PHYSICAL MEDICINE

AND
REHABILITATION OF
THE
MUSCULOSKELETAL
PROBLEMS
Dr. 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-psychosocio-vocational disruptions concomitant with
them.

REHABILITATION MEDICINE

R.
R.
R.
R.
R.
R.
R.

of MUSCULOSKELETAL SYSTEM
of NEUROMUSCULER SYSTEM
of CARDIOVASCULER SYSTEM
of RESPIRATORY
of PEDIATRIC
of GERIATRIC
of SPORT INJURY

MANAGEMENT OF
REHABILITATION MEDICINE
1. EXERCISES
2. PHYSICAL MODALITIES
3. PROSTHETIC - ORTHOTIC
4. MEDICAMENTOUSE

FUNCTIONAL DIAGNOSE IN
REHABILITATION MEDICINE

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

A. THERAPEUTIC EXERCISE
1.

STRENGTHENING EXERCISE

PATIENT CAN BE INSTRUCTED

MMT 3

ANY RESISTANCE

3. 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 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

2. RANGE OF MOTION EXERCISE

( ROM EXERCISE )
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

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 THERAPY
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 THERAPY
USED FOR 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

CERVICAL & PELVIS TRACTION.

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

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 EXERCISE

ELECTRO DIAGNOSE

IONTOPHOROSIS

CONTRAINDICATION 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 KAROTIS

C. ORTHOTIC AND PROSTHETIC

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

A. ORTHOTIC OF LOWER EXTREMITY

FO : ( FOOT ORTHOSES )

AFO

KAFO : ( KNEE ANKLE FOOT ORTHOSES )

HKAFO

: ( ANKLE FOOT ORTHOSES )

: ( HIP KNEE ANKLE FOOT ORTHOSES )

B. ORTHOTIC OF SPINE

CO

: ( CERVICO ORTHESA )

CTO

: ( CERVICO THORACO ORTHESA )

CTLSO : ( CERVICO THORACO LUMBOSACRAL ORTHESA )

TLSO

LS KORSET : ( LUMBOSACRAL KORSET )

: ( THORACO LUMBOSACRAL ORTHESA )

PROSTHETIC IS EQUIPMENT WHICH SUBTITUTE AT

ELICITED PART OF THE BODY

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

PROTESA BELOW KNEE

22

NON TRAUMATIC MUSCULOSKELETAL

DISORDERS

REHABILITATION PROBLEMS OF
RHEUMATIC DISORDERS
1.
2.
3.
4.
5.
6.

Pain / Joint pain / Bone pain

Stiffness, contracture
Weakness
Deformity
Decreasing of endurance
Psychosocial problems

OA

OSTEOARTHRITIS

ANAMNESIS

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 ROM
SIGN

RISK FACTORS, SIGN &

SYMPTOM

Family history
Age
Gender
Previous injury
Over use
Obesity
The other joint
Pain related activity
Duration of morning stiffness

Crepitus on ROM
Localized tenderness of joints

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

PHYSICAL

EXAMINATION

OSTEOARTHRITIS

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

OSTEOARTHRITIS

OA

LABORATORY

X RAY

NORMAL LIMITS

1.
2.
3.
4.

NARROWING JOINT SPACE

MARGINAL OSTEOPHYTE
SUBCHONDRAL SCLEROSIS
SUBCHONDRAL CYST

osteofit

Celah sendi
menyempit
RTD PERDOSRI JATIM JULI 2012

RTD PERDOSRI JATIM JULI 2012

35

35

35

NON
PHARMACOLOGIC

EXERCISE

LABORATORY

OSTEOARTHRITIS MANAGEMENT

1. QUADRICEPS ( AND HAMSTRING ) STRENGTHENING

EXERCISE
2. RANGE OF MOTION EXERCISE
3. STRETCHING EXERCISE

1.
2.
3.

URIC ACID
RHEMATOID FACTOR
COMPLEMENT REACTIVE PROTEIN ( CRP )

ALL IS NORMAL LIMITS

MANAGEMENT

OA

NON
PHARMACO
LOGIC

PHARMACO
LOGIC

1.
2.
3.

STRENGTHENING EXERCISE AND ACTIVE ROM

ASSISTIVE DEVICE
JONIT PROTECTION AND ENERGY CONVERVATION

-.
-.
-.

