ANKLE & FOOT. Yulianto W, Dipl.PT, M.Kes.

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ANKLE & FOOT

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BASIC BIOMEKANIK

Sendi

Situasi

Posisi

Tibiofibular Talocrural Subtalar Resting position CPP Pola kapsular Resting position CPP Pola kapsular Resting position CPP Pola kapsular Plantar fleksi

Max. Dorsi fleksi Nyeri / stress

100_plantar

Max. Dorsi fleksi Dorsi fleksi

Neutral Supinasi

(3)

Sendi

Situasi

Posisi

Midtarsal/chopart’s Tarsometatarsal Metatarsophalange al Interphalangeal Resting position CPP Pola kapsular Resting position CPP Pola kapsular Resting position CPP Pola kapsular Resting position CPP Pola kapsular neutral Supinasi

Dorsi, plantar, add, endo Netral

Supinasi None

100 ekstensi Full ekstensi

Hallux: ekst – fleksi Jari2: variable

Sedikit fleksi Full ekstensi

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Beban pd Kaki saat Berjalan



_Berjalan

_{: 1,2 x BB}



Lari

: 2 x BB

(5)

Penyebab Overuse Injury

(Taunton, Smith & Magee, 1996)



Latihan berlebihan



_{Force saat aktifitas}



Latihan / kompetisi pd permukaan keras



_{Perubahan jenis permukaan}



Lari menurun



_{Fleksibilitas yg menurun}



Individual muscle weakness



_{Langkah berlebihan}



Posture yg jelak

(6)

Penyebab Toeing-in & Toeing-out pd Anak

(Tachdjian, 1990)

Level of affection

Toe-in

Toe-out

Feet-ankle

Leg-knee

Femur-hip

Kaki pronasi

Metatarsal varus

Talipes varus /

equinus

Tibia varus

Tibia torsi medial

Genu valgus

Femur antetorsi +

Spastisitas endo

Pes valgus

Talipes

calcaneovalgus

Tibia torsi lateral

Femur retrotorsi

Flaccid endo

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Klasifikasi Sprain Ankle

(Reid, 1992)

Grade I (mild), stable



Patologi: Mild stretch, No instability, 1

ligamen (lig. Tibiofibular anterior)



_{Tanda – gejala: No hemorrage, Oedem}

minimal, Point tenderness, Ant drawer sign

-, Varus laxity -.



Disability: minimal functional loss,

difficulty hopping, recovery 8 hr (range 2-

10 hr)

(8)

Grade II (moderate), stable



_{Patologi: spectrum injury luas, instabiltas}

ringan s/d sedang, lig.talofibular anterior

putus atau LTFA + lig calcaneofibular

robek



_{Tanda – gejala: hemorage ringan, oedem}

lokal (sekitar tepian tendo achiles), ant

drawe sign + , varus laxity -.



_{Disability: jalan pincang, toe raising -,}

hopping -, lari -, Recovery 20 hr (range 10 –

30 hr)

(9)

Grade III (severe), unstable



Patologi: spectrum injury luas, instabil

nyata, lig.talofibular anterior – kapsul

anterior - lig calcaneofibular putus.



_{Tanda – gejala: hemorage, oedem medial &}

lateral tendo achiles, tenderness sisi medial

& lateral, ant drawer sign + , varus laxity +.



_{Disability: weight bearing -, nyeri}

menyengat, tidak mampu bergerak,

Recovery 40 hr (range 30 – 90 hr)

(10)

Deformities, Deviations & Injuries

1.

Talipes equinus:

 Dorsi fleksi talocrural terbatas (< 100)

 O.k. Contracture gastroc, soleus, achiles.

 O.k. deformitas talus  subtalr pronasi ++.

 Berakibat plantar fasciitis, metatarsalgia, heel spurs, nyeri talonavicular.

2.

Clubfoot:

3.

Subtalar varus:

 Inversi calcaneus  pronasi terbatas

 O.k. tibia varus

 Berakibat plantar fasciitis, hamstring strain serta keluhan pd ankle & knee

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4. Rearfoot valgus

–

Eversi calcaneus.

–

Kaki bag. Belakang mobile



pronasi ++,

supinasi -.

–

O.k. genu valgus

–

Andil tjdnya flaatfoot

5. Forefoot valgus

–

Midtarsal deviasi, Forefoot eversi

–

Saat WB midtarsal supinasi



bag lateral

tidak kontak dg lantai.

–

Andil tjdnya flaatfoot, sprain ankle lateral,

nyeri tungkai bawah dan paha

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6.

Forefoot varus

– Midtarsal deviasi, Forefoot inversi

– Saat WB midtarsal pronasi komplet  caput metatarsal I kontak kuat dg lantai.

– Andil tjdnya clubfoot, tibialis posterior paratenonitis, patellofemural syndrome, stress lig mediale, postural fatique

7.

Pes Cavus (Hollow Foot or Rigid Foot)

– Causa: spina bifida, PM, TEV, muscle imbalance.

– Forefoot drop thd hindfoot (pd metatarsal)

– Claw toes

– Painfull pd caput metarsal

(13)

Klasifikasi Pes Cavus:

1. Mild: arcus longt meninggi saat NWB,

normal saat WB, jari2 claw saat NWB,

normal saat WB, hind foot varus

2. Moderate: arcus longt meninggi saat

NWB/WB, jari2 claw saat NWB/WB, tjd

calus pd caput metatarsal, dorsi fleksi -.

