INTRODUCTION
1.1 Background
Neuro-Musculoskeletal system are the seventh block in the 3rd semester
competency-based curriculum in medical faculty of Muhammadiyah
Palembang University . Learning in this block is very important to learn in
medical faculty of Muhammadiyah Palembang University.
On this occasion, a case study tutorial of scenario A which presents
cases that related to the Neuro-Musculoskeletal .
Iwan, 20 years old, camoe to hospital with chief complaint of pain in his
right ankle since 2 hours ago. Complaints caused by right foot twisted in and
fell when playing futsal. Complaints accompanied by swelling and more pain
when moved. Iwan complaints he can’t walk because of pain on his ankle.
Physical examination:
General situation : compos mentis ; respiratory rate 22x/min ; pulse rate
102x/min ; blood pressure 130/80 mm Hg; temperature 37.0℃
Spesific examination:
Height : 160 cm , Weight: 57 kg
Head : conjungtiva anemis (-), icteric sclera (-)
Thorax : Cord an pulmo are normal
Abdomen : flat, hepar and lien not palpable
Upper extremity : normal
Lower Extremity:
- Left : normal
- Right : region ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
- Open wound (-), active bleeding (-)
1
Feel : Tenderness (+), crepitation (-) palpable tension on the lateral ankle
skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)
Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible fracture,
visible swelling of soft tissue in the lateral
1.2 Purpose
the purpose of this case study tutorial report are:
1. As a group task report which is a competency-based curriculum learning
system in the medical faculty of Muhammadiyah Palembang.
2. Can solve cases given in a scenario by group analysis and learning
methods
3. The purpose of the tutorial learning method is reached
2
CHAPTER II
DISCUSSION
2.2 Scenario
Iwan, 20 years old, camoe to hospital with chief complaint of pain in his
right ankle since 2 hours ago. Complaints caused by right foot twisted in and
fell when playing futsal. Complaints accompanied by swelling and more pain
when moved. Iwan complaints he can’t walk because of pain on his ankle.
Physical examination:
General situation : compos mentis ; respiratory rate 22x/min ; pulse rate
102x/min ; blood pressure 130/80 mm Hg; temperature 37.0℃
Spesific examination:
Height : 160 cm , Weight: 57 kg
3
Head : conjungtiva anemis (-), icteric sclera (-)
Thorax : Cord an pulmo are normal
Abdomen : flat, hepar and lien not palpable
Upper extremity : normal
Lower Extremity:
- Left : normal
- Right : region ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
- Open wound (-), active bleeding (-)
Feel : Tenderness (+), crepitation (-) palpable tension on the lateral ankle
skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)
Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible fracture,
visible swelling of soft tissue in the lateral
4
7.Swelling : An abnormal enlargement of a part of the body
8.Tenderness : Very sensitive to touch or press
9.Crepitation : Is a sound when someone make a fraction from two
point of broken bone
10. ROM : Range of motion
(Dorland, 2009)
5
Feel : Tenderness (+), crepitation (-) palpable tension on the lateral
ankle skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)
5. Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible fracture,
visible swelling of soft tissue in the lateral
o Fibula
The fibula is the lower leg bone that is located more laterally
than the tibia. In the proximal part, the fibula articulates with
the tibia. While in the distal, the fibula forms lateral malleolus
and facies for articulation with the tarsal bones (Snell, 2012).
6
o Tarsal
The tarsal is the 7 bones that form the articulation with the
fibula and the tibia in the proximal and with the distal
metatarsal. There are 7 tarsal bones, namely calcaneus, talus,
cuboid, navicular, and cuneiform (1, 2, 3). Calcaneus acts as a
standing bone (Snell, 2012).
Foot Joints:
o Distal Tibio Fibular Joint
The distal tibio fibular joint is a syndesmosis joint with a small
motion freedom. Reinforced anterior and posterior tibiofibular
ligaments and membrane interroseum. Arthokinematic and
osteokinematic are shear motions in very small sagittal plots
7
and angular motion in the frontal plane as opening and closing
forks (Kisner and Colby, 2012).
