, or if exertional collapse and metabolic disease are on the list)
• Events leading to the present injury — this is MOI

MOI is not optional. Reconstruct joint position, direction of force, contact versus non-contact, whether the foot was planted, whether a pop or tear was felt or heard, whether swelling was immediate (minutes: intra-articular hemarthrosis until proven otherwise) or delayed (hours: more often extra-articular sprain), and whether the athlete continued. A non-contact plant-and-cut with a pop and immediate swelling raises pretest probability of anterior cruciate ligament (ACL) injury before your hands move. A hyperextension blow to the anterior tibia raises posterior cruciate ligament (PCL). A valgus load with a planted foot raises medial collateral ligament (MCL), and a combination of valgus, rotation, and pop raises the unhappy triad in the differential, not as a reflex diagnosis.

If the athlete cannot give MOI (amnesia, language barrier, collapse), use witnesses, video, and the position found. Do not invent a mechanism to justify the special test you like.

Red Flags: When History Ends the Orthopedic Hour

A red flag does not mean the athlete "probably has cancer." It means you do not proceed as if this were a routine sprain. You withhold, document, and refer on an emergency or urgent pathway as indicated.

Ask the bathroom, fever, night-pain, and weight-loss questions out loud. Silence is not a negative screen.

Comorbidities, Medications, Demands, and the EBP Triad

History is individualized because two identical MRIs do not produce two identical plans of care.

• Prior injury remains the strongest predictor of the next musculoskeletal injury. An "old ankle sprain" that never regained inversion control is not background noise; it is the diagnosis until the new story proves a second lesion.
• Comorbidities: diabetes (healing, sensation, infection), bleeding disorders and anticoagulants (expect more ecchymosis and question an unusually large hematoma), rheumatoid or other inflammatory arthritis, asthma, sickle cell trait, seizure disorder, immunosuppressive therapy, and pregnancy when relevant.
• Medications and supplements: corticosteroids (tissue quality, infection risk), fluoroquinolones (tendinopathy and rupture risk, classically Achilles), anticoagulants, recent antibiotic or acne isotretinoin history when wound healing or joint pain is odd, and stimulants or diuretics that change exertional risk. "I only take over-the-counter stuff" is an incomplete answer.
• Occupation and sport demands: a catcher's knees, a pitcher in week 12 of a showcases season, a nurse who stands 12-hour shifts, and a lineman in a scholarship year do not have the same success criteria. Position, level, season phase, and the next meaningful competition belong in the chart.
• Patient goals and values: this is the third leg of the evidence-based practice (EBP) triad (best available research + clinician expertise + patient values and circumstances). "I need to play Friday" is data. So is "I need to climb stairs to class pain-free and I will accept missing the tournament." Shared decision-making is not the athlete overruling a red flag.

Interview Technique

How you ask changes what you hear.

1. Open, then closed. Start with "Tell me what happened" or "What brings you in today?" Let the narrative run. Then close the gaps: "Which way did the knee go?" "Could you keep playing?" "Any numbness into the foot?"
2. Do not lead. "The pain shoots down your leg, right?" teaches the athlete the answer you expect. "Where do you feel it, and does it travel?" does not.
3. Avoid stacking. One question, then silence. Athletes fill silence with the detail you needed.
4. Trauma-informed care: explain before you touch; obtain consent for each sensitive region; offer a chaperone; do not force a reenactment of a violent MOI; protect privacy for menstrual, sexual, assault, and mental-health history. State mandatory-reporting rules apply when a minor discloses abuse. A crowded hallway is the wrong room.
5. Language access: use a qualified medical interpreter (phone or in-person). A teammate or parent who "speaks both" is a confidentiality breach and a medical-error risk. Title VI obligations in many U.S. settings make "the other kid on the team" an indefensible plan.
6. Health literacy: replace jargon. "Did you hear a pop?" is better than "Was there an acute tensile failure of the ACL?" Confirm with teach-back: "Tell me what you think is going on so I know I explained it."
7. Document in the athlete's words when the phrase is diagnostic ("my knee gave out and I heard a pop") and then translate into clinical language in the assessment.

On-Field Versus Clinic History

On the field you may only get: "I planted, my knee went in, I heard a pop, I cannot walk." That is enough to immobilize, treat for shock if indicated, and defer Lachman testing until the joint and the athlete can tolerate it. In clinic the next day you add locking, giving-way episodes, swelling timeline, prior ACL, and whether they have already loaded the knee.

Worked Example: Do Not Skip MOI

A 19-year-old point guard sits on your table and says, "My knee is messed up. Can you just do the tests?" Observation: mild limp, no deformity, small effusion. The wrong sequence is bilateral Lachman, anterior drawer, pivot, McMurray, and a shrug. The right sequence is:

1. Watch the limp and how they climb onto the table.
2. Open question: "Start at the beginning — what happened?"
3. MOI: non-contact deceleration, foot planted, valgus and rotation, audible pop, could not continue.
4. Swelling: tight within 30 minutes.
5. Giving way when she tried to walk to the bus.
6. No saddle symptoms, no fever, no night pain, no syncope (red-flag negatives you actually asked).
7. Prior ipsilateral ACL reconstruction two years ago — recurrence or graft failure is now in the differential, not just a "first-time sprain."
8. Goal: she has a conference tournament in 10 days and also has a history exam tomorrow (values and occupation of being a student).

Only then do you examine the comparable side, the neurovascular status of the limb, and a short list of tests that discriminate ACL, MCL, meniscus, and patellar dislocation. The history did the heavy lifting. Special tests refine it.

The trap this section exists to kill: skipping MOI and jumping to a special test. A positive test without a story is a parlor trick. A negative test after a high-pretest-probability history is a reason to keep looking, not a reason to clear the athlete for the second half.