Cause Achilies Tendon Ruptured

Tendon Ruptures
Bismillahirahmanirrahim...

Come we learn another interesting topic ..

ACHILLES TENDON RUPTURE

What is the Achilles Tendon?

Tendon = band of tissue that connects a muscle to a bone.

Achilles tendon

a.k.a the "heel cord, 

a strong band of elastic connective tissue that runs down at the back of the lower leg

the Achilles tendon is formed from the gastrocnemius, soleus, and plantar muscles of the calf and is attached to the calcaneous (heel-bone).

largest and strongest tendon in the body.

What is an Achilles Tendon Rupture?

Partial :partly torn but still joined to the calf muscle.

Complete :completely torn so that the connection between the calf muscles and the ankle bone is lost.

Mechanism of injury : occurs when the tendon is stretched beyond its capacity such as :

• forceful jumping or pivoting
• sudden accelerations of running
• falling or tripping.
• forceful push off with the foot
• suddenly forced into an upward pointing position
• deep cut at the back of the ankle

The Achilles tendon is weak due to :

• Corticosteroid medication (prednisolone) - mainly if it is used as long-term treatment rather than a short course.
• Corticosteroid injection near the Achilles tendon.
• Older age (60 years onwards).
• Certain rare medical conditions such as Cushing's syndrome, where the body makes too much of its own corticosteroid hormones.
• 'Tendonitis' (inflammation) of the Achilles tendon.
• Other medical conditions : rheumatoid arthritis, gout and SLE (lupus).
• Certain antibiotics (quinolone).
• The risk  actually very low, and mainly applies if you are also taking corticosteroid medication or are over age 60.  

Risk factors :

Typically, middle-aged people participating in sports in their spare time.

Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures

 

Signs and Symptoms

•  Sudden sharp pain (which feels like a kick or a stab) in the back of the ankle or calf – usually settles quickly and often subsiding into a dull ache.
• A popping or snapping sensation.
• Swelling on the back of the leg between the heel and the calf.
• Difficulty walking (especially upstairs or uphill).  
• Difficulty rising up on the toes.
• Flat footed walk - can walk and bear weight, but cannot push of the ground properly on the side where the tendon is ruptured
• May feel a gap just above the back of the heel in complete tear. However, if there is bruising then the swelling may disguise the gap.

TREATMENTS

Early action that should be taken - the "R.I.C.E." method

1. Rest. Stay off the injured foot and ankle, since walking can cause pain or further damage.
2. Ice. Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
3. Compression. Wrap the foot and ankle in an elastic bandage to prevent further swelling.
4. Elevation. Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.

Decision of Rx are based on the

• severity of the rupture
• the patient’s health status
• activity level (active VS less active)‏
• individual preference and circumstances.
• Types of Rx :
• Non-Surgery
• Surgery

Both options will involve having a plaster cast or brace (orthosis) for about 8 weeks, to protect the tendon while it heals.

 The plaster or brace is positioned so that the foot is pointing slightly downwards, which takes the strain off the tendon.Traditionally, patients were given crutches to keep weight off the leg during the first few weeks of treatment.

       Now there is a trend towards 'early mobilization' involves fitting a plaster or brace which you can walk on more convenient because do not need to use crutches. Physiotherapy is often provided as well.

Non-Surgery
-a.k.a 'conservative treatment’.

-the tendon heal naturally, resting it in a brace or plaster cast.

-Generally associated with a higher rate of re-rupture

Selected for

• minor ruptures
• Older or less active patients
• those with medical conditions that prevent them from undergoing surgery

Involves use of

• Cast
• walking boot
• brace

Fx : to restrict motion and allow the torn tendon to heal.

A surgical repair can then be done later, if the tendon :

does not heal on its own and re-rupture.

Surgery
recommended for

• younger people
• those doing sports.
• delay in starting treatment.

Offers important potential benefits such as :

• Decreasing the likelihood of re-rupturing the Achilles tendon,
• Often increases the patient’s push-off strength and improves muscle function and movement of the ankle.

Various surgical techniques are available :

• type of surgery called ‘percutaneous’ -  uses smaller cuts than the traditional operation. It  reduce the risk of getting a wound infection.
• sews together the torn ends of the Achilles tendon
• may also use another tendon
• a tendon graft to help with the repair.

The surgeon will :

• select the procedure best suited to the patient.
• determine when the patient can weight bearing.
•  Following surgery, the foot and ankle are initially immobilized in a cast or walking boot.
•  after surgery, a brace seems to be better than a plaster cast in terms of faster recovery and return to normal activities, a lower complication rate and patient preferences. 

Complications such as :

• incision-healing difficulties - the tendon may scar or become shorter
• re-rupture of the tendon
• nerve pain
• wound infection
• reduced sensation near the operation site

PHYSIOTHERAPY MANAGEMENTS

ACHILLES TENDON REPAIR
REHABILITATION PROTOCOL

PHASE I (0-8 WEEKS)

WEIGHT BEARING –

i.  (0-4 weeks) :Heel toe touchdown weight bearing in post-op splint.

ii. (4-8 weeks) : As tolerated with crutches & cam walker.

