Standar Operasional Prosedur Permasalahan Sendi Pergelangan Kaki

SOP-Ankle Joint ID#ARA 01 Rev 1# 13 Mei 2015 30 Halaman

Standar Operasional Prosedur Permasalahan Sendi Pergelangan Kaki SOP - Ankle & Foot Problems Diperuntukkan pelayanan ARA Physiotherapy UPH-Karawaci & Bodysoul-Kemang

Rev 1# 13 Mei 2015 Disusun Oleh

Abdurrasyid, SSt. FT, M.Fis

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1. Anatomi 1.1 Tulang 1.1.1 Tibia 1.1.2 Fibula 1.1.3 Talus 1.1.4 Calcaneus 1.1.5 Navicular

1.1.6 1.1.7 1.1.8 1.1.9

Cuboid Cuneiform 1,2,3,& 4 Metatarsal 1,2,3,4,&5 Phalang1,2,3,4,&5

Gambar 1.1 Kaki kanan tampak atas

Gambar 1.2 Kaki kanan tampak bawah

Gambar 1.3 kaki kanan tampak belakang (posterior)

1.2 Sendi 1.2.1 Tibiafibular joint inferior 1.2.2 Tibiotalar joint 1.2.3 Calcaneofibular joint 1.2.4 Talocalcaneal joint 1.2.5 Talofibular joint SOP-Ankle Joint, ID#ARA 01, Rev 1#| 2

1.3 Ligamen 1.3.1 tibiofibular ligament 1.3.2 tibiotalar ligament 1.3.3 talofibular ligament 1.3.4 calcaneofibular ligament

1.3.5 1.3.6 1.3.7 1.3.8

Interosseous membrane

posterior tibiofibular ligament posterior talofibular ligament posterior talocalcaneal ligament deltoid ligament Interosseous membrane

Posterior tibiofibular ligament

talofibular ligament Posterior talofibular ligament talofibular ligament

tibiotalar ligament

deltoid ligament calcaneofibular ligament

Gambar 1.4 Ligamen kaki kanan sisi belakang (posterior)

Gambar 1.6 Ligamen kaki kanan sisi lateral

Gambar 1.5 Ligamen kaki kanan sisi depan

Gambar 1.7 Ligamen kaki kanan sisi medial

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Gambar 1.8 ligamen kaki kanan sisi medial

Gambar 1.9 ligamen kaki kanan sisi plantar

1.4 Otot

Gambar 1.10 Otot Ekstremitas bawah kanan sisi anterior

Gambar 1.11 Otot ekstensor pergelangan kaki kanan sisi anterior

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Gambar 1.12 Otot ekstensor halluces longus & tibilais anterior

Gambar 1.13 Otot ekstremitas bawah sisi lateral

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Gambar 1.14 Otot ekstremitas bawah sisi posterior

Gambar 1.16 Otot ekstremitas bawah sisi posterior dengan plantar fleksi (b)

Gambar 1.15 Otot ekstremitas bawah sisi posterior dengan plantar fleksi (a)

Gambar 1.17 Otot ekstremitas bawah sisi posterior dengan plantar fleksi (c)

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Gambar 1.18 Tendon ekstremitas bawah sisi posterior & anterior

Gambar 1.19 Otot Plantaris kaki kanan

Gambar 1.20 Otot Plantaris deep muscle kaki kanan

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Gambar 1.21 Tendon Peroneal (sisi lateral)

Gambar 1.22 Tendon sisi medial (a)

Gambar 1.23 Tendon sisi medial (b)

1.5 Biomekanika 1.5.1 Plantar fleksi 1.5.2 Dorsal fleksi 1.5.3 Inversi 1.5.4 Eversi 1.5.5 Convex to concave law (Talocrural dorsal or posterior glide increases dorsiflexion & Talocrural ventral or anterior glide increases plantarflexion)

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Gambar 1.24 Gerakan normal dorsiflexi dan plantar flexi

Gambar 1.25 Gerakan normal dorsiflexi saat berjalan

Gambar 1.25 Gerakan dorsiflexi saat berjalan

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2. Pemeriksaan 2.1 Ottawa Rule Test Pemeriksaan dengan memberikan tekanan pada area fibula, posterior tibia, cuboid & navicular. Ditujukan untuk mengetaahui adanya faktur atau patah pada tulang yang di sekita sendi ankle.

