MUSCULOSKELETAL PROBLEM

PHYSICAL MEDICINE AND REHABILITATION OF THE MUSCULOSKELETAL PROBLEMSDr. Moch. Ridwan, Sp.KFR

PHYSICAL MEDICINE AND REHABILITATION is a branch of medicine concerning with the study of the comprehensive management of physical disability arising from disease or injury of the neuro-musculo-skeletal and cardiorespiratory systems and the bio-psycho-socio-vocational disruptions concomitant with them. REHABILITATION MEDICINER. of MUSCULOSKELETAL SYSTEMR. of NEUROMUSCULER SYSTEMR. of CARDIOVASCULER SYSTEMR. of RESPIRATORYR. of PEDIATRICR. of GERIATRICR. of SPORT INJURY

MANAGEMENT OF REHABILITATION MEDICINE1. EXERCISES

2. PHYSICAL MODALITIES

3. PROSTHETIC - ORTHOTIC

4. MEDICAMENTOUSEFUNCTIONAL DIAGNOSE in REHABILITATION MEDICINE IMPAIRMENT : Any loss or abnormality of physichologycal, physiological, or anatomical structure or functionDISABILITY : Any restriction or lack resulting from an impairment of the ability to perform an activity in the manner or within the range considered normal for a human beingHANDICAP :A disadvantage for a given individual, resulting from an impairment or disability, that limits or prevents the fullfilment of a role that is normal for that individual

A. THERAPEUTIC EXERCISE1. STRENGTHENING EXERCISE PATIENT CAN BE INSTRUCTEDMMT 3ANY RESISTANCE3. TYPE OF STRENGTHENING EXERCISE :a. ISOMETRIC EXERCISE / STATIC EXERCISE* ANY MUSCLE CONTRACTION.* NO JOINT MOTIONS * MUSCLE CONTRACTION IN 6 SECOND. * PRECAUTION IN HYPERTENTION & CORONARY HEART DISEASE PATIENT.

b. ISOTONIC EXERCISEANY MUSCLE CONTRACTION WITH JOINT MOTION.2 TYPE : CONCENTRIC CONTRACTION : SHORTHENINGECCENTRIC CONTRACTION : LENGTHENING

c. ISOKINETIC EXERCISE( COMBINE OF ISOMETRIC & ISOTONIC )USED A TOOLCONTANTLY SPEEDMORE SAFETY FOR HYPERTENTION & CHD PATIENT

2. RANGE OF MOTION EXERCISE( ROM EXERCISE ) TO MAINTAIN A ROM PREVENT A CONTRACTURE WITHOUT RESISTANCEANY 2 TYPE OF ROM EXERCISE : PASSIVE ROM EXERCISE, IF MMT < 2ACTIVE ASSISTIVE, IF MMT = 2ACTIVE ROM EXERCISE, IF MMT 3

3. STRETCHING EXERCISE : FOR A STIFFNESS OR CONTRACTURE OF JOINT. THROUGH A PAIN POINT. SHOULD NOT BE EXERTED

4. ENDURANCE EXERCISE

THIS EXERCISE INCLUDE STRENGTHENING & ENDURANCE.IN STRENGTHENING EXERCISE : OPTIMAL RESISTANCE & LOW FREQUENCY IN ENDURANCE EXERCISE : LOW RESISTANCE , HIGH FREQUENCY & LONG DURATION.CONDITIONING : IN HEALTHY PEOPLE FOR INCREASING ENDURANCE RECONDITIONING : IN ILLNESS PEOPLE FOR ENDURANCE RECOVERY

B. PHYSICAL MODALITIES HEAT THERAPY COLD THERAPY MASSAGE CERVICAL & LUMBAL TRACTION ELECTRICAL STIMULATION HYDROTHERAPY

HEAT THERAPYANY 2 TYPE, BASED ON PENETRATIONSUPERFICIAL : PENETRATION CUTIS SUBCUTISINFRARED, WARM COMPRESS, UAP PANAS, PARAFFIN

