Rehabilitation in Orthopedic

8/6/2019 Rehabilitation in Orthopedic

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Scope

Soft tissue injury: muscle & ligament Tendinitis Fracture Peripheral nerve injury Entrapment neuropathy Rheumatologic etc.


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G oal

Functional goalA DL (A ctivities of daily living)

feeding, grooming, dressing,hygiene care, transferring

Cooking, gardening, housekeepingA mbulation with or without

gait aids


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Rehabilitation management

Medication Modality Therapeutic exercise

ROME Strengthening exercise Endurance exercise

A ssistive deviceA dvice


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Soft tissue injury

Muscle strain Ligament sprain : ankle, shoulder Contusion, Bruise

DiagnosisSeverity

Duration


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Muscle strain

Cause Over stretch or repetitive stretch Not warm up before exercise Over use


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Diagnosis muscle strain


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Degree of Muscle strain

First degree : muscle pull, mild tear Second degree : partial tear

Third degree : complete tear,

weakness, no ROM


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Treatment Muscle strain

Cool pack 48 hr then deep heat(Ultrasound) Rest Isometric before and isotonic last week later NS A ID & analgesic drug

Cool pack 48 hr then deep heat(Ultrasound) Rest Isometric before and isotonic last week later NS A ID & analgesic drug

Rehabilitation in muscle strain

Stretching & warm up before exercise Increase strength & endurance


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A nkle Sprain


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Mechanism of InjuryInversion sprain Most common

A TFL2 nd common CFL

Eversion sprain Deltoid lig. Severe,

avulsion Fx


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ClassificationG rade I (mild) minor ligamentousdisruption (stretch) with maintenance ofintegrity & no signs of instability : tap strapping

G rade II (moderate) near completedisruption with macroscopic tearing &swelling, moderate functional loss, mild-mod. instability : Brace

G rade III (severe) - completeligamentous rupture with obvious swelling,discoloration, & tenderness, significantfunctional loss


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A ssessment

R/O Fx Point of maximum tenderness Palpation for defect Sensory examination + lightpercussion on superficial n.


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Special Test: Lateral

A nterior drawer test Hallmark of A TFL integrity

Normal < 4 mm > 8mm -> at least A TFL tear

Inversion test (talar tilt)

More sensitive for CFL Separation of talus surface

from tibia Normal < 5 degree


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Special Test: Deltoid Ligament

Eversion testDeltoidintegrity

Tibiotalar jointwidening

Positive

Widening of joint space


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A cute Treatment

PRICEprinciple

ProtectionRestIce : 48 hr C ompression : tapestrapping, brace

Elevation

PRICE


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Rehabilitation : A cute Phase Early mobilization with supports

G ait aids Exercise: ankle pumping, writing

alphabet, gastrosoleus stretching Full weight able: single limbbalance program Balance on affected side 30-60s on

hard floor Eye-closed Change surface (carpet, grass,

foam cushion)


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Rehabilitation: Next PhaseStrengthening:

everters, inverters, DF,PF,hip abductors

Balance board:Propioception : +strengthening

Bicycle Exercise:maintain/increaseendurance

Bicycle Exercise:maintain/increaseendurance


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Tendinitis

De quervain tenosynovitis A PL & EPB Finklestein test

Medication NS A ID & analgesic Local steroid

Thumb spica splint or dequervain splint


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Tennis elbow

Lateral epicodylitis Extensor forearm tendon :

ECRB Treatment

Modified activities Prevent over use

Medication Physical modality Counter force brace


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G olfer elbow

Medial epicodylitis Flexor forearm muscle :

FCR Treatment : same tennis

elbow


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A nserinus tendinitis

Pes anserinus Median side of knee

Sar torius tendon G ra cillis tendon Semi ten dinosus tendon

Clinical : female, over weight,O

Aknee Tender at2 inch below medial

tibial joint line


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A nserinus tendinitis

Treatment Rest NSI A D

Local steroid Physical modality Stretching Quadricep &

A dductor muscle

Treat O A


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Plantar Fasciitis Traction-induced microtear of plantar

fasciaCause

Excessive load: standing + walkingBiomecanical defect: pronation limit DF tight gastrosoleus complex Flat foot

calcaneal spur


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Plantar FasciitisClinical

- Painful 1 st step in the morning- Progressively worsening painduring exertion- Pain + tenderness beneathanterior portion of heel -> sole- Point of deep tendernessalong medial fascia

