Musculoskeletal

Dr. Moch. Ridwan, Sp.KFR

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-psychosocio-vocational disruptions concomitant with them.

 R.

of MUSCULOSKELETAL SYSTEM  R. of NEUROMUSCULER SYSTEM  R. of CARDIOVASCULER SYSTEM  R. of RESPIRATORY  R. of PEDIATRIC  R. of GERIATRIC  R. of SPORT INJURY

1. EXERCISES
2. PHYSICAL MODALITIES 3. PROSTHETIC - ORTHOTIC 4. MEDICAMENTOUSE

IMPAIRMENT :  Any loss or abnormality of physichologycal, physiological, or anatomical structure or function  DISABILITY :  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 being  HANDICAP :  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




1. STRENGTHENING EXERCISE


PATIENT CAN BE INSTRUCTED




MMT  3
ANY RESISTANCE

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 EXERCISE ANY MUSCLE CONTRACTION WITH JOINT MOTION. 2 TYPE :
 

CONCENTRIC CONTRACTION : SHORTHENING ECCENTRIC CONTRACTION : LENGTHENING

c. ISOKINETIC EXERCISE ( COMBINE OF ISOMETRIC & ISOTONIC )
  

USED A TOOL CONTANTLY SPEED MORE SAFETY FOR HYPERTENTION & CHD PATIENT

TO MAINTAIN A ROM  PREVENT A CONTRACTURE  WITHOUT RESISTANCE  ANY 2 TYPE OF ROM EXERCISE : PASSIVE ROM EXERCISE, IF MMT < 2 ACTIVE ASSISTIVE, IF MMT = 2 ACTIVE ROM EXERCISE, IF MMT  3


 



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


    

HEAT THERAPY COLD THERAPY MASSAGE CERVICAL & LUMBAL TRACTION ELECTRICAL STIMULATION HYDROTHERAPY

ANY 2 TYPE, BASED ON PENETRATION SUPERFICIAL : PENETRATION CUTIS  SUBCUTIS  INFRARED, 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

WATER COMPRESS IN 20 MINUTTES  ICE MASSAGE IN 5 MINUTTES  COOLING SPRAY SUCH AS CHLORETYL SPRAY  3 TIMES PER DAY CONTRAINDICATION OF COLD THERAPY  VASCULER DISORDERS  HYPERSENSITIVITY OF COLD TEMPERATURE

INDICATION OF CERVICAL TRACTION
 

CERVICAL ROOT SYNDROME ( CRS ) SPASME OTOT

CONTRAINDICATION OF CERVICAL TRACTION
    

SPONDYLITIS, OSTEOMYELITIS MALIGNANCY OF CERVICAL

COMPRESSION OF MYELIUM
HIPERTENSI MALIGNA & PJK OSTEOPOROSIS

RELATIF CONTRAINDICATION OF CERVICAL TRACTION

 

GERIATRIC
PREGNANCY RHEUMATOID ARTHRITIS CERVICAL




MUSCLE SPASME
HNP (KONSERVATIF)

CONTRAINDICATION OF PELVIS TRACTION



= CERVICAL TRACTION
PREGNANCY IN PELVIC TRACTION IS ABSOLUTE CONTRAINDICATION



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 EXERCISE ELECTRO DIAGNOSE IONTOPHOROSIS



  

 


 



PATIENT WITH CARDIAC PACEMAKER CORONARY HEART DISEASE REGIO THORAX (CLOSE WITH COR) REGIO UTERUS IN PREGNANCY OPEN WOUND, FRACTURE PRECAUTION IN SINUS KAROTIS

ORTHOTIC 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 PAIN


   

FO AFO

: ( FOOT ORTHOSES ) : ( ANKLE FOOT ORTHOSES ) : ( KNEE ANKLE FOOT ORTHOSES ) : ( HIP KNEE ANKLE FOOT ORTHOSES )

KAFO HKAFO

B. ORTHOTIC OF SPINE
    

CO CTO CTLSO TLSO

: ( CERVICO ORTHESA ) : ( CERVICO THORACO ORTHESA ) : ( CERVICO THORACO LUMBOSACRAL ORTHESA ) : ( THORACO LUMBOSACRAL ORTHESA )

LS KORSET : ( LUMBOSACRAL KORSET )

THE FUNCTION AS :  SUPPORT WEIGHT BEARING  RECOVERY OF FUNCTION  COSMETIC
a. PROTHESE OF LOWER EXTREMITY :  BELOW KNEE PROTHESE  ABOVE KNEE PROTHESE b. PROTHESE OF UPPER EXTREMITY :  FINGER PROTHESE  BELOW ELBOW PROTHESE

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 NON

TRAUMATIC MUSCULOSKELETAL DISORDERS

1. 2. 3. 4. 5.