8
o Midtarsal joint (Mid foot) / Inter Tarsal Joint
Midtarsal joint (Mid foot) / Inter Tarsal Joint consists of (Barr,
2005):
a. Talo calcaneo navicular joint, has a complex joint basin,
including joint joint type of joint. Reinforced by a
plantar calcaneonavicular ligament.
b. Calcaneo cuboid joint, is a joint plan, along with
talonavicularis to form a transverse tarsal (mid tarsal
joint). Reinforced ligament spring, dorsal talo navicular
ligaments, bifurcatum ligaments, Calcaneo cuboid
ligaments, Plantar calcaneocuboid ligaments.
c. Cuneo navicular joint, navikular jointed with
cuneiforme I, II, III, shaped concave. Cuneiforms of
plantar sections are smaller, along with cuboids forming
a transverse arc. Main motion; plantar - dorsal flexion.
When plantar flexion occurs cuneiform sideways to
plantar.
d. Cuboideocuneonavicular joint, the main joint is
cuneiform II-cuboid in the form of a joint plan. The
most important motion is inversion and eversion. When
cuboid inversion translates to medial plantar to
cuneiform III.
e. Intercuneiforms joint, with navicular forming transverse
arc when inversions occur arc additions.
Arthrokinematiknya in the form of translational motion
between os. tarsal Joint.
f. Cuneiforms I-II-III jointed with metatarsal I-II-III,
cuboid jointed with IV-V metatarsal, Metatarsal II to
proximal so jointed also with Cuneiforms I-III, so that
the joint is most stable and its motion is very small.
Arthrokinematiknya traction motion Metatrsal to distal
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o Metatarso phalangeal dan Inter phalangeal Joint (Fore Foot)
a. Metatarso phalangeal Joint.
A convex-shaped metatarsal distal forms an ovoid-hinge
joint with motion: flexion-extension and abduction-
adduction. Maximally lose pack position (MLPP) =
Extension 110, close pack position (CPP) = full extension.
Motion motion in the direction of angular motion, traction
always direction distal direction axis longitudinal phalang.
Front legs function for mobility, especially for the process
of putting the feet while walking. At the time of running the
possibility of motion of flexion and extension, as well as on
the joints of the toes (interphalangeal) another.
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Gambar 2.2 Persendian kaki kaki
Atlas Anatomi Manusia (Sobotta, 2010)
Arcus of Feet
There are two arcus, Longitudinal Arc and Transverse Arc
(Bonnel et al., 2010):
o Longitudinal Arc: is the continuum of the calcaneus and the
metatarsal caput.
o Transverse Arc: proxikmal section restricted os. Cuboideum,
lateral cuneiforme, mid cuneiforme and medial cuneiforme are
more concave and distal to the more flat metatarsalia.
Fascia
Ankle and foot is a fascia superficialis dorsum pedis located in
the distal portion of the retinaculum musculorum extensoren
inferius. This fascia forms a fascia cruris and extends distally into
the extensorisal aponeurosis of the fingers. In the proximal
portion attached to the retinaculum musculorum extensor superior
and forming the crossing with the retinaculum musculorum
11
extensorum inferius can only be seen in slow dissection and the
lateral part of the proximal crus is often absent. Next to the
tendons of the musculus extensor digitorum longus which is a
dense, rigid, and rigidly attached layer of fascia dorsum pedal
fascia tissue (Kisner and Colby, 2012).
12
Gambar 2.3 Sruktur ligamen sebagai stabilisasi pasif.
Sumber: Atlas anatomi (Sobotta, 2010)
13
M. peroneus longus and M. peroneus brevis, is the most
powerful pronator to prevent occurrence of lateral ankle sprain,
this muscle is innervated by N. peroneus (fibularis)
superficialis L5-S1. Its function is for pronation (abduction and
eversion) and pedicular flexion plantar, not only on the
ligaments, other tissues such as the tendon can be injured, the
tendons are often injured in the ankle sprain is the peroneus
longus and brevis tendons that function against the movement
of eversion in the foot (Farquhar, et al 2013).