Gambar 2.1 Area Ottawa Rule test

2.2 Pemeriksaan Spesifik / Tes Khusus Pemeriksaan khusus untuk mengetahui kesobekan pada sendi ankle.

Gambar 2.2 (A) Anterior Drawer Test (ADT) khusus ligament anterior fibular ligament (ATFL) dilakukan pada posisi lutut fleksi. Sendi ankle pada posisi 10o-15o plantar fleksi dan Fisioterapis menarik tumit ke anterior dan menahan tulang tibia. (B) Talar tilt test untuk ATFL & calcaneofibular ligament (CFL) dilakukan posisi sendi netral. Tumit posisi stabil saat mendorong sendi ke arah inversi talus dan calcaneus.

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Gambar 2.3 Pemeriksaan khusus cedera pada sindesmosis. Pemeriksaan akan ditemui rasa nyeri pada area sindesmosis. (A) Kleiger test/External Rotation test dilakukan dengan menahan tibia dan lakukan external rotasi pada ankle. (B) Squeeze test, dengan memberikan tekanan pada tibia dan fibula di atas pertengahan calf. (C) Crossed Leg test, menyilangkan kaki pada kaki lainnya dan memberikan dorongan ke bawah pada lutut. 2.3 Antropometri Pengukuran khusus pada sendi ankle adalah dengan melakukan antropometri Figure 8, ditujukan untuk mengetahui seberapa besar bengkak pada sendi ankle.

A

B

Gambar 2.4 Pengukuran antropometri bengkak sendi ankle. (A) sisi medial, dimana pangkal meteran diletakkan pada sisi maleous lateral kemudian dikelilingkan pada navicular, plantar dan cuboid. (B) sisi lateral, dari cuboid meteran mengelilingi maleous medial dan berakhir pada maleous lateral.

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2.4 Range Of Motion

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2.5 Accessory Movement test dan Manual terapi

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3. Diagnosa & Protokol

Gambar 3.1 Algoritma Pemeriksaan dan diagnosis SOP-Ankle Joint, ID#ARA 01, Rev 1#| 18

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3.1 Sprain Ankle Sprain ankle merupakan kesobekan ligamen sendi ankle pada sisi lateral dan medial. Mekanisme cedera persendian ankle overstretch kea rah inversi (lateral) & eversi (medial).

Gambar 3.1 Lateral sprain ankle Tabel 3.1 Derajat sprain dan pemeriksaannya

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Lateral Sprain Ankle Protocol ATFL & CFL tear Grade 1 pemulihan 2- 4 minggu, Grade 2 (partial)-3 (total) pemulihan 4-8 minggu Frekuensi terapi 3-4 kali/minggu Phase I: Fase Akut (0-3 days) Goal  Pain & swelling control  Prevent tibialis anterior & calf atrofi  Protect Ligament  Manual Muscle Test 3 point  Normal dorsal flexi when walking

Phase 2: Poliferasi 1 (3day- 1week) Goals:  Normal ROM  Reduce Pain  Normal gait  Balance & postural stability  Prevent peroneus syndrome/compartmend syndrome with ankle brace 1 week

Physiotherapy Programs:  RICE  US & FUP/TENS 10 menit  Distraction grade III (pain free) 60 x, 10 sec rest, 2 sets  Dorsal glide grade III (pain free) 60 x, 10 sec rest, 2 sets  Tibiafibular dorsal glide III (pain free) (stop when sindesmosis finding) 60 x, 10 sec rest, 2 sets  Dorsal & Plantar Flexi isometric 6 sec, 10x, 2 sets  Towel exc 3 sets  Tapping/Brace (1 week)