6.

Pain / Joint pain / Bone pain Stiffness, contracture Weakness Deformity Decreasing of endurance Psychosocial problems

OA

OSTEOARTHRITIS

ANAMNESIS

SIGN

• Dull aching pain increased with activity, relieved by rest • Later pain occurs at rest • Joint stiffness < 30 minutes, becomes worse as the day goes on • Joint giving away • Articular gelling ―> stiffness lasting short periode and dissipate after initial ROM • Crepitus on ROM

OSTEOARTHRITIS

SYMPTOMS - 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 SYNOVITIS

OA

OSTEOARTHRITIS

PHYSICAL
EXAMINATION

INSPECTION : -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 MUSCLE

OA

OSTEOARTHRITIS

LABORATORY

NORMAL LIMITS

X RAY

1. 2. 3. 4.

NARROWING JOINT SPACE MARGINAL OSTEOPHYTE SUBCHONDRAL SCLEROSIS SUBCHONDRAL CYST

osteofit

Celah sendi menyempit
RTD PERDOSRI JATIM JULI RTD 2012 PERDOSRI JATIM JULI 2012

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29

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NON PHARMACOLOGIC

OSTEOARTHRITIS MANAGEMENT

EXERCISE

1. QUADRICEPS ( AND HAMSTRING ) STRENGTHENING EXERCISE 2. RANGE OF MOTION EXERCISE 3. STRETCHING EXERCISE

LABORATORY

1. URIC ACID 2. RHEMATOID FACTOR 3. COMPLEMENT REACTIVE PROTEIN ( CRP )
ALL IS NORMAL LIMITS

OA

MANAGEMENT

NON PHARMACO LOGIC

1. STRENGTHENING EXERCISE AND ACTIVE ROM 2. ASSISTIVE DEVICE 3. JONIT PROTECTION AND ENERGY CONVERVATION NSAIDS ACETAMINOPHEN ORAL STEROIDS ARE CONTRAINDICATED- NOT PROVEN

PHARMACO LOGIC

OSTEOARTHRITIS

PATIENT EDUCATION

WEIGHT LOSS ACTIVITY DAILY LIVING

RHEMATHOID ARTHRITIS

PATTERN OF ONSET

Insidious – 50% - 70% 1. Initial symptoms can be systemic or articular 2. Slow onset from weeks to months 3. Constitutional symptoms : fatigue, malaise 4. Diffuse musculoskeletal pain may be the first non specific complaint with joint involvement later 5. Most commonly symmetric involvement although asymmetric involvement may be seen early 6. Morning stiffness in the involved joint lasting one hour or more 7. Swelling, erythema 8. Muscle atrophy around the affected joints 9. Low grade fever without chills

RHEMATHOID ARTHRITIS

DIAGNOSIS OF RA

American 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 stiffness • In and around the joint • Must at least one hour before maximal improvement 2. Arthritis of Three or More Joints • Three or more joint areas simultaneously affected with soft tissue swelling or fluid • Observed by physician • 14 possible joint areas are bilateral proximal interphalangeal (PIP), metacarpal phalangeal (MCP), wrist, elbow, knee, ankle, and metatarsal phalangeal (MTP)

RHEMATHOID ARTHRITIS

3. Morning stiffness • At least one joint area swollen in the wrist, MCP and/or PIP
4. Symmetric Arthritis • Simultaneous involvement at the same joint area on both sides of the body • Absolute symmetry is not needed 5. Rheumatoid Nodules • Subcutaneous nodules over extensor surface, bony prominence or in juxta-articular regions • Observed by a physician

6. Serum Rheumatoid Factor (RF [+]) 7. Radiographic Changes (Hand and Wrist) • Erosions, bony decalcification and symmetric joint-space narrowing

