통증물리치료학및 실습 CH 10. 근육및인대손상재활. Gachon University Department of Physical Therapy. Hwi-young Cho, PT, PhD

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1 통증물리치료학및 실습 CH 10. 근육및인대손상재활 Gachon University Department of Physical Therapy Hwi-young Cho, PT, PhD

2 Sprain & Strain 4B_qz6c Sprain Ligament Strain Muscle & Tendon

Sprain An injury involving the stretching or tearing of a ligament (tissue that connects bone to bone) or a joint capsule, which help provide joint stability.

3 Sprain An injury involving the stretching or tearing of a ligament (tissue that connects bone to bone) or a joint capsule, which help provide joint stability. 1 or more ligaments can be injured at the same time Severity of injury extent of injury and number of ligaments involved

4 Symptom Sprain pain, swelling, the inability to move a limb, popping sound, difficulty using the affected limb Severe damage Cause joint instability

5 Severity of Sprain & Strain Grade I (mild) Some stretching or minor tearing of a ligament or muscle. Grade II (moderate) A ligament or muscle that is partially torn but still intact. Grade III (severe) The ligament or muscle is completely torn, resulting in joint instability.

$Sprain Diagnosis Physical examination based on the clinical presentation and method of injury X-ray : ensure that there is no fracture$

7 Sprain Diagnosis Physical examination based on the clinical presentation and method of injury X-ray : ensure that there is no fracture Magnetic resonance imaging (MRI) : look at surrounding soft tissues and the ligament

8 Risk factor of Sprain Sudden movement or twist Fall down Blow to body that forces a joint out of its normal position and stretches or tears the ligament supporting that joint

9 Where Do Sprains Usually Occur? Most common site the ankle Frequently occurred site the wrist sprain to the thumb common in skiing and other sports

Strain Involve the stretching or tearing of a musculo-tendinous (muscle and tendon) structure Acute strain By a direct blow to the body, overstretching or excessive muscle

10 Strain Involve the stretching or tearing of a musculo-tendinous (muscle and tendon) structure Acute strain By a direct blow to the body, overstretching or excessive muscle contraction Chronic strain The result of overuse - prolonged, repetitive movement of muscles and tendons

11 Strain 급성염좌 (Acute strain) Occurs at the junction where the muscle is becoming a tendon. When a muscle is stretched and suddenly contracts, as with running or jumping. Symptom : pain, muscle spasm, loss of strength, and limited range of motion. 만성염좌 (Chronic strain) Gradually build up from overuse or repetitive stress, resulting in tendinitis (inflammation of a tendon). Ex: Tennis elbow, Golfer elbow

12 Strain Severe Strain - muscle or tendon is partially or completely ruptured, leaving person incapacitated. Moderate Strain - muscle or tendon is overstretched and slightly torn, leaving some muscle functions lost. Mild Strain - muscle or tendon stretched or pulled slightly

13 What Causes a Strain? Heavy work Sudden movement Repeated & persistent activity Twisting or pulling a muscle or tendon Acute or chronic: recent trauma or result of overuse

14 Where Do Strains Usually Occur? Common sites: Back & Hamstring Calf, Foot, Hand and Forearm

Signs and Symptoms of Strain Muscle pain and tenderness, especially after an activity that stretches or violently contracts the muscle -- Pain usually increases when you move the muscle but is

15 Signs and Symptoms of Strain Muscle pain and tenderness, especially after an activity that stretches or violently contracts the muscle -- Pain usually increases when you move the muscle but is relieved by rest. Muscle swelling, discoloration or both Muscle cramp or spasm Either a decrease in muscle strength or (in Grade III strains) a complete loss of muscle function A pop in the muscle at the time of injury A gap, dent or other defect in the normal outline of the muscle (in Grade III strain)

16 Repetitive Strain Injuries Carpal tunnel syndrome (CTS), tendonitis, and many of the ergonomic injuries result from straining muscles or ligaments. Workplace set up for person is the first step. Remember the rule of 90s for office operations (knees at 90 degrees, back/legs at 90 degrees, elbows at rest and at 90 degrees with arms). Job rotation is another method to reduce job stress. Take stretch breaks as needed. Exercise and stretch to help with blood flow and keep muscles loose.

17 TX for Sprains and Strains RICE Therapy

18 1. Rest Take a break from normal activities This is the easiest of the 4 first aid measures but is often the hardest to implement. For 48 hours

19 2. Ice Apply a cold pack as soon as possible after the injury. Cold therapy has two benefits: Reduces swelling Relieves pain Method: Apply cold therapy to the injured area for 20 minutes at a time. Remove the cold pack for at least 30 minutes to allow the skin to rewarm.

20 3. Compression Use compression when elevating a sprain or strain during early treatment. Wearing an elastic compression bandage for at least 2 days will reduce swelling.