DEEP : PENETRATION UNTIL MUSCLE, EXCEPT USD UNTIL BONE USD ( ULTRA SOUND DIATHERMY)SWD ( SHORT WAVE DIATHERMY )MWD ( MICRO WAVE DIATHERMY )USED FOR SUBACUTE PHASE (3 DAYS AFTER ACUTE PHASE)COLD THERAPY USED FOR ACUTE PHASECOLD WATER COMPRESS IN 20 MINUTTESICE MASSAGE IN 5 MINUTTESCOOLING SPRAY SUCH AS CHLORETYL SPRAY3 TIMES PER DAY CONTRAINDICATION OF COLD THERAPYVASCULER DISORDERSHYPERSENSITIVITY OF COLD TEMPERATURE CERVICAL & PELVIS TRACTION.INDICATION OF CERVICAL TRACTION CERVICAL ROOT SYNDROME ( CRS ) SPASME OTOTCONTRAINDICATION OF CERVICAL TRACTION SPONDYLITIS, OSTEOMYELITIS MALIGNANCY OF CERVICAL COMPRESSION OF MYELIUM HIPERTENSI MALIGNA & PJK OSTEOPOROSISRELATIF CONTRAINDICATION OF CERVICAL TRACTION GERIATRIC PREGNANCY RHEUMATOID ARTHRITIS CERVICAL

INDICATION OF PELVIC TRACTION MUSCLE SPASME HNP (KONSERVATIF)

CONTRAINDICATION OF PELVIS TRACTION = CERVICAL TRACTION PREGNANCY IN PELVIC TRACTION IS ABSOLUTE CONTRAINDICATION

ELECTRICAL STIMULATION INDUCE MUSCLE CONTRACTION, STRENGHTEN THE MUSCLE, MAINTAN MUSCLE STRENGTH, INCREASE VASCULARISATION, PREVENT MUSCLE ATHROPY. DECREASE MUSCLE SPASM & PAIN WITH LOW INTENSITY STIMULATION, USED TENS ( TRANSCUTANEUS ELECTRICAL NERVE STIMULATION )BIOFEEDBACK EXERCISEELECTRO DIAGNOSEIONTOPHOROSISCONTRAINDICATION OF ELECTRICAL STIMULATION PATIENT WITH CARDIAC PACEMAKER CORONARY HEART DISEASE REGIO THORAX (CLOSE WITH COR) REGIO UTERUS IN PREGNANCY OPEN WOUND, FRACTURE PRECAUTION IN SINUS KAROTISC. ORTHOTIC AND PROSTHETICORTHOTIC IS EQUIPMENT WHICH ADDED AT A PART OF THE BODY WITH SPECIAL FUNCTION FUNCTION OF ORTHOTIC : SUPPORT WEIGHT BEARING CORRECTION OF DEFORMITY ADD JOINT STABILITY FUNCTION RECOVERY PREVENT OF DEFORMITY CONTROLE INVOLUNTER MOVEMENT REDUSE PAINa. ORTHOTIC OF LOWER EXTREMITY FO : ( FOOT ORTHOSES ) AFO : ( ANKLE FOOT ORTHOSES ) KAFO : ( KNEE ANKLE FOOT ORTHOSES ) HKAFO : ( HIP KNEE ANKLE FOOT ORTHOSES )

B. ORTHOTIC OF SPINE CO: ( CERVICO ORTHESA ) CTO : ( CERVICO THORACO ORTHESA ) CTLSO: ( CERVICO THORACO LUMBOSACRAL ORTHESA ) TLSO : ( THORACO LUMBOSACRAL ORTHESA ) LS KORSET: ( LUMBOSACRAL KORSET )PROSTHETIC IS EQUIPMENT WHICH SUBTITUTE AT ELICITED PART OF THE BODY THE FUNCTION AS : SUPPORT WEIGHT BEARING RECOVERY OF FUNCTION COSMETICa. PROTHESE OF LOWER EXTREMITY : BELOW KNEE PROTHESE ABOVE KNEE PROTHESEb. PROTHESE OF UPPER EXTREMITY : FINGER PROTHESE BELOW ELBOW PROTHESEPROTESA BELOW KNEE22

NON TRAUMATIC MUSCULOSKELETAL DISORDERSREHABILITATION PROBLEMS OF RHEUMATIC DISORDERS Pain / Joint pain / Bone painStiffness, contractureWeaknessDeformityDecreasing of endurancePsychosocial problems