14
2. The expulsion of chemicals or mediators of pain such as
prostaglandins, bradykinin, which can stimulate peripheral
nerves around inflammation so that become pain.
(Hertel, 2002).
Synthesis :
15
c. How is the pathophysiology of pain ?
Answer :
Physcal trauma
localized edema
pain
16
capillary permeability, plasma protein scome out of the capillaries,
accumulation of plasma proteins occur, there’s a localized edema,
then local stretching in edema tissue, and he fell pain in his ankle
(Sherwood, 2014).
17
Refered is amcommon phenomenon is a visceral pain
because many organs don’t have pain receptors.
Characteristics of pain can be felt in parts of the body
separate from the source of pain and can be felt with
various characteristics.
Radiation
Radiation is widespread pain sense from the initial
place of injury to other parts of body.
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Chronic Pain
Chronic pain is a continuous pain for 6 months or more.
This pain lasts beyond the estimated healing time and
often can not be attributed to specific causes or injuries.
Chronic pain is different from acute pain and shows
new problems. In chronic pain syndrome can be caused
by disease factors or pathologic processes are persistent.
But chronic pain is also the disease itself. The client
becomes anxious and frustrating. Chronic pain affects
all aspects of the client's life
Patients with chronic pain have no or less demonstrated
autonomic hyperactivity but exhibit symptoms of
irritability, loss of spirit, and impaired ability to
concentrate. This chronic pain often affects all aspects
of the life of the sufferer, causing distress, emotional
turmoil, and disrupting physical and social function .
Chronic pain generally arises irregularly, intermittently,
or even persistent. This pain causes mental and physical
fatigue.
Chronic pain is divided into two chronic non-malignant
and malignant pain. Non-malignant chronic pain is a
pain caused by a non-progressive or healing tissue
injury , may occur without obvious causes such as low
back pain, and pain based on chronic conditions, eg
osteoarthritis While malignant chronic pain called
cancer pain has an identifiable cause of pain that occurs
due to changes in the nerves, this change may occur due
to suppression of nerves due to metastasis of cancer
cells and the influence of chemicals produced by cancer
itself.
19
Most cancer pain sufferers do not come from pain
experience. And some have psychological pain that
comes from the malignancy process. Anyway, a lot
experience pain in the late stages of the disease, and is
generally associated with metastasis. About 60 to 80%
of hospitalized cancer patients suffer from severe pain.
20
d. Classification of Organ Based Pain (Tamsuri,2007):
Organic Pain
Organic pain is pain caused by damage (actual or
potential) organ.
Neurogenic Pain
Neurogenic pain is pain due to neuronal disorders, eg in
neuralgia and may occur acutely or chronically.
Psychogenic Pain
Psychogenic pain is pain due to various psychological
factors, usually occurs when psychogenic effects such
as anxiety and acute arise in the patient.
e. Classification Pain Based on Nature (Gillenwater et al, 1996):
Incidental is a pain that arises at any time and
disappears. This incident occurred in patients suffering
from bone cancer.
A steady pain is a pain that arises and persists and is felt
for a long time. In acute kidney distention the capsule
and ischemic is one of the most common types of pain.
The constant level of pain in obstruction and distension.
Proximal pain is a pain that is felt high intensity and
strong. The pain usually lasts ± 10-15 minutes, then
disappears, then reappears. This pain occurs in patients
with Carpal Tunnel Syndrome.
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Pain was moderately ill with intensity medium. While
the patient is being objectively hissing, grinning, can
indicate where the illness can be describe it, can follow
the command.
Pain Weight
Severe pain is a pain that arises with that intensity
weight. On the patient's painful objective pain
sometimes unable to follow orders but still response to
action, may indicate the location of pain, can not
describe it, can not be overcome with over long breath
position.
f. What is the meaning of chief complaint of pain in his right ankle since
2 hours ago ?