21 4. Elevation Keep the injured part elevated above the level of the heart to reduce swelling Keep the affected area higher than your heart if possible. This is another trick to help reduce swelling and inflammation. Try placing a couple of pillows under the injured arm or leg.

22 Proper Lifting Procedures Plan the lift. Test load before lifting. Place feet shoulder - width apart close to object. Bend the knees. Get a secure grip. Lift with legs, keeping the back straight. Lift evenly and slowly - no jerky motions. Keep load as close to the body as possible.

23 Ankle Sprain Developed for Physical Therapy Students by Hwi-young Cho, Ph.D, P.T. Gachon University College of Health-Science Department of Physical therapy 2014 Second semester

$X-rays did not reveal a fracture, but the player left the game on crutches. http://images.google.com/imgres?imgurl=http://www.kvue.$

24 Mini Case A basketball player was getting in position for a rebound when he stepped on another player s foot and rolled his ankle. X-rays did not reveal a fracture, but the player left the game on crutches.

25 Approaching the Problem Differential? (break, sprain, etc.) Tissue changes? (swelling, warmth, ecchymosis) Pain can patient bear weight? ROM decreased? Neuro deficits? Treatment? Don t just look at the ankle think how it affects the rest of the patient s body also

26 Joint stability Main components 1. Shape of Bones 2. Ligaments 3. Strength of muscles

Anatomy 26 bones of the foot Plus 2 sesamoid bones under great toe

Calcaneous, talus, navicular, first 3 cuneforms, first 3

Lateral longitudinal arch Calcaneous, cuboid, 4 th and 5 th

27 Anatomy 26 bones of the foot Plus 2 sesamoid bones under great toe for weight bearing and balance 33 joints Medial longitudinal arch Calcaneous, talus, navicular, first 3 cuneforms, first 3 metatarsals Strengthened by calcaneonavicular (Spring) ligament Lateral longitudinal arch Calcaneous, cuboid, 4 th and 5 th metatarsals Weight bearing Transverse arches Weight bearing and springing off with foot

28 Anterior aspect of the right ankle skeleton and superior aspect of the foot skeleton muscle/anatomysurgical.htm

29 Posterior aspect of the right ankle skeleton and superior aspect of the foot skeleton muscle/anatomysurgical.htm

30 Soleus and Plantaris muscles and the contents of the popliteal fossa (gastrocnemius muscle removed)

Overview http://www.emedicinehealth.com/ankle_sprain/article_em.

31 Overview The distal end of the The distal end of the fibula forms the tibia forms the lateral malleolus medial malleolus

32 Anterior Ankle Tibiofibular Joint

33 Medial Ankle Joint

34 Posterior Ankle Tibiofibular Joint

35 Lateral Ankle Joint

36 Superior aspect of the right tarsus with ligaments

37 The foot is divided into 3 general regions:

38 Hindfoot The talus & the calcaneus (or heel bone). The two long bones of the lower leg, the tibia and fibula, are connected to the top of the talus to form the ankle. Connected to the talus at the subtalar joint, the calcaneus, the largest bone of the foot, is cushioned inferiorly by a layer of fat

39 Midfoot The five irregular bones the cuboid, navicular, and 3 cuneiform bones 3 cuneiform bones: form the arches of the foot which serves as a shock absorber Connected to the hind- and fore-foot by muscles and the plantar fascia. Tarsometatarsal jt.

40 Forefoot 5 toes and the corresponding five proximal long bones forming the metatarsus 5 metatarsals 5 proximal phalanges 4 middle phalanges 5 distal phalanges Metatarsophalangeal (MTP) jt. Proximal interphalangeal (PIP) jt. Distal interphalangeal (DIP) jt.

42 Joints in the Ankle

43 Tibiofibular joint Syndesmotic jt. ( 인대결합관절 ) Joined at both proximal & distal tibiofibular joints Ligaments and a strong, dense interosseus membrane between tibia & fibula shafts provide support Minimal movement possible Distal joint becomes sprained occasionally in heavy contact sport

44 Talocrural joint (ankle jt.) Hinge jt. Talus, distal tibia & distal fibula Dorsiflexion-plantarflexion 50 degrees of plantar flexion 15 to 20 degrees of dorsiflexion Greater range of dorsiflexion with knee flexed (reduces GCM tension) Fibula rotates 3 to 5 degrees externally with ankle dorsiflexion & 3 to 5 degrees internally during plantarflexion Syndesmosis jt. widen by 1 to 2 mm during full dorsiflexion

45 Subtalar & transverse tarsal joint Inversion & eversion Combined movement of 20 to 30 degrees of inversion 5 to 15 degrees of eversion

Metatarsophalangeal joint Phalanges join metatarsal Great toe metatarsophalangeal (MP) jt flexes 45 degrees & extends 70 degrees MP jt of the four