OAANAMNESISSIGNOSTEOARTHRITIS Dull aching pain increased with activity, relieved by rest Later pain occurs at rest Joint stiffness < 30 minutes, Articular gelling > stiffness lasting short periode and dissipate after initial ROM Crepitus on ROMRisk factors, sign & symptomFamily historyAgeGenderPrevious injuryOver useObesity The other joint Pain related activityDuration of morning stiffnessCrepitus on ROMLocalized tenderness of joints

SYMPTOMSOSTEOARTHRITIS MONOARTICULAR, SHOWS NO OBVIOUS JOINT PATTERN LOCALIZED TENDERNESS OF JOINTS PAIN AND CREPITUS OF INVOLVED JOINTS ENLARGEMENT OF THE JOINT > CHANGES IN THE CARTILAGE AND BONE SCONDARY TO PROLIFERATION OF SYNOVIAL FLUID AND SYNOVITISOAPHYSICAL EXAMINATIONOSTEOARTHRITISINSPECTION :SWELLING RARE DEFORMITY GENU VALGUS ENLARGEMENT OF THE JOINT ATROPHY QUADRICEPS MUSCLES

PALPATION : - MOVEMENT : - CREPITUS OF THE JOINT - STIFFNESS OF THE JOINT - MUSCLES WEAKNESS, PRIMARY QUADRICEPS MUSCLEOALABORATORYX RAYOSTEOARTHRITISNORMAL LIMITS

NARROWING JOINT SPACEMARGINAL OSTEOPHYTESUBCHONDRAL SCLEROSISSUBCHONDRAL CYST

35

Celah sendi menyempitosteofit35RTD PERDOSRI JATIM JULI 201235RTD PERDOSRI JATIM JULI 201235NON PHARMACOLOGICEXERCISELABORATORYOSTEOARTHRITIS MANAGEMENT

QUADRICEPS ( AND HAMSTRING ) STRENGTHENING EXERCISE RANGE OF MOTION EXERCISESTRETCHING EXERCISE

1. URIC ACID2. RHEMATOID FACTOR3. COMPLEMENT REACTIVE PROTEIN ( CRP )

ALL IS NORMAL LIMITS

OANON PHARMACOLOGICPHARMACOLOGICMANAGEMENTSTRENGTHENING EXERCISE AND ACTIVE ROMASSISTIVE DEVICEJONIT PROTECTION AND ENERGY CONVERVATION

NSAIDSACETAMINOPHENORAL STEROIDS ARE CONTRAINDICATED- NOT PROVEN

PATIENT EDUCATIONOSTEOARTHRITISWEIGHT LOSSACTIVITY DAILY LIVING

PATTERNOF ONSETRHEMATHOID ARTHRITISInsidious 50% - 70%Initial symptoms can be systemic or articularSlow onset from weeks to monthsConstitutional symptoms : fatigue, malaiseDiffuse musculoskeletal pain may be the first non specific complaint with joint involvement laterMost commonly symmetric involvement although asymmetric involvement may be seen earlyMorning stiffness in the involved joint lasting one hour or moreSwelling, erythemaMuscle atrophy around the affected jointsLow grade fever without chills

DIAGNOSISOF RAAmerican Rheumatologic Association Criteria (Arnett et al.)1988 Must satisfy 4 7 criteria criteria 1 through 4 must be present for at least six weeks

ARA Criteria :1. Morning stiffnessIn and around the jointMust at least one hour before maximal improvement

2. Arthritis of Three or More JointsThree or more joint areas simultaneously affected with soft tissue swelling or fluidObserved by physician14 possible joint areas are bilateral proximal interphalangeal (PIP), metacarpal phalangeal (MCP), wrist, elbow, knee, ankle, and metatarsal phalangeal (MTP)RHEMATHOID ARTHRITIS3. Morning stiffnessAt least one joint area swollen in the wrist, MCP and/or PIP

4. Symmetric ArthritisSimultaneous involvement at the same joint area on both sides of the bodyAbsolute symmetry is not needed5. Rheumatoid NodulesSubcutaneous nodules over extensor surface, bony prominence or in juxta-articular regionsObserved by a physician