NSAIDS
ACETAMINOPHEN
ORAL STEROIDS ARE CONTRAINDICATED- NOT PROVEN

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.

5.

6.
7.

Symmetric Arthritis
Simultaneous involvement at the same joint area on both sides
of the body
Absolute symmetry is not needed
Rheumatoid Nodules
Subcutaneous nodules over extensor surface, bony prominence
or in juxta-articular regions
Observed by a physician
Serum Rheumatoid Factor (RF [+])
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

LAB TESTS

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

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

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

EDUCATION

1.
2.
MEDICATION

NSAID, Salicylates
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

RADIOLOGIC

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

GOUT ARTHRITIS

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

destruction
TREATMENT

Acute attacks
Colchicine --- inhibits phagocytosis of the urate
crystals
NSAIDs --- 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

CLINICAL

-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
Parkinsons disease
Iatrogenic disorders
Cervical disc disease
Insulin dependent diabetes mellitus
Hypothyroidism
Pain, with significant reduction in range of motion both
actively and passively

FROZEN SHOULDER

SPECIAL
TEST

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

APPREHENSION TEST

YERGASON TEST

DROP ARM TEST

APLEY SCRACTH 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

FACTS
ABOUT

OSTEOPOROSIS

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

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

TREATMENT

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)

OSTEOPOROSIS

TREATMENT

NON
PHARMACOLO
GICAL

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

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

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

PAIN
-TENDERNESS
-CREPITUS
- EFFUSION
-

PALPATION

SPORT INJURY

MOVEMENT

. ROM LIMITATION
. PAIN
. COMPARE BOTH SIDE

SPORT INJURY

SPECIAL
TEST

. MMT
. NEUROLOGY
. SPECIAL TEST

SPORT INJURY MANAGEMENT

ACUTE
INJURY

TREATMENT

PHASE I (ACUTE INJURY)

PREVENT DISABILITIES
REDUCE PAIN & INFLAMMATION
RESTORING MOVEMENT

(RICE) /PRICE / PRICES : ( 1 3 days )

1. PROTECTION
2. REST
3. ICING
4. COMPRESSION
5. ELEVATION
6. SUPPORT

PROTECTION

ACUTE
INJURY

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.

REST

ACUTE
INJURY

TREATMENT

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

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

Definition
by MAYO
CLINIC

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.

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 :
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

Differential
diagnosis
ANKLE
SPRAIN

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

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

KNEE INJURY

INSPECTION

The examination begins with an inspection of

the entire limb for deformity, bruising, and
swelling.

PALPATION

Palpate for localized tenderness, beginning

in the non-painful areas.
CREPITUS

MOVEMENT

The knees active and passive range of

motion, within the limits of pain, should be
tested next.

SPECIAL TEST

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.

RADIOGRAPHY

X RAY : AP / LATERAL , / OBLIQUE

USG
MRI
ARTHROSCOPY

MANAGEMENT

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

PEMBIDAIAN

1. MINTA IJIN DAN MENERANGKAN

TUJUAN PEMBIDAIAN KPD PASIEN
2. LAKUKAN PEMERIKSAAN PD REGIO YG
PATAH TULANG
3. BILA ADA PERDARAHAN HENTIKAN DG
MEMBALUT LUKA
4. BILA ADA LUKA DITUTUP DG KASSA
STERIL

5. JANGAN MEREPOSISI ATAU MEMASUKAN

TULANG YG PATAH
6. PAKAI BIDAI YG AMAN ATAU DIBALUT
KASSA , PANJANG BIDAI SEDIKIT
MELEWATI 2 SENDI
7. BIDAI YG DIPAKAI MINIMAL 3 BUAH
8. SEBELUM BIDAI DIPASANG PERIKSA
SIRKULASI, SENSASI DAN GERAKAN DISTAL
ANGGOTA GERAK

9. LETAKKAN 3 BIDAI SATU DIBAWAH &

YG 2 BIDAI DISAMPING, BILA ADA RUANG
LONGGAR BISA DILAPISI DG KAPAS
10. IKAT BIDAI YG CUKUP DG ERAT TDK
KENDOR ATAU TERLALU KENCANG
11. PERIKSA LAGI BAGIAN SIRKULASI,
SENSASI DANGERAKAN BAGIAN DISTAL
ANGGOTA GERAK

TERIMA KASIH
125