RHEMATHOID ARTHRITIS

Duration and Location in the Major Arthritis of Morning Stiffness

• • •

Rheumatoid Arthritis >>> PIP, MCP, MTP Joints Duration > 1-2 hours Osteoarthritis (OA) >>> Distal Interphalangeal Joint (DIP) Duration < 30 minutes Ankylosing Spondylitis >>> Lumbosacral Spine Duration ~ 3 hours

LAB TESTS

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 Protein • CBC : Thrombocytosis, hypochromic microcytic anemia, eosinophilia • Synovial fluid analysis

NON PHARMACO LOGIC

TREATMENT OF RHEUMATOID ARTHRITIS

• EXERCISE •

Acute disease : with severely inflamed joints, actual splinting to produce immobilization with twice daily full and slow passive range of motion to prevent soft tissue contracture Mild disease : (moderate synovitis) requires isometric program

Isometric Exercise : • Causes least amount of periarticular bone destrucyion and joint inflammation • Restores and maintains strength • Generates maximal muscle tension with minimal work, fatigue and stress • Isotonics 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 inflamation

ORTHOTICS / SPLINT

Indication : . Decrease pain and inflamation . Reduce weight through joint . Decrease joint motion – stabilization . Joint rest

EDUCATION

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

MEDICATION

1. NSAID, Salicylates 2. DMARD ( Disease –Modifying Antirhematic drug ) ( Hydroxychloroquine, Sulfalazine, Auranofin, Methothrexate, Cyclosporine ) 3. Corticosteroids

GOUT ARTHRITIS

CLINICAL PRESENTATION

• • •

Asymptomatic hyperuricemia Acute intermittent >>> Acute gouty arthritis Exquisite pain, warm tender swelling --- first MTP joint (Podagra) • Monoarticular • Other sites : midfoot, ankles, heels, knees • Fever, chills, malaise, cutaneous erythema • May last days to weeks with a mean time of 11 months between attacks Chronic Tophaceous Gout • Tophi form after several years of attacks • Cause structural damage to the articular cartilage and adjacent bone Polyarticular Gout • Sites of involvement : Olecranon bursae, wrists, hands, renal parenchyma with uric acid nephrolithiasis

•

•

GOUT ARTHRITIS

•
PROVOCATIVE FACTORS

Acute Gout Attacks • Trauma --- Influx of synovial fluid urate production • Alcohol --- Increase uric acid production • Drugs --- Thiazides • Hereditary

LABS : Hyperuricemia Acute Gouty Arthritis • Soft tissue swelling around the affected joint • Asymmetric • MTP most frequent joint involved • Others : fingers, wrists, elbows Chronic tophaceous • Tophi appear as nodules in lobulated soft tissue masses • Bone erosions develop near the tophi just slighty removed from the periarticular surface, develop overchanging margins Joint space is preserved No osteopenia

RADIOLOGIC

GOUT ARTHRITIS

Goal >>> Pain relief, prevent attacks, tophi and joint destruction
TREATMENT

Acute attacks • Colchicine --- inhibits phagocytosis of the urate crystals • NSAID’s --- Indocin • Corticosteroids Chronic • Allopurinol --- decrease synthesis of urate • Probenecid --- uricosuric increases the renal excretion of urate

FROZEN SHOULDER

-Inflammation of the shoulder joint (glenohumeral) -Painful shoulder with restricted glenohumeral motion

Etiology -Unknown -May be : Autoimmune, trauma, inflammatory
Stages -Painful stages : progressive vague pain lasting roughly 8 months -Stiffening stage : decreasing range of motion lasting roughly 8 months -Thawing stage :
an increase of range of motion with decrease of shoulder pain

FROZEN SHOULDER

PATHOLOGY

-Synovial tissue of the capsule and bursa become adherent -More common in women over the age of 40 years -Associated with a variety of conditions : Intracranial lesions : CVA, hemorrhage and brain tumor Clinical depression Shoulder-hand disease Parkinson’s disease Iatrogenic disorders Cervical disc disease Insulin dependent diabetes mellitus Hypothyroidism Pain, with significant reduction in range of motion both actively and passively

CLINICAL

FROZEN SHOULDER

SPECIAL TEST

. APPREHENSION TEST . DROP ARM TEST . YERGASON TEST . APLEY SCRATH TEST

FROZEN SHOULDER

DIFFERENTIA L DIAGNOSIS

. TENDINITIS BICIPITALIS . TEAR ROTATOR CUFF . INSTABILITY SHOULDER

FROZEN SHOULDER

-X RAY
IMAGING

-USG -MRI

TREATMENT

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

OSTEOPOROSIS

DEFINITION

Disease 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 disease -In 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 fracture -Major underlying cause of long bone fractures in the elderly is osteoporosis -Diagnosis is not dependent on a fracture