6. Serum Rheumatoid Factor (RF [+])7. Radiographic Changes (Hand and Wrist)Erosions, bony decalcification and symmetric joint-space narrowingRHEMATHOID ARTHRITISDuration and Location in the Major Arthritis of Morning StiffnessLAB TESTSRheumatoid Arthritis >>> PIP, MCP, MTP JointsDuration > 1-2 hoursOsteoarthritis (OA) >>> Distal Interphalangeal Joint (DIP)Duration < 30 minutesAnkylosing Spondylitis >>> Lumbosacral SpineDuration ~ 3 hours

Although no single test is definitive in diagnosing RA,typical laboratory findings in active disease include :Rheumatoid factor (85% [+])Acute phase reactants : ESR and C-Reactive ProteinCBC : Thrombocytosis, hypochromic microcytic anemia, eosinophiliaSynovial fluid analysis

RHEMATHOID ARTHRITIS

NON PHARMACOLOGICEXERCISETREATMENT OF RHEUMATOID ARTHRITISAcute disease : with severely inflamed joints, actual splinting to produce immobilization with twice daily full and slow passive range of motion to prevent soft tissue contractureMild disease : (moderate synovitis) requires isometric program

Isometric Exercise :Causes least amount of periarticular bone destrucyion and joint inflammationRestores and maintains strengthGenerates maximal muscle tension with minimal work, fatigue and stressIsotonics and isokinetic may exacerbate the flare and should be avoided

MODALITIES. Superficial moist heat :- Should not be used in acutely inflamed joints- Depth of 1 cm- Decreases pain and increases collagen extensibility - Increase collagenase enzyme activity which causes increased joint destruction. Other superficial heating / modalities : paraffin, fluidotherapy . Cryotherapy :- Pain relief in an acutely inflamed joint- Decreases the pain indicators of inflamationORTHOTICS / SPLINTIndication :. Decrease pain and inflamation. Reduce weight through joint. Decrease joint motion stabilization. Joint rest

EDUCATIONMEDICATION. Joint protection. Home exercise program. Required for the acutely inflamed program

NSAID, SalicylatesDMARD ( Disease Modifying Antirhematic drug )( Hydroxychloroquine, Sulfalazine, Auranofin, Methothrexate, Cyclosporine )3. CorticosteroidsCLINICAL PRESENTATIONGOUT ARTHRITISAsymptomatic hyperuricemiaAcute intermittent >>> Acute gouty arthritisExquisite pain, warm tender swelling --- first MTP joint (Podagra)MonoarticularOther sites : midfoot, ankles, heels, kneesFever, chills, malaise, cutaneous erythemaMay last days to weeks with a mean time of 11 months between attacks

Chronic Tophaceous GoutTophi form after several years of attacksCause structural damage to the articular cartilage and adjacent bone

Polyarticular GoutSites of involvement : Olecranon bursae, wrists, hands, renal parenchyma with uric acid nephrolithiasisPROVOCATIVE FACTORSRADIOLOGICGOUT ARTHRITISAcute Gout AttacksTrauma --- Influx of synovial fluid urate productionAlcohol --- Increase uric acid productionDrugs --- ThiazidesHereditary

LABS : Hyperuricemia

Acute Gouty ArthritisSoft tissue swelling around the affected jointAsymmetricMTP most frequent joint involvedOthers : fingers, wrists, elbowsChronic tophaceousTophi appear as nodules in lobulated soft tissue massesBone erosions develop near the tophi just slighty removed from the periarticular surface, develop overchanging marginsJoint space is preservedNo osteopenia

TREATMENTGOUT ARTHRITISGoal >>> Pain relief, prevent attacks, tophi and joint destruction

Acute attacksColchicine --- inhibits phagocytosis of the urate crystalsNSAIDs --- IndocinCorticosteroids

ChronicAllopurinol --- decrease synthesis of urateProbenecid --- uricosuric increases the renal excretion of urateFROZEN SHOULDERInflammation of the shoulder joint (glenohumeral)Painful shoulder with restricted glenohumeral motion

EtiologyUnknownMay be : Autoimmune, trauma, inflammatory

Stages Painful stages : progressive vague pain lasting roughly 8 monthsStiffening stage : decreasing range of motion lasting roughly 8 monthsThawing stage : an increase of range of motion with decrease of shoulder pain