46 Metatarsophalangeal joint Phalanges join metatarsal Great toe metatarsophalangeal (MP) jt flexes 45 degrees & extends 70 degrees MP jt of the four lesser toes 40 degrees of flexion 40 degrees of extension Also abduct & adduct minimally

47 Interphalangeal (IP) joint Greater toe interphalangeal (IP) joint flexes from 0 degrees of full extension to 90 degrees of flexion PIP jt. in lesser toes flexes from 0 degrees of extension to 35 degrees of flexion DIP jt. flexes 60 degrees & extend 30 degrees Much variation from joint & from person to person

48 Anatomy-Lateral Ligaments

49 LATERAL LIGAMENTS

50 Lateral ligament = Lateral collateral ligament of the ankle Division 1 The anterior talofibular ligament - extends anteromedially from the anterior margin of the fibular malleolus to the neck of the talus. 2 The posterior talofibular ligament - extends almost horizontally from the lateral malleolar fossa to the lateral tubercle of the talus. 3 The calcaneofibular ligament - is a long cord which passes from a depression anterior to the apex of the fibular malleolus to a tubercle on the lateral calcaneal surface. It is crossed by the tendons of the peroneus longus and brevis.

51 Anatomy-Medial Ligaments

MEDIAL ANKLE http://ourhumananatomy.blogspot.

52 MEDIAL ANKLE

53 Deltoid ligament = Medial collateral ligament of the ankle Superficial fibers : - The most anterior (tibionavicular) fibers pass forward to be inserted into the tuberosity of the navicular bone, and immediately behind this they blend with the medial margin of the plantar calcaneonavicular ligament (spring ligament). - The middle (tibiocalcaneal) fibers descend almost perpendicularly to be inserted into the whole length of the sustentaculum tali of the calcaneum - The posterior fibers (posterior tibiotalar) pass backward and laterally to be attached to the medial side of the talus, and its medial tubercle. Deep fibers : - The deep fibers (anterior tibiotalar) are attached to the anterior part of medial surface of the talus. The deltoid ligament is crossed by the tendons of the tibialis posterior and Flexor digitorum longus.

54 PALPATION 1 Anterior Inferior Tibiofibular Ligament 2 Anterior Talofibular 3 Calcaneofibular Lig. 4 Base of 5 th Metatarsal

55 Anatomy of Foot/Ankle Talus is wider anteriorly Medial malleolus only comes down over 1/3 of the talus and is more anterior Lateral malleolus covers entire talus Inversion > eversion Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture

56 Biomechanics In dorsiflexion foot everts, toeing out Most stable position closed packed position In plantarflexion foot inverts, toeing in Ligaments less taut Joint more vulnerable to injury

57 Muscles associated with ankle motion - 1 Plantar-Flexion Gastrocnemius Soleus Plantaris Peroneus Longus & Brevis Tibialis Posterior Flexor Hallucis Longus Flexor Digitorum Longus Dorsi-Flexion Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus Peroneus Tertius

58 Muscles associated with ankle motion - 2 Inversion, Adduction & Supination Tibialis Posterior Tibialis Anterior Flexor Digitorum Longus Flexor Hallucis Longus Extensor Hallucis Longus Eversion, Abduction & Pronation Peroneus Longus Peroneus Brevis Peroneus Tertius Extensor Digitorum Longus

59 Cause of Ankle Sprain 85% are due to inversion Deltoid ligament is stronger than the lateral ligaments Anterior tibiotalar, tibiocalcaneal, tibionavicular, and posterior tibiotalar ligaments Lateral malleolus is longer than medial malleolus Axis of talo-crural joint In plantar flexion, ankle naturally inverts In dorsiflexion, ankle is very stable

60 Pathoanatomy and Mechanisms of Injury The most common mechanism of injury is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular and posterior talofibular ligaments. The anterior talofibular ligament is the most easily injured. The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.

61 Mechanism of injury high ankle sprain

62 Cause OUCOM CORE OMM curriculum session 7

63 Grading Grade I: anterior talofibular ligament (ATF) Grade II: ATF plus calcaneofibular ligament (CF) Grade III: ATF plus CF plus posterior talofibular ligament

64 Ligaments used in Grading Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture

65 Diagnosis History of trauma Swelling/discoloration Pain/tenderness Eversion restriction Anterior drawer test for ankle X-ray es/ankle.jpg

66 PAIN RESPONSE OF DAMAGED TISSUE 1. Damaged muscle and ligaments are painful when stretched. 2. Damaged muscle is painful to contract. 3. Both structures are painful if palpated at the site of tear.

67 DX: The anterior drawer test and the inversion stress test The inversion stress test can be used to assess the integrity of the calcaneofibular ligament. The anterior drawer test can be used to assess the integrity of the anterior talofibular ligament.