FACTS ABOUT
OSTEOPOROSIS

OSTEOPOROSIS

CLASSIFICATION

Generalized – affects different parts of whole skeleton Primary Basic etiology unknown -Evolutional – most common -Postmenopausal (Type I) -Senile (Type II) – age associated osteoporosis -Juvenile – children and adolescents, self-limited -Idiopathic – premenopausal females, middle-aged males Secondary Acquired or inherited disease / medications (Type III)

OSTEOPOROSIS

Lokalized – discrete regions of reduced bone mass Primary -Transient regional – rare, migratory, predominantly involves hip, usually self-limited -Reflex sympathetic dystrophy – radiographic changes may occur in first 3-4 weeks, showing patchy demineralization of affected area Secondary - immobilization, inflammations, tumors, necrosis

OSTEOPOROSIS

RISK FACTORS FOR OSTEOPOROSIS

Increased Risk -Caucasian -Female -Advanced age -Thin habitus -Smoking -Excess alcohol -Excess caffeine intake -Inactivity/immobilization -Diminished peak bone mass (PBM) at skeletal maturity -History of fracture as adult -Positive family history -Loss of ovariom function/estrogen depletion, testosteron deficiency -Exercise-induced amenorrhea

OSTEOPOROSIS

PATHOGENESIS

Multifactorial cause for reduced bone mass including genetic and environmental factors

PHYSIOLOGY

Cellular components of bone remodeling -Osteoblasts – bone forming cells form organic matrix which is mineralized to form normal lamellar bone -Osteoclasts – bone resorption cells -Osteocytes – osteoblasts incorporated in a new bone matrix

OSTEOPOROSIS

DIAGNOSIS

First clinical indication is usually a fracture •Fracture of proximal femur, distal forearm Usually associated with minimal trauma Pain usually present •Fracture of vertebrae Usually associated with minimal trauma Pain or asymptomatic Pharmacologic -Preserve or improve bone mass -Decrease bone resorption (anti-bone resorbers)

TREATMENT

OSTEOPOROSIS

TREATMENT

1. 2. 3. 4. 5. 6.

Calcium Vitamin D Estrogen Calcitonin (salmon) Bisphosphonate Selective Estrogen Receptor Modulators (SERMs)

NON PHARMACOLO GICAL

Therapeutic Exercise Tailored to fitness level and anticipated propensity to fracture or current fractures Lessen bone loss, increase strength and balance to prevent falls and avoid fracture

OSTEOPOROSIS

GOALS OF THERAPEUTIC EXERCISE

1. Short Terms – Education: proper posture, body mechanics, increasing strength and aerobic capacity 2. Long Terms – Prevention of falls and fractures: proper nutrition, strength, aerobic capacity with adequate spine support, pain management, psych support

OSTEOPOROSIS

EXERCISES

1. 2. 3. 4. 5. 6. 7. 8.

Pectoral stretching, back extension Strengthening – back extension, isometric exercise to strengthen the abdomen, upper and lower extremities Deep breathing exercise Weight-bearing exercise – walking, low impact aerobics, jogging, stair-climbing (weight-bearing exercise improve bone density) Balance and transfer training Proper lifting techniques, body mechanics Posture correction – avoid kyphotic posture Avoid spine flexion exercises in spinal osteoporosis, which may predispose to vertebral compression fracture

 TRAUMATIC

MUSCULOSKELETAL DISORDERS

SPORT INJURY
MUSCLE / TENDON/LIGAMENT//BONE/SOFT TISSUE ? WHAT KIND TISSUES INJURY ?