PATHOLOGYCLINICALFROZEN SHOULDERSynovial tissue of the capsule and bursa become adherentMore common in women over the age of 40 yearsAssociated with a variety of conditions :Intracranial lesions : CVA, hemorrhage and brain tumorClinical depressionShoulder-hand diseaseParkinsons diseaseIatrogenic disordersCervical disc diseaseInsulin dependent diabetes mellitusHypothyroidism

Pain, with significant reduction in range of motion both actively and passively

SPECIAL TESTFROZEN SHOULDER . APPREHENSION TEST. DROP ARM TEST. YERGASON TEST. APLEY SCRATH TEST

APPREHENSION TEST

YERGASON TEST

DROP ARM TEST

APLEY SCRACTH TEST

DIFFERENTIAL DIAGNOSISFROZEN SHOULDER. TENDINITIS BICIPITALIS. TEAR ROTATOR CUFF. INSTABILITY SHOULDER

IMAGINGTREATMENTFROZEN SHOULDERX RAY

USG

MRI

REHABILITATION ~ Restoring passive and active range of motion ~ Stretching exercises ~ Decreasing pain ~ Modalities : Ultrasound and electrical stimulation ~ Home program : Stretches in all range of motion

DEFINITIONFACTSABOUTOSTEOPOROSISOSTEOPOROSISDisease characterized by bone mass reduction and deterioration in the bone microarchitecture. It is caused by an imbalance between bone formation and bone resorption (ultimately leading to osteopenia)

Most common metabolic bone diseaseIn osteoporosis there is a normal ratio of organic and mineral components but less bone tissue, differs from osteomalacia (bone tissue is normal or increased, but reduced mineral content to organic component ratio)First clinical presentation is usually a fractureMajor underlying cause of long bone fractures in the elderly is osteoporosisDiagnosis is not dependent on a fracture

CLASSIFICATIONOSTEOPOROSISGeneralized affects different parts of whole skeleton

PrimaryBasic etiology unknownEvolutional most commonPostmenopausal (Type I)Senile (Type II) age associated osteoporosisJuvenile children and adolescents, self-limitedIdiopathic premenopausal females, middle-aged males

SecondaryAcquired or inherited disease / medications (Type III)

OSTEOPOROSISLokalized discrete regions of reduced bone mass

PrimaryTransient regional rare, migratory, predominantly involves hip, usually self-limitedReflex sympathetic dystrophy radiographic changes may occur in first 3-4 weeks, showing patchy demineralization of affected area

Secondary- immobilization, inflammations, tumors, necrosis

RISK FACTORS FOROSTEOPOROSISOSTEOPOROSISIncreased RiskCaucasianFemaleAdvanced ageThin habitusSmokingExcess alcoholExcess caffeine intakeInactivity/immobilizationDiminished peak bone mass (PBM) at skeletal maturityHistory of fracture as adultPositive family historyLoss of ovariom function/estrogen depletion, testosteron deficiencyExercise-induced amenorrhea

PATHOGENESISPHYSIOLOGYOSTEOPOROSISMultifactorial cause for reduced bone mass including genetic and environmental factors

Cellular components of bone remodelingOsteoblasts bone forming cells form organic matrix which is mineralized to form normal lamellar boneOsteoclasts bone resorption cellsOsteocytes osteoblasts incorporated in a new bone matrix

DIAGNOSISTREATMENTOSTEOPOROSISFirst clinical indication is usually a fractureFracture of proximal femur, distal forearmUsually associated with minimal traumaPain usually presentFracture of vertebraeUsually associated with minimal traumaPain or asymptomatic

PharmacologicPreserve or improve bone massDecrease bone resorption (anti-bone resorbers)

TREATMENTNON PHARMACOLOGICALOSTEOPOROSISCalciumVitamin DEstrogenCalcitonin (salmon)BisphosphonateSelective Estrogen Receptor Modulators (SERMs)

Therapeutic ExerciseTailored to fitness level and anticipated propensity to fracture or current fracturesLessen bone loss, increase strength and balance to prevent falls and avoid fracture

GOALS OFTHERAPEUTIC EXERCISEOSTEOPOROSISShort Terms Education: proper posture, body mechanics, increasing strength and aerobic capacityLong Terms Prevention of falls and fractures: proper nutrition, strength, aerobic capacity with adequate spine support, pain management, psych support