Answer :
The meaning he complaint of pain in his right ankle since 2 hour
ago is Iwan was twisted when playing futsal. Twisted motion can
cause injury to the ligaments. A ligament is soft tissue which
connects bone to bone Palpable pain should raise suspicion of an
asteocondraltalar dome lesion. The lesion result from direct trauma
between the talus and fibula (anteriolatreral lesion) or between the
posteromedial talus and tibia (postmedial lesion). Trauma causes of
occurrence of tissuedamage. Tissue demage lead to an
inflammatory response which is an adaptive response of the body
to eliminate damage tissues.Inflammation can be acute or chronic,
acute inflammation is rapid in onset and of short duration lasting
from a few minutes to as long a few days. While the cronic
inflammation may be more insidiousis of longer duration (days to
years). So pain happen because inflammation mediator cause by
injury.
(Robbins, 2015)
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g. What is the relation between age and gender in this case ?
Answer :
There’s nothing relation between age and gander because
complaints caused by trauma and can occur in male or female at
any age. There’s the relation between activity and complaint is in
every physical activity, aspecially sport activity can cause injuring
one of part of body which usually injury is on joint of ankle. Injury
at the ankle are usually caused by movement to the outher (lateral)
or the innes (medial) side of the sudden ligament. When the
ligamentum muscle fibers for eversoon are not strong enough to
resist, the ligamentum fibers from lateral will depressed and
become inverse. It will causes sprain on the outher side. Sprained
ankles often result from a fall, a sudden twist cor a blow that forces
the ankle joint one of its normal position.
Ankle sprains commonly occur while participating in sports
wearing inappropriate shoes, or walking or running or anunever
surface.
Sometimes ankle sprain occur because of weak ankles, a condition
that some people are born with.
Previous ankles or foot injuries can also weaker the ankle and lead
to sprains.
The sign and symtoms of ankle sprain may include
1) Paint or soreness
2) Swelling
3) Bruising
4) Difficulty walking
5) Stiffness in the joint
23
2. Complaints caused by right foot twisted in and fell when playing
futsal.
a. What is the meaning complaints caused by right foot twisted in and
fell when playing futsal ?
Answer :
that means was the ankle got ligament injury caused by blunt
trauma.
24
b. Sharp trauma, due to injury:
Iris ulcers → inside the wound is smaller than the
length of the cut wound.
Stab wound → inside the wound is larger or deeper
than the length of the wound.
Cut wound → in the wound is more or less the same
as the length of the wound.
c. Firearms
The skin around the wound is burning or black from
smoke.
Hair around scorched wounds.
Clothes that cover burnt wounds.
Black and tattoo tattoos more outside the wound.
2. Physical trauma
a. Hot temperature (burns)
Eritem with the characteristics of intact epidermis,
restlessness, heal without leaving sikatriks.
Vesicles, bulls and bleps with high albumin or NaCl.
Coagulativa necrosis characterized by dark brown
black color and healed by leaving sikatriks (litteken).
Carbonization (already becoming charcoal).
b. Cold trauma (hypothermia and frostbite
Hypothermia)
Pale skin due to red vasoconstriction due to
vasodilation due to paralysis of the vasomotor center.
25
Skin turns into a blackish red, swollen (skin blister),
itching and pain. Then arise irreversible superficial
gangrene.
3. Chemical trauma
a. Strong acids → coagulate protein → dry corrosive
wounds,paper like permanent paper.
b. Strong base → forming sapling reaction → wet, slippery
cuts → damage to the inside.
(Bengmark S. 1998 )
Synthesis :
1. Vulnus Laceratum
This type of wound is caused by a collision with a blunt object,
with uneven cuts and wound hemorrhage and increased
risk of infection.
2. Vulnus Excoriation
The cause of injuries due to accidents or falls that cause blisters
on the surface of the skin is an open wound but affected only
the coolies.
3. Vulnus Punctum
The cause is a sharp pointed object or something into the skin, an
open wound from the outside looks small but inside may be
severely damaged, if the abdomen / thorax is called vulnus
penetrosum (penetrating wound).