SPORT INJURY

INSPECTION

LOCATION : -HEMATOME - SWELLING -DEFORMITY - LACERATION

SPORT INJURY

PALPATION

PAIN -TENDERNESS -CREPITUS - EFFUSION
-

SPORT INJURY

MOVEMENT

. ROM LIMITATION . PAIN . COMPARE BOTH SIDE

SPORT INJURY

SPECIAL TEST

. MMT . NEUROLOGY . SPECIAL TEST

SPORT INJURY MANAGEMENT

ACUTE INJURY

PHASE I (ACUTE INJURY) PREVENT DISABILITIES REDUCE PAIN & INFLAMMATION RESTORING MOVEMENT

TREATMENT

(RICE) /PRICE / PRICES : ( 1 – 3 days ) 1. PROTECTION 2. REST 3. ICING 4. COMPRESSION 5. ELEVATION 6. SUPPORT

PROTECTION
The 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 INJURY

REST

ACUTE INJURY

Avoid activities that cause sharp pain Ensure the availability of crutches if the patient cannot walk without limp. Continue relative rest until the pain and swelling are negligible on weight bearing

TREATMENT

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 healing Ice provides some pain relieve Apply ice 20 minutes initially every hour, then 3 to 4 times every 24 hour for 72 hours

COMPRESSION
Reduce swollen area Use elastic bandage Various compression dressing combined with ice decrease swelling in the acute inflammatory

ELEVATION
REDUCE Swollen POSITION LEVEL ABOVE THE HEART Sims 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.

SPRAINS & STRAINS
A 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.

Definition by MAYO CLINIC

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.

 TRAUMATIC
   

:

STRAIN SPRAIN FRACTURE DISLOCATION

 OVERUSE


:



TENDINITIS BURSITIS

ANKLE SPRAINS

GENERAL

 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 injured  Calcaneofibular ligament (CFL) - Second most common * Function : Stabilize the ankle during inversion • Mechanism of injury - Inversion on a plantarflexed foot is the most vulnerable position - History of “rolling over” the ankle

ANKLE SPRAINS

CLINICAL

Grade 1 (Mild) - Partial tear of the ATFL - CFL and PTFL are intact - Mild swelling with point tenderness at the lateral aspect of the ankle - No instability - Stress tests * Anterior draw : Negative * Talar tilt : Negative Grade 2 (Moderate) - Complete tear of the ATFL - Partial tear of the CFL - Diffuse swelling and ecchymosis - Stress test * Anterior drwa : Positive ^ Large anterior shift of the ankle or palpable clunk * Talar tilt : Negative

ANKLE SPRAINS

Grade 3 (Severe) - Complete tear of the ATFL and CFL - Stress tests * Anterior draw : Positive * Talar tilt : Positive ^ Inverting the talus on the tibia looking for a clinical asymmetry in comparison Dislocation - Complete tear of the ATFL, CFL and PTFL

IMAGING

• X ray, A/P, lateral, oblique • USG • MRI

ANKLE SPRAINS

Physical examination

Inspection : - Edema, hematome, lesion, deformity Palpation : - Crepitus, Pain Movement : - Limitation, Pain Special test : - Anterior Drawer test - Lachman test - Thomson test

Differential diagnosis ANKLE SPRAIN

Fracture ankle Dislocation ankle

Strain ankle TENDON ACHILLES RUPTURE

ANKLE SPRAINS

TREATMENT

Grade 1 and 2 - Acute * Rest, ice, compression, elevation (RICE), NSAIDs, analgesics, immobilization * Early mobilization - Conservative : Rehabilitation * Range of motion, strengthening, proprioceptive exercises, taping and bracing * Modalities - Most heat, warm whirlpool, contrast baths, ultrasound, short wave diathermy Grade 3 Controversial : Conservative vs. surgical - 6 months trial of rehabilitation and bracing - Ligament repair, tenodesis of the peroneus brevis - If 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

ANKLE SPRAINS

ANALGESIC :
TREATMENT MEDICATION

- ACETAMINOPHEN - ACETYL SALYSILATES - KETOROLAC - IBUPROFEN NSAID : . MELOXICAM . NA DECLOFENAC . PIROXICAM

 The

examination begins with an inspection of the entire limb for deformity, bruising, and swelling.

 Palpate

for localized tenderness, beginning in the non-painful areas.  CREPITUS

 The

knee’s active and passive range of motion, within the limits of pain, should be tested next.

 PATELLAR

TAP TEST  DRAWER TEST  COLLATERAL MEDIAL AND LATERAL TEST  COMPRESSION AND DISTRACTION APLEY TEST

Lachman'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.

X

RAY : AP / LATERAL , / OBLIQUE  USG  MRI  ARTHROSCOPY

 ACUTE

PHASE : - PRICE - PHARMACOLOGICAL  AND THEN TREATMENT RELATED WITH DIAGNOSIS

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