3. Severe: calcaneus tak bisa pronasi > 5

0

,

(14)

8. Pes Planus (Flaatfoot)

–

Arcus longt.medial -.

–

Causa: congenital, muscle weakness, ligament

laxity, “drooping” caput talus

–

Ada 2 jenis: rigid FF (congenital FF) &

flexible FF (hypermobile FF).

–

Flexible FF o.k torsi tibia/femur, coxa vara &

defect subtalar.

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Klasifikasi Pes Planus

1. Mild: hindfoot valgus 4

0

– 6

0

, forefoot

valgus 4

0

– 6

0

2. Moderate: hindfoot valgus 6

0

– 10

0

,

forefoot valgus 6

0

– 10

0

, shock absorber

pd tumit -.

3. Severe: hindfoot valgus 10

0

– 15

0

, forefoot

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Special Test

Scoring Scale for Subjective and Functional Follow-up

Evaluation After Ankle Injury (Kaikkonen dkk, 1994)

1. Subjective asessment of the injured ankle: pain,

sweeling, stiffness, tenderness, giving way during activity (mild: 1 symptoms, moderate: 2 – 3 sympt. Severe: > 4)

– No symptoms of any kind 15

– Mild symptoms 10

– Moderate symptoms 5

– Severe symptoms 0

2. Can you walk normally?

 Yes 10

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3. Can you run normally?

 Yes 10

 No 0

4. Climbing down stairs (length 12 m, 44 steps)

– Less than 18 seconds 15

– 18 to 20 seconds 10

– Longer than 20 seconds 0

5. Rising on heels with injured leg

– > 40 x 15

– 30 – 39 x 10

– < 30 x 0

6. Rising on toes with injured leg

– > 40 x 15

– 30 – 39 x 10

(18)

7. Single-limbed stance with injured leg

– > 55 seconds 15

– 50 – 55 seconds 10

– < 50 seconds 0

8. Laxity of the ankle joint (ant.drawer sign)

– Stable (< 5 mm) 15

– Moderate instability (6 – 10 mm) 10

– Severe instability (>10 mm) 0

9. Dorsi flexion ROM

– > 100 ₁₅

– 50_{- 10}0 ₁₀

– < 50 ₀

Total score:

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Anterior Drawer Test of the Ankle

Cara 1:

 Tes u/ injuri lig talofibular anterior

 Px telentang dg kaki rileks

 1 tangan memfiksasi tungkai bawah

 Tangan lain memegang kaki pd posisi 200_{PF dan tarik talus}

ke depan

 U/ lig sisi medial & lateral (lig deltois, lig talofibular ant. dan kapsul anterolateral), lakukan pd posisi DF

Cara 2:

 Px telentang dg lutut fleksi

 1 tangan memfiksasi kaki, lainnya mendorong tibia ke posterior

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Prone Anterior Drawer Test

 Px tengkurap dg kaki di luar bed

 1 tangan memfiksasi tungkai bawah, tangan lain mendorong calcaneus ke depan.

 Posisi 200 PF u/ lig talofibular ant.

 Posisi DF u/ lig sisi medial & lateral (lig deltois, lig talofibular ant. dan kapsul anterolateral)

Talar Tilt

 Px side lying dg lutut fleksi

 Angkat talus ke adduksi (U/ tes lig. Calcaneofibular), ke abduksi (u/ tes lig deltoid, tibionavicular, tibiocalcanea & tibiotalar posterior)

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Squeeze Test of the Leg

 Px telentang dg kaki di luar bed

 Pegang tengah-tengah tungkai bawah dan lakukan penjepitan/peremasan fibula thd tibia.

 Nyeri pd tungkai bawah: injury syndesmosis / fraktur

Distal Tibiofibular Compression Test

 Px telentang

 Jepitan pada dg 2 tangan pd maleolus medial & lateral

 Nyeri : injury syndesmosis / fraktur

(22)

External Rotation Stress Test

 Px duduk ongkang-ongkang

 Pegang kaki Px dari telapak pd posisi ankle 900_{, kemudian}

beri tekanan pada kaki ke lateral rotasi

 Nyeri pd lig tibiofibular posterior dan membrana interosei

 injuri syndesmosis

Cotton Test

 Px telentang

 1 tangan memfiksasi tibia bag distal, tangan lain melakukan translasi kaki ke lateral

(23)

Kleiger Test

 Px duduk ongkang-ongkang

 Pegang kaki Px dari telapak pd posisi ankle 900_{, kemudian}

gerakkan kaki ke lateral rotasi

 Nyeri pd medial & lateral ankle serta talus displacement dari maleolus medialis  kerobekan lig deltoid.

Thompson”s / Simmonds Test

 U/ ruptur tendo achilles

 Px tengkurap, lakukan remasan pd calf muscle

(24)

Test for Peroneal Tendon Dislocation



_{Px tengkurap dg lutut fleksi 90}

0



Lakukan inspeksi pd regio posterolateral ankle



_{Px diminta menggerakkan ankle dorsi-plantar}

flexi+eversi >< tahanan terapis



Positif bila tendo subluksasi dari belakang

maleolus lateralis

Swing Test for Posterior Tibiotalar Subluxation

 Px duduk ongkang-ongkang, terapis memegang kaki dari dorsum, ibun jari pd talus bagian depan medial

 Lakukan gerakan plantar-dorsal fleksi