4. Vulnus Contussum
Cause: hard object collision. This wound is a closed wound, as
a result of damage to the soft tissue and rupture of blood
vessels causing pain and bleeding (hematoma) when small it
will be absorbed by the surrounding tissue if the organ in the
collision can cause serious consequences.
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5. Vulnus Scissum / Insivum
The cause of this type of wound is a sharp incision or needle is
an open wound resulting from therapy for invasive action,
sharp cut edges and slippery.
6. Vulnus Schlopetorum
The cause is a shot, a grenade. On the edge of the wound looks
blackish, can be irregular sometimes found corpus alienum.
7. Vulnus Morsum
The cause is an animal or human bite, the likelihood of a large
infection of a wound form depends on the shape of the tooth.
8. Vulnus Perforatum
This type of wound is a penetrating wound or a broken wound.
Causes due to arrows, spears or infectious processes that extend
beyond the serous membranes / epithelial tissue organs.
9. Vulnus Amputatum
Cut wounds, beheaded with the cause of large / heavy sharp
objects, saws. The wound forms a circle according to the cut
organ. Bleeding is great, the risk of infection is high, there are
symptoms of limb pathom.
10. Vulnus Combustion
Causes due to thermis, radiation, electrical or chemical Skin
tissue damaged by various degrees ranging from blisters (bull -
carbonization / burn). Pain and / or anesthesia.
(Hendriati, 2010).
27
3. Complaints accompanied by swelling and more pain when moved.
Iwan complaints he can’t walk because of pain on his ankle.
a. What is cause of swell ?
Answer :
Swell is cause by increased capillary ermeability, increased blood
and fluid flow yo the injury tissue so that plasma proteins can get
out of the blood vessels into the interstitial space .
(corwid 2008)
28
may be impaired on ligament damage weight. When the ankle joint
sprained, it will be followed by inflammation process around the
ankle. Light sprays are usually accompanied by partial hematomas
ligament fibers break, while in sprain is effusion fluid that causes
swelling and on the entire weight sprain broken ligament fibers so
they can not be moved usually with severe pain, swelling and
bleeding in the joints (Ulfah, M., 2013).
4. Physical examination:
General situation : compos mentis ; respiratory rate 22x/min ; pulse
rate 102x/min ; blood pressure 130/80 mm Hg; temperature 37.0℃
Spesific examination:
Height : 160 cm , Weight: 57 kg
Head : conjungtiva anemis (-), icteric sclera (-)
Thorax : Cord an pulmo are normal
Abdomen : flat, hepar and lien not palpable
Upper extremity : normal
Lower Extremity:
- Left : normal
- Right : region ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
- Open wound (-), active bleeding (-)
Feel : Tenderness (+), crepitation (-) palpable tension on the
lateral ankle skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)
29
a. What is the interpretation of the physical examination?
Answer :
Interpretation
Takikardi, Hematoma:
30
Exercise → Blunt Trauma → Plantar invertion → Ligament
over stretching → Blood capiler disconnected → Hematoma
→ Decreased of Hb → Vasokontriction → Takikardi
(Calatayud, et al., 2014)
5. Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible
fracture, visible swelling of soft tissue in the lateral
a. What is the interpretation of supporting investigation?
Answer :
interpretation of laboratory examination.
Physical
HB Leukosit
Laboratory
11,4 mg/dl 9.000/mm3
14,0 – 18,0 5000 -
Normal
mg/dl 10.000/mm3
interpretation Abnormal normal
31
b. How the abnormal phatophysiology of the supporting investiation?
Answer :
Exercise → Blunt Trauma → Plantar invertion → Ligament over
stretching → Blood capiler disconnected → Hematoma →
Decreased of Hb (Calatayud, 2014).
6. How to diagnose ?
Answer :
Anamnesis
Pain in his right ankle since 2 hours ago. Complaints caused by
right foot twisted in and fell when playing futsal. Complaints
accompanied by swelling and more pain when moved. Iwan
complains he can’t walk because of pain on his anckle.
