Athletic training evaluation, low complexity, requiring these components: A history and physical activity profile with no comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing
CPT4 code
Name of the Procedure:
Athletic Training Evaluation, Low Complexity (Technical term: Musculoskeletal Assessment)
Summary
An athletic training evaluation of low complexity involves a straightforward examination of an athlete's affected body area along with other related systems. This evaluation includes taking a basic history and physical activity profile without considering any existing comorbidities that could affect physical activity.
Purpose
The procedure aims to identify the cause of physical discomfort or dysfunction in athletes. By doing so, the goal is to develop a targeted treatment plan that helps alleviate symptoms, enhance performance, and promote a safe return to physical activity.
Indications
- Experiencing pain or discomfort in a specific body area during or after physical activity.
- Experiencing reduced performance ability without obvious underlying conditions.
- Recent minor injuries that do not involve complications.
Preparation
- Wear comfortable, athletic clothing that allows easy movement and access to the affected area.
- No specific diagnostic tests are required unless previously indicated by a healthcare provider.
Procedure Description
- Initial Consultation: The athletic trainer reviews the athlete's history and physical activity profile.
- Examination:
- Inspection and palpation of the affected body area.
- Assessment of range of motion, strength, and flexibility.
- Evaluation of related systems, such as the cardiovascular and nervous system, if symptomatic concerns are present.
- Discussion: Trainer discusses the findings with the athlete and proposes a possible treatment or training plan.
Duration
Typically takes 30-45 minutes.
Setting
The procedure is performed in a sports medicine clinic, gym, or other outpatient settings.
Personnel
- Certified Athletic Trainer (ATC)
- May consult with a physical therapist or a sports medicine physician if more complex issues are identified.
Risks and Complications
- Minimal to no risks associated with the evaluation.
- Potential for transient discomfort during physical examination.
Benefits
- Accurate assessment of the athlete's condition.
- Immediate recommendations for treatment or referrals.
- Personalized advice tailored to enhance performance and prevent injury.
Recovery
- No recovery period needed for the evaluation itself.
- Follow-up appointments may be scheduled based on the treatment plan.
- Home exercise or therapy regimens may be advised.
Alternatives
- Higher complexity evaluations involving comprehensive assessments of multiple body systems if needed.
- Self-assessment with online tools and resources, although not recommended for accuracy and safety.
- Immediate consultation with a specialist if severe symptoms are present.
Patient Experience
- The patient should feel comfortable and encouraged to communicate openly about symptoms and concerns.
- Some physical tests may cause mild discomfort, but pain management and comfort measures are taken as needed.
- Overall, the experience is designed to be educational and beneficial, setting a clear path to recovery and improved performance.