EXERCISESOSTEOPOROSISPectoral stretching, back extensionStrengthening back extension, isometric exercise to strengthen the abdomen, upper and lower extremitiesDeep breathing exerciseWeight-bearing exercise walking, low impact aerobics, jogging, stair-climbing (weight-bearing exercise improve bone density)Balance and transfer trainingProper lifting techniques, body mechanicsPosture correction avoid kyphotic postureAvoid spine flexion exercises in spinal osteoporosis, which may predispose to vertebral compression fracture

TRAUMATIC MUSCULOSKELETAL DISORDERSWHAT KIND TISSUES INJURY ?SPORT INJURYMUSCLE / TENDON/LIGAMENT//BONE/SOFT TISSUE ?

INSPECTIONSPORT INJURYLOCATIONHEMATOME SWELLINGDEFORMITY LACERATION

PALPATIONSPORT INJURY PAINTENDERNESSCREPITUS EFFUSION

MOVEMENTSPORT INJURY. ROM LIMITATION. PAIN. COMPARE BOTH SIDE

SPECIAL TESTSPORT INJURY. MMT. NEUROLOGY. SPECIAL TEST

ACUTE INJURYTREATMENTSPORT INJURY MANAGEMENTPHASE I (ACUTE INJURY)PREVENT DISABILITIESREDUCE PAIN & INFLAMMATIONRESTORING MOVEMENT

(RICE) /PRICE / PRICES : ( 1 3 days )PROTECTIONRESTICINGCOMPRESSIONELEVATIONSUPPORTACUTE INJURYPROTECTIONThe rationale for protection and rest after an acute soft tissue injury is to minimize bleeding, and prevent excessive distension or rerupture of weakened tissue at the injury site. The optimal nature and duration of protection/rest is not clear and ultimately depends on injury severity and tissue types. There is potential that excessive protection/rest (tissue unloading) will do harm. It is important to avoid movements in the plane of injury during the early acute phase of injury.ACUTE INJURYTREATMENTRESTAvoid activities that cause sharp painEnsure the availability of crutches if the patient cannot walk without limp.Continue relative rest until the pain and swelling are negligible on weight bearing

ICING ( 40 C- 90 C ) Ice provides local contraction of blood vessel so that blood flow is reduced to the injured area.Reduction of swelling enhances healingIce provides some pain relieve Apply ice 20 minutes initially every hour, then 3 to 4 times every 24 hour for 72 hours

COMPRESSIONReduce swollen areaUse elastic bandageVarious compression dressing combined with ice decrease swelling in the acute inflammatory

ELEVATION REDUCE SwollenPOSITION LEVEL ABOVE THE HEARTSims demonstrated with volumetric testing that elevated limbs have a significant decrease in volumetric displacement because the lymphatics have to work against decreased pressure to return excess fluid.

Definition by MAYO CLINICSPRAINS & STRAINSA sprain is a stretching or tearing of ligaments the tough bands of fibrous tissue that connect one bone to another in your joints. The most common location for a sprain is in your ankle.

A strain is a stretching or tearing of muscle or tendon. A tendon is a fibrous cord of tissue that connects muscles to bones. Strains often occur in the lower back and in the hamstring muscle in the back of your thigh.

TYPES SPORT INJURY TRAUMATIC :STRAINSPRAINFRACTUREDISLOCATIONOVERUSE :TENDINITISBURSITIS

GENERALANKLE SPRAINS Most common ankle sprain accounting for up to 85% of all ankle sprains result from plantar flexion inversion injuries causing lateral ankle sprains Anatomy : Ligaments Anterior talofibular ligament (ATFL) - Most common ligament injured Posterior talofibular ligament (PTFL)- Last to be injuredCalcaneofibular ligament (CFL)- Second most common* Function : Stabilize the ankle during inversionMechanism of injury- Inversion on a plantarflexed foot is the most vulnerable position- History of rolling over the ankle

CLINICALANKLE SPRAINSGrade 1 (Mild)Partial tear of the ATFLCFL and PTFL are intactMild swelling with point tenderness at the lateral aspect of the ankleNo instabilityStress tests* Anterior draw : Negative* Talar tilt : Negative