Physical examination :
General Situation : puls rate 102x/minute blood pressure
130/80 mmHg,
Spesific examination:
Lower extremity : Right : Regio ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
Feel : Tendernees (+) , creptitation (-), Palpable tension on the
lateral ankle skin
Move : Pain when the right ankle is moved inside
ROM : ankle joint is limited
Laboratory : Hb : 11,4 gr%
Radiological examination : Ankle dextra AP/ Lateral : Visible
swelling of soft tissue in the lateral.
32
7. What is the differential dignose ?
Answer :
33
The Ottawa Ankle Rules state that a foot radiographic series is
required only if the patient has any pain in the midfoot zone and
any of the following 3 findings:
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular bone
Inability to bear weight immediately after the injury and in the
emergency department
The Ottawa Ankle Rules are contingent upon the patient presenting
within 10 days of the injury. Although they were not originally
intended for patients younger than age 18 years, a meta-analysis of
12 studies showed that the Ottawa foot and ankle rules can be
reliably used to exclude fractures in children older than age 5
years. The studies included a total of 3,130 patients and identified
671 fractures, resulting in a prevalence of 21.4%. Demonstrating a
pooled sensitivity of 98.5% and a missed fracture rate of 1.2%, the
report indicated that the Ottawa foot and ankle rules are useful
(level 2 evidence) for excluding fractures in children. Another
study suggests they may be useful for children as young as 2 years.
Radiographic studies of the ankle should include the following
views:
An anteroposterior (AP) film with the ankle in 5-15° of
adduction
A true lateral film
A 45° oblique film with the ankle in dorsiflexion (ie, Mortise
view)
34
tilt and anterior drawer tests. Because of muscular guarding due to
patient pain, the accuracy of these tests is dramatically increased
with the use of local anesthesia. Compare the stress views with
those of the uninvolved ankle in both tests. Other variables in
determining the reliability of these tests include the degree of
patient relaxation and cooperation, the amount of force used, the
angle of ankle flexion, and the amount of laxity in the uninvolved
side. (See Clinical Presentation.)
Computed Tomography Scanning
Computed tomography (CT) scanning may be indicated if imaging
of soft tissues is warranted or if bone imaging beyond radiography
is indicated. CT scanning is useful for evaluating osteochondritis
dissecans and stress fractures. In complex injuries, 3-dimensional
CT scanning may be useful.
MRI
MRI may be a useful evaluation when a syndesmotic or high ankle
sprain is suspected or if osteochondrosis or meniscoid injury is
suspected in patients with a history of recurrent ankle sprains and
chronic pain. However, caution must be used when evaluating the
findings on MRI since a study of asymptomatic patients revealed
that approximately 30% had findings consistent with abnormal
anterior talofibular ligaments and peroneal muscles.
Arthrographic Imaging
Ankle arthrograms may be useful for determining capsular damage
and the number of ankle ligaments damaged; however,
arthrography is indicated only if surgery is needed, and the criteria
for surgery to repair double lateral ligament complete tears are still
under debate. Staples found that arthrograms provide the most
preoperative information.
Ankle arthrograms are not indicated in every patient considered for
surgical treatment. Marked clinical instability in a young individual
35
with great physical demands being considered for surgery requires
an ankle arthrogram.
Bone Scanning
A bone scan can detect subtle bone abnormalities (e.g., stress
fracture, osteochondral defects). A bone scan can also detect
syndesmotic disruption.
(Young, 2017)
36
Compression, build a useful compress to stop excessive blood
flow at the time.
Elevation, conditions where the area must be higher than the
heart. This serves to reduce blood flow in the area of the
injured and also to reduce the swelling.
3. Rehabilitation:
Avoid exercises that cause pain or swelling
Rotate the ankle for 10-15 times for 2-3 times a day
The Achilles tendon is stretched at a 30-second level at each
foot position (fingers) inward, fingers outward, straight ahead,
doing for 3-4 times a day
Lifting the toes for 10 times, 1-3 sets, for 3-4 times a day
weight / body support between edera and can not stand on the
ankle, this movement can be done for 20 minutes until severely
free from illness. The activity is carried out for 2-3 times a day
Work on stretching by proprioceptive neurofacilitator (PNF) at
the ankle with the help of spouse / other person for 2-3 times a
day
Followed by a forward motion going forward with a short step.