Physiotherapy Program:  US 5 menit  PROM (pain free) 30 x, 3 sets  Calf & soleus stretch NWB (pain free) 30 sec, 3 sets (edu 3x/hari)  Calf & soleus stretch WB c/ decline (pain free) 30 sec, 3 sets (edu 3x/hari)  Alphabet exc (A,B, &C) 5 x, 2 sets (edu 3x/hari)  Distraction grade IIIII (pain free) 60 x, 10 sec rest, 2 sets  Dorsal glide grade IIIII (pain free) 60 x, 10 sec rest, 2 sets  Tibiafibular dorsal glide IIIII (pain free) 60 x, 10 sec rest, 2 sets  Ankle exc isometric 6 sec, 5 x, 2 set  Ankle exc isotonic (rubber) 10x, 2 sets  Bilateral calf & soles raise 10x,2 set  Walking on heel & toes 2 lap  Towel exc 3 sets  Ankle rhytm 15 sec, 2-3 sets  Circular wobble board (Clock & counter clock wise) bilateral & unilateral stance 10 x, 3 sets  Walking on different surface (flat, soft, & unstable) 10 x, 4 set  Level 1 run program

Outcome Clinical finding:  Increase ROM Dorsal flexi  Decrease pain dorsal flexi  Increase step speed, step length, & single support time (bertumpu)

Outcome Clinical finding:  Romberg Test  SEBT

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Phase 2: Poliferasi ( 2-3 week) Goals:  Normal ROM  No Pain  Normal gait  MMT 4 point  Lower Leg Stability Physiotherapy Program:  Calf & soleus stretch NWB (pain free) 30 sec, 3 sets (edu 3x/hari)  Calf & soleus stretch WB c/ decline (pain free) 30 sec, 3 sets (edu 3x/hari)  Distraction grade IIIII (pain free) 60 x, 10 sec rest, 2 sets (stop when no pain & functional increase)  Dorsal glide grade IIIII (pain free) 60 x, 10 sec rest, 2 sets  Tibiafibular dorsal glide IIIII(pain free) 60 x, 10 sec rest, 2 sets  Ankle exc isotonic (rubber) 10x, 3sets  Bilateral calf & soles raise 10x,2 set (c/progress weight)  Walking on heel & toes 2 lap  Towel exc 3 sets  Circular wobble board (Clock .counter clock wise, front & back board no touch the floor) bilateral & unilateral stance 10 x, 3 sets  Wobble board unilateral touch 3 cone15-20x, 3 set  Squat with heel raise on bosu with passing 10x, 3 set  Unilateral stance on bosu 30 sec, 3 set  Hip adduction with stance on unstable surface (spons) 10x 3 set  1 leg dead lift 10x, 2 set  Basic core 30 sec, 2 set  Four square hopping  Side to side 10x, 2 set  Front to back 10x, 2 set  Straight line hop 10x 2 set  Level 2 or 3 run programs

Phase 3: maturation/functional (3-4weeks) Goals:  No pain  Return to sport Physiotherapy program:  Calf & soleus raise w/ weigth 10x, 3 sets  Ankle press 10x, 2-3 sets  Forward & Side walk c/rubber on ankle 10x, 2-3 set  Wobble board unilateral touch 3 cone15-20x, 3 set  Squat with heel raise on bosu with passing 10x, 3 set  Unilateral stance on bosu 30 sec, 3 set  Hip adduction with stance on unstable surface (spons) 10x 3 set  Front & Side Lunge 10x 2 set  Front & Drop Jump 10 x 2 set  Four square hopping  Four square 5x, 2 set  Triangles 5x, 2 set  Crisscross 5x, 2 set  Line zigzag 10x 2 sets Outcome Clinical Finding:  Hop Test