Grade 2 (Moderate)Complete tear of the ATFLPartial tear of the CFLDiffuse swelling and ecchymosisStress test* Anterior drwa : Positive^ Large anterior shift of the ankle or palpable clunk* Talar tilt : NegativeIMAGINGANKLE SPRAINSGrade 3 (Severe)Complete tear of the ATFL and CFLStress tests* Anterior draw : Positive* Talar tilt : Positive^ Inverting the talus on the tibia looking for a clinical asymmetry in comparison

DislocationComplete tear of the ATFL, CFL and PTFL

X ray, A/P, lateral, obliqueUSGMRI

Physical examinationDifferential diagnosis ANKLE SPRAINANKLE SPRAINSInspection :- Edema, hematome, lesion, deformityPalpation :- Crepitus, Pain Movement :- Limitation, PainSpecial test :- Anterior Drawer test- Lachman test- Thomson test

Fracture ankleDislocation ankleStrain ankleTENDON ACHILLES RUPTURE

TREATMENTANKLE SPRAINSGrade 1 and 2Acute* Rest, ice, compression, elevation (RICE), NSAIDs, analgesics, immobilization* Early mobilizationConservative : Rehabilitation* Range of motion, strengthening, proprioceptive exercises, taping and bracing* Modalities- Most heat, warm whirlpool, contrast baths, ultrasound, short wave diathermy

Grade 3Controversial : Conservative vs. surgical6 months trial of rehabilitation and bracingLigament repair, tenodesis of the peroneus brevisIf patient is a high-performance athlete, and conservative Tx fails (i.e., patient has persistent critical instability), then surgical reconstruction of torn ligaments may be considered as early as 3 months post injury

TREATMENT MEDICATIONANKLE SPRAINSANALGESIC :

- ACETAMINOPHEN- ACETYL SALYSILATES- KETOROLAC- IBUPROFEN

NSAID :

. MELOXICAM. NA DECLOFENAC. PIROXICAMKNEE INJURY

INSPECTIONThe examination begins with an inspection of the entire limb for deformity, bruising, and swelling.PALPATIONPalpate for localized tenderness, beginning in the non-painful areas.CREPITUS MOVEMENTThe knees active and passive range of motion, within the limits of pain, should be tested next.SPECIAL TESTPATELLAR TAP TESTDRAWER TESTCOLLATERAL MEDIAL AND LATERAL TESTCOMPRESSION AND DISTRACTION APLEY TESTLachman's test:Flex the knee to 15-20.Hold the lower thigh in one hand and the upper tibia in the other.Push the thigh in one direction and pull the tibia in the other.Reverse the direction, pushing the tibia and pulling the thigh, and look for increased movement or laxity between the tibia and the femur.RADIOGRAPHYX RAY : AP / LATERAL , / OBLIQUEUSGMRIARTHROSCOPY

MANAGEMENTACUTE PHASE :- PRICE- PHARMACOLOGICALAND THEN TREATMENT RELATED WITH DIAGNOSISPEMBIDAIAN1. MINTA IJIN DAN MENERANGKAN TUJUAN PEMBIDAIAN KPD PASIEN2. LAKUKAN PEMERIKSAAN PD REGIO YG PATAH TULANG3. BILA ADA PERDARAHAN HENTIKAN DG MEMBALUT LUKA4. BILA ADA LUKA DITUTUP DG KASSA STERIL5. JANGAN MEREPOSISI ATAU MEMASUKAN TULANG YG PATAH 6. PAKAI BIDAI YG AMAN ATAU DIBALUT KASSA , PANJANG BIDAI SEDIKIT MELEWATI 2 SENDI7. BIDAI YG DIPAKAI MINIMAL 3 BUAH8. SEBELUM BIDAI DIPASANG PERIKSA SIRKULASI, SENSASI DAN GERAKAN DISTAL ANGGOTA GERAK9. LETAKKAN 3 BIDAI SATU DIBAWAH & YG 2 BIDAI DISAMPING, BILA ADA RUANG LONGGAR BISA DILAPISI DG KAPAS10. IKAT BIDAI YG CUKUP DG ERAT TDK KENDOR ATAU TERLALU KENCANG11. PERIKSA LAGI BAGIAN SIRKULASI, SENSASI DANGERAKAN BAGIAN DISTAL ANGGOTA GERAK125

TERIMA KASIH