68 Ottawa Ankle Rules Radiographs should be obtained to rule out fracture when a patient presents (within 10 days of injury) with bone tenderness in the posterior half of the lower 6 cm (2.5 in) of the fibula or tibia or an inability to bear weight immediately after the injury. Bone tenderness over the navicular bone or base of the fifth metatarsal is an indication for radiographs. Anteroposterior, lateral and mortise radiographs should be obtained after the initial physical examination. The mortise projection is an anteroposterior view obtained with the leg internally rotated 15 to 20 degrees. 이러한항목중한가지라도해당되는것이있다면, 즉시병원에서 X-ray 를통해발목골절및이학적검사를통해진단을받아야함.

70 Functional Rehabilitation Prolonged immobilization of ankle sprains is a common treatment error. Functional stress stimulates the incorporation of stronger replacement collagen. The four components of rehabilitation are: 1. Range-of-motion rehabilitation 2. Progressive muscle-strengthening exercises 3. Proprioceptive training 4. Activity-specific training

71 Range of Motion Achilles tendon stretch, nonweight-bearing. Use a towel to pull foot toward face. Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day. Maintain extremity in a nongravity position with compression. Achilles tendon stretch, weight-bearing. Stand with heel on floor and bend at knees. Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day. Alphabet exercises, Move ankle in multiple planes of motion by drawing letters of alphabet (lower case and upper case). Repeat four to five times a day. Exercises can be performed in conjunction with cold therapy.

73 Muscle Strengthening Isometric exercises, Resistance can be provided by immovable object (wall or floor) or contralateral foot. For each exercise, hold 5 seconds; do 10 repetitions; repeat three times a day. Strengthening exercises should only be done in positions that do not cause pain. Plantar flexion, Push foot downward (away from head). Dorsiflexion, Pull foot upward (toward head). Inversion, Push foot inward (toward midline of body). Eversion, Push foot outward (away from midline of body). For each exercise, hold 1 second for concentric component and perform eccentric component over 4 seconds; do three sets of 10 repetitions; repeat two times a day.

74 Muscle-Strengthening Exercises FIGURE 9. Use of elastic tubing in strengthening exercises for eversion. FIGURE 8. Achilles tendon stretching using a towel.

Toe curls can be done throughout the day, at work or at home. Toe raises, heel walks and toe walks, Lift body by rising up on toes.

75 Muscle Strengthening Toe curls Marble pickups Toe curls and marble pickups, Place foot on a towel; then curl toes, moving the towel toward body. Use toes to pick up marbles or other small object. Two sets of 10 repetitions; repeat two times a day. Toe curls can be done throughout the day, at work or at home. Toe raises, heel walks and toe walks, Lift body by rising up on toes. Walk forward and backward on toes and heels. Three sets of 10 repetitions; repeat two times a day; progress walking as tolerated. Strengthening can occur from using the body as resistance in weight- bearing position.

76 Muscle-Strengthening Exercises FIGURE 11. Single-leg wobble board exercise to increase proprioception. FIGURE 10. Single-leg toe raises done on a step.

77 Range of Motion Range of motion must be regained before functional rehabilitation is initiated. Regardless of weight-bearing capacity, Achilles tendon stretching should be instituted within 48 to 72 hours after the ankle injury because of the tendency of tissues to contract following trauma. Once range of motion is attained, and swelling and pain are controlled, the patient is ready to progress to the strengthening phase of rehabilitation.

78 Rehabilitation/Strengthening

79 Training for Return to Activity When walking a specified distance is no longer limited by pain, the patient may progress to a regimen of 50 percent walking and 50 percent jogging. When this can be done without pain, jogging eventually progresses to forward, backward and pattern running. Circles and figure-eights are commonly employed for pattern running. Although these routines are time-consuming, they represent the final phase and are essential for the recovery of ankle stability.

82 Ankle Taping 실제운동경기도중 Taping 시행하는예 Ankle Knee

83 Ankle Taping Non-Elastic Tape 하는방법 h?v=u1tu72odu6i h?v=0lyatixamge h?v=bzrydh6ruxe h?v=zb4l7wlpmda Elastic Tape 하는방법 h?v=elsu25gow0i h?v=kje9nobzgr4 h?v=xnpy0_s5rnm h?v=kp1qhc4ancu h?v=ioc7ub7ew9c

84 Ankle Taping

Main Menu. Ankle and Foot Joints click here. The Power is in Your Hands

Main Menu. Ankle and Foot Joints click here. The Power is in Your Hands 1 The Ankle and Foot Joints click here Main Menu Copyright HandsOn Therapy Schools 2009 K.8 http://www.handsonlineeducation.com/classes/k8/k8entry.htm[3/27/18, 1:40:03 PM] Ankle and Foot Joint 26 bones