Outcome Clinical finding:  SEBT

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3.2 Sindesmosis Sindesmosis (high ankle sprain) adalah cedera sendi ankle sisi lateral yang megalami kesobekan ligament interesous membrane, ATFL & PTFL. Cedera ini sulit diprediksi pemulihannya karena letak impairmennya yang diantara tulang fibula dan tibia. Mekanisme cedera ini selalu tulang tibia rotasi medial dan ankle rotasi ke lateral, sehingga menyebabkan gerakan fibula ke lateral yang berdampak pada sobeknya ligament interoseus bahkan bias mematahkan tulah fibula. Pemeriksaan khusus yang digunakan untuk kasus ini adalah kleiger test, squeeze test & crossed leg test.

Gambar 3.2 Mekanisme cedera sindesmosis (high ankle sprain)

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Sindesmosis Protokol Target pemulihan 55 hari/ 6 minggu Frekuensi 3-4x / minggu Phase 1 Acute 3-1 minggu Goal:  Control pain & swelling  Protect joint Note:  

Non Weight Bearing 3 day Avoid painfull dorsiflexion & eversion

Physiotherapy Programs:  RICE  US & FUP/TENS 10 menit  Distraction grade III (pain free) 60 x, 10 sec rest, 2 sets  Dorsal glide grade III (pain free) 60 x, 10 sec rest, 2 sets  Lateral glide 60 x, 10 sec rest, 2 sets  Towel exc 3 sets  Tapping/Brace (1 week)  Hip exc 10-15x, 3 sets Clinical outcome  No painfull dorsal flexi & eversi

Phase 2 sub acute (1-2 minggu) Goals:  Maintain ROM & improve flexibility  Progressing weight bearing  Strength & balance  Prevent atrofi gastroc & soleus muscle Note: 

Continue crutches for weight bearing

Physiotherapy Prorams:  Stretch gastroc, soleus & hamstring 15-20 sec, 2 sets  US & FUP/TENS 10 menit    Lateral glide ) 60 x, 10 sec rest, 2 sets  Proximal & distal tibia fibular glide 60 x, 10 sec rest, 2 sets  Seated heel raise c/ weigth 10-15x, 3 sets  Ankle rhytm/seated toe raise 15-20 sec, 3 sets  Isotonic ankle exc c/rubber 10-15x, 3 sets  Squat balance board/wobble 10-15x, 15 sec hold, 3 sets  1 leg bridge 10-15x, 15 sec hold, 3 sets  Wobble board exc (anteroposterior, clockwise & counter clockwise) Clinical outcome  Full ROM  No pain

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Phase 3 srengthening Goal:  Maximal strength  Neuromuscular control  Single limb exercise

Phase 4 return to sport Goal:  Dynamic & proprioception exc  No pain when jog & run  No pain when cutting, pivoting, & specific drill

Note: 

Note: 

Full weight bearing still use ankle brace

Physiotherapy prorams:  Advance ankle exc isotonic c/rubber 20x, 3 sets  Standing heel raise (calf & soleus muscle, double & single limb) c/weight 10-15x, 3 sets  Forward & side lunges 10-15x, 3 sets  Ankle press 10-15x, 3 sets  Side walk straight leg c/rubber 10-15x, 3 sets  Single leg wobble touch cone 15-20x, 3 sets  Single leg wobble passing/kick 15-20, 3 sets  Single leg deadlift 10-15x, 2-3 set  Hip adduction with stance on unstable surface (spons) 10x 3 set  Treadmill 10-15 minute Clinical outcome:  SEBT