- Inability to run


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Plantar FasciitisTreatment

A cute: PRICE + NS A IDs Steroid injection Shoe modification: NA S, heel pad,

heel cup Strengthening: intrinsic foot

muscles

Stretching: PF, gastrosoleus


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Fracture

G oal Pain relief Maintain ROM & strength

Improve function


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A cute phase Immobilization

Cast, Internal or External fixation Problem : pain, edema ManagementMedication : NS A ID, A nalgesic,

steroid injectionModalities: cold, TENSExercise Positioning : elevation Isometric/isotonic or ES ROM (other joints) A ROME


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Convalescent phase Problem: edema, joint stiffness,

weakness, impaired function Management

Medication : NS A ID, A nalgesic Modalities: heat, ES Exercise ROM, strength, endurance A mbulation

Three point gait (NWB, PWB) Walker or Crutches

A dvice: elevation, joint precaution,home program


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Peripheral nerve injuryClassification

Seddon1.Neurapraxia2. A xonotmesis

axon

epineurium,perineurium,endoneuriumSchwann cells

3.Neurotmesis axon

Sunderland1. 1 st degree Neurapraxia2. 2 nd degree A xonotmesis

3. 3rd

degreeA xonotmesis +

endoneurium 4. 4 th degree A xonotmesis +

endoneurium +

perineurium 5. 5 th degree Neurotmesis


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Peripheral nerve injury

Problem Insensate skin Weak or paralyzed muscle

Deformity Diagnosis

Clinical Electrodiagnosis (NCS/EM G )


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Peripheral nerve injuryG oal Prevent deformity Restore function

Management Medication Modality: ES Therapeutic exercise

A ssistive device A dvice


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Foot drop : Common Peroneal n.

Most common site - Fibular head Etiology

A cute compression of nerve at fibular head Improperly fitting braces / cast /

circumferential bandage External rotation of lower limbs of

unconscious in hard mattress / bedrail Improper positioning of lower limbs during

surgical procedure


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habitual leg crossing Precipitous weight loss Occupation - chronic kneeling /

squatting Strawberry pickers palsy

Tight peroneal tunnel Tumor, cyst Systemic disease (Mononeuropathy)

Hyperthyroidism, DM, Vasculitis, Leprosy

Unknown


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Clinical Usually involve DP > SP portion Foot drop

steppage gait weak ankle and toe dorsiflexion ankle eversion may be sparing

less affect SPN


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Loss of sensation A nterodistal portion of leg Dorsum of foot

may be spareing of lateralcalf sensation Pain

knee pain associated with etiology

Investigation NCV/EM G


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Wrist drop

Radial nerve injury : Clinical : wrist drop &

sensory loss at dorsolateral

of forearm and dorsum ofhand If injury only PIN, spare ECR

and no sensory loss

Common in humerusfracture, Saturday nightpalsy


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Splint for nerve injury

Static splint Dynamic splintRadial nerve injury


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Entrapment Neuropathy Carpal tunnel syndrome idiopathic,

increase canal volume Cubital tunnel syndrome ; most common

side of elbow entrapmentG uyon canal syndrome ; cyclingactivities, wrist ganglion, R A

Tarsal tunnel syndrome : tibial n. injuryfrom flexor retinaculum

Treatment : adaptive activities, splint,medication, surgery


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Rheumatologic

R AG outA S


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Joint protection program1 .Unload jt. When very painful2.Avoid prolong period in thesame position3.Minimize stress on particular jt.By promote good position4.Maintain ROM , S trength &Alignment5.Modify task to decrease jt. stress


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Joint protection program6 .Use strongest & largest jt.Available for specific task 7.Carry object close to the body

8.Plan work areas so that themost frequency use equipmentis reached easily9.Use appropriate adaptivedevice & splint


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Energy conservation1 .Maximize biomechanical functionof jt. By using of proper orthotics andassistive devices to effect energyefficient ambulation & hand function2.Provide proper environmentaldesign3.Have rest periods throughout theday

4.Maintain ROM and strength5.Maintain proper posture


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Exer cise Pre sc r iptionsA void !

Resistive exercise Increase intra-articular

pressure Increase joint temperature


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Ul nar Deviation Sp lint

Ring Sp lint


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Rehabilitation in Orthopedic

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