(priyoniadi, Bambang 2005.)
4. Conservative Therapy
Physical therapy during the recovery phase is aimed at the patient
regaining full range of motion, strength, and proprioceptive
abilities, and may include the following :
37
Strengthening exercises : starts with isometric exercises, then
adnvances to use of elastic bands or surgical tubing
Proprioception rehabilitation : starts with single-leg-stance
exercise in a single plane, then progresses to multiplanar
exercises
Other exercises : uses a balance or tilt board, then advances
to functional drills, jogging, sprinting, and cutting, and then
progresses to figure-of-eight and carioca drills
5. Surgery
In most patients, there is no improved outcome with operative
repair of third-degree anterior talofibular ligament tears and
medial ankle ligament tears.
(Young, 2017).
Synthesis :
Prognosis lateral ligament reconstruction. Very good functional
results have been reported in approximately 90% of patients
38
undergoing Brostrom/Gould ligament reconstruction, with
radiographic evidence of less residual laxity. The results are less
satisfactory in patients who have generalized hypermobility of the
joints or long-standing ligamentous insufficiency (>10 years), as
well as in those who have undergone previous ankle joint ligament
surgery. Anatomic repair using the original ligament is technically
simple, giving rise to few complications, and producing short- and
long-term satisfactory functional results.
(Maffulli dan Longo. 2010).
39
“what comes to you of good is from God, but what comes to you of
evil, is from yourself” (An-Nisa: 79)
Content :
From the hadith can be taken the lesson that every disaster is a
reeporoach from Allah SWT for the sins we have committed and
calamity to introspection our self for be better, to be
rahmatanlilalamin.
2.6 Conclution
Iwan, 20 years old, complaint of pain in his right ankle and
accompanied by swelling and more pain when moved because of sprain at
causa exercise.
40
2.7 Scema of Synthesis
Exercise
Mechanic trauma
41
BIBLIOGRAPHY
American Orthopaedic Foot and Ankle Society. 2012. Ankle Sprain. United
States. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716575/.
Accessed on 14 November 2017.
Backley. L.S., 2006. Buku Saku pemeriksaan Fisik dan Riwayat Kesehatan Bates.
Ed. 5. Jakarta : EGC.
Barr K dan Harrast M 2005. Evidence -Based Treatment of Foot and Ankle
Injuries in Runners. Phys Med Rehabil Clin N Am 16 (2005) 779 –
799 Department of Rehabilitation Medicine, Box 356490, University
of Washington, Seattle, WA 98195
Calatayud J, Borreani S, Colado J.C, FlandesJ, Page P. 2014. Exercise and Ankle
Sprain Injuries a comprehensive review. Page 88-93, Vol 42,
ISSN- 0091- 3847. http://www.physsportsmed.com. Accessed on
14 November 2017.
42
Gillenwater J, Y., et al .1996. Adult and Pediatrict Urology. Diakses dari
http://books.google.co.id/books?id=tKhdpB6CQIC&pg=PA748&lpg=
PA748&dq=Gillenwater+et+all,1996&source=bl&ots=pV_Fj_UefL&s
ig=Y20U9gWpSvzewYKZ0cy0EUc2FvY&hl=id&ei=ynzwSvPQF5e
QkQXCs9CJBw&sa=X&oi=book_result&ct=result&resnum=1&ved=
0CAgQ6AEwAA pada tanggal 14 November 2017
International Association for the Study of Pain. IASP taxonomy. IASP Web Site.
1979.http://www.iasppain.org/Conten/NavigationMenu/GeneralResour
ceLinks/PainDefinitions/default.htm pada tanggal 14 November 2017
Sobbota. 2010. Sobotta Atlas Anatomi Manusia. Edisi 21. EEG Penerbit Buku
Kedokteran. Jakarta.
43
https://journal.unnes.ac.id/nju/index.php/miki/article/viewFile/2556/26
09. Accessed on 14 November 2017.
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