Sum total of return to sport criteria

Physiotherapy programs:  Standing heel raise (calf & soleus muscle, double & single limb) c/weight 10-15x, 3 sets  Forward & side lunges 10-15x, 3 sets  Ankle press 10-15x, 3 sets  Side walk straight leg c/rubber 10-15x, 3 sets  Single leg wobble passing/kick 15-20, 3 sets  Single leg deadlift 10-15x, 2-3 set  Four square hopping  Side to side 10x, 2 set  Front to back 10x, 2 set  Four square 5x, 2 sets  Triangle 5x, 2 sets  Crisscross 5x 2 sets  Straight line hop 10x 2 set Clinical outcome:  Hop test

3.3 Chronic Ankle Instability Kondisi cedera sprain ankle yang sudah lebih dari 2-3 bulan tidak pulih sempurna. Ditandai dengan keterbatasan gerak sendi, instabilitas ankle (ADT & Talar Tilt), nyeri saat berjalan & lari. Pemeriksaan yang dapat dilakukan adalah ROM, Pemeriksaan spesifik, & Ankle Instability Instrument (AII) (min 5 jawaban “Ya”).

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Chronic Ankle Instability Protokol Target pemulihan 4-6 minggu Frekuensi 3-4x / minggu Phase 1: ROM & Neuromuscular control 1 minggu Goals:  Full ROM Dorsi flexi & plantar flexi  Decrease pain  Balance

Phase 2: Advance Strengthening 2-3 minggu Goals:  Increase peroneal strength  Increase flexibility  Maintain ROM

Physiotherapy programs:  Distraction grade IIIIV (pain free) 60 x, 10 sec rest, 2 sets  Dorsal glide grade IIIIV (pain free) 60 x, 10 sec rest, 2 sets  Tibiafibular dorsal glide III (pain free) (stop when sindesmosis finding) 60 x, 10 sec rest, 2 sets  Isometric Eversi (eccentric) & Inversi (Concentric) 6 sec, 10 x, 3 sets  Ankle Rhytm 15-20 sec, 2-3 sets  Towel exercise 4 sets  Double leg heel raise isometric 6 sec, 10 x, 3 sets  Double leg bridge 12x, 2 sets  Miniband series 10x 2 sets  Single leg stance on wobble lv.1-2 30 sec, 3x, 2 sets  Single leg stance on balance board perturbation 30 sec, 3x, 2 sets

Physiotherapy Programs:  Distraction grade IIIIV (pain free) 60 x, 10 sec rest, 2 sets  Dorsal glide grade IIIIV (pain free) 60 x, 10 sec rest, 2 sets  Tibiafibular dorsal glide III (pain free) (stop when sindesmosis finding) 60 x, 10 sec rest, 2 sets  4 way Ankle Exc c/ rubber band 15x, 3 sets  Double/single leg heel raise eccentric (calf & soleus) 10x, 2 sets  Double/single leg bridge (box) 12x, 2 sets  Lunges 10x, 2 sets (see ankle dorsi flexion)  Miniband walk 4 cone 10x, 2 sets  Single leg stance on bosu 30 sec, 3x, 2 sets  Single leg stance on wobble touch 3 cone 15x, 2 sets  Double leg Box jump 10x, 2 sets  Ladder forward run 10x

Clinical Outcome:  No painfull dorsal flexi & inversi  Stork test

Clinical outcome :  Star excursion balance test (SEBT)

Phase 3: Return to sport 4-6 minggu Goals:  No pain running, jump, hopping  Body conditioning Physiotherapy programs:  4 way ankle exc c/rubber

    



Ankle press 10-15x, 3 sets Side walk straight leg c/rubber 10-15x, 3 sets Single leg wobble passing/kick 15-20, 3 sets Single leg deadlift 10-15x, 2-3 set Four square hopping  Side to side 10x, 2 set  Front to back 10x, 2 set  Four square 5x, 2 sets  Triangle 5x, 2 sets  Crisscross 5x 2 sets Straight line hop 10x 2 set

Clinical outcome:  Hop test

Daftar Pustaka SOP-Ankle Joint, ID#ARA 01, Rev 1#| 28

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