BRACE –

i.  (0-2 weeks) : Worn at all times.

ii. (2-4 weeks) : Locked at 20 ° of plantarflexion – worn at all times except for exercise & hygiene.

iii.(4-8 weeks) : Worn during weight bearing activities.

ROM –

i.  (0-2 weeks) :NO physical therapy & motion

ii. (2-6 weeks) : Limit active dorsiflexion to 90° with knee flexed at 90°

iii.(6-8 weeks) : ROM to tolerance

THERAPEUTIC EXS -

i.  (0-2 weeks) : NO physical therapy & motion

ii. (2-8 weeks) : Inversion/eversion ROM, stationary bike with brace on, knee/hip strengthening, joints mobilizations – NO passive heel cord strecthing

PHASE II (8-12 WEEKS)

WEIGHT BEARING – As tolerated with crutches – discontinue crutch use when gait is normalized

BRACE – None

ROM – gain full & pain free

THERAPEUTIC EXS – Begin light dorsi/plantarflexion exs with knee flexed, inversion/eversion isometrics, cont. with bicycle & knee/hip strengthening

PHASE III (12 WEEKS - 5 MONTHS)

WEIGHT BEARING – Full with normalized gait pattern

BRACE – None

ROM – Full & pain-free

THERAPEUTIC EXS – Progress Phase II activities, begin inversion/eversion isotonics, aggressive dorsi/plantarflexion resisitive exs with emphasis on plantar eccentrics

Besides that, generally what we can do….

• Help reduce swelling and pain though application of :
• Electrotherapy such as ultrasound
• compression bandaging
• Passive exs – to increse ROM
• AROM - avoid pain when exercising
• active free exs : plantarflexion, dorsiflexion, pronation, supination, inversion and eversion
• Mobilising exs :
• Ankle Circles : Sit on the floor or in a chair. Remove shoes and socks. Moving only your ankle, draw circles. Repeat 10 to 20 times.
• Drawing The Alphabet: Sit on the floor or in a chair. Remove shoes and socks. Moving only your ankle, draw the alphabet on the floor. Do the entire alphabet once.

Stretching exercises :

Gastrocnemius

Soleus

Strengthening exercises :

Hip :SLR, hip pattern

knee : SQE, IRQ

Ankle : Resistive Tubing Exercises (Theraband)‏

                : Toe Raises

                : Walking on Heels

                : Toe Scrunch:

-Place a towel on the floor near your chair.

-Sit down, placing the toes of one foot on  the towel.

-Use your toes to scrunch up the cloth.    

Keep your heels flat on the floor.

Repeat 10 to 20 times

: Wobble Board

Postural challenge - partner challenges a person's stability while he or she is standing on one leg, gently touching the person in one direction and then the other.

Mini Trampoline Exercises -Stand on a mini trampoline with one foot. Work up to two minutes without falling, then switch to the other ankle.

Progression to :

hop and stop

throw ball

fig 8's

running

Instruct on use of crutches if needed

• NWBC
• PWBC
• Strap the ankle to make walking easier.
• Functional actvt e.g. ambulation,step up & down, running, jumping

Pt education :

• keep ball of foot supported when long sitting to avoid your ligament healing in a lengthened position. 

For sports

Advise on when to return to sport.

Start with warm-up exercises.

Recommend ankle braces

Corticosteroid medication (prednisolone)‏

Should be used carefully and the dose should be reduced if possible. But note that there are many conditions where corticosteroid medication is important or lifesaving.

Quinolone antibiotics

Should be used carefully in people over 60 or who are taking steroids. 

wallahuallam... 

Pushing Syndrome in stroke patient

Managing Pushing syndrome after stroke
Bismillahirahmanirrahim ....

lets go for another topic that are related in stroke management , there are calling a pusher syndrome...

Abstract

• Pusher syndrome in patients post-stroke is characterized by leaning and active pushing toward the hemiplegic side with no compensation for the instability,  and resistance to passive correction toward midline.
• require longer than average to reach independence in activities of daily living and ambulation 
• present primarily in patients with right hemispheric lesions centered in the area of the posterolateral thalamus. 
• misperceive body orientation in space, 18° tilted toward the ipsilesional side
• Visual cues and cognitive strategies as potential rehabilitation tools for correction of body posture.

Patients with pusher syndrome tend to have profound functional limitation(self transfering, standing and gait.

Purpose of this review

    -characteristic of pusher syndrome in post-

     stroke pt

    -location of stroke lesion

    -cause of behavior disorder

    -discussion of physical therapy intervention

Characteristic of Patient with Pusher Syndrome

• left hemiplegia (right brain lesion)
• spatial and sensory neglect of the hemiplegic side(physical and environmental)
• postural asymmetries
• shift of body weight toward the hemi-plegic side with no attempt to support or compensate for the resultant imbalance 
• no protective responses when active pushing leads to postural instability in sitting and standing
  Therefore at high risk for falls. 
• In severe case, sensory impaired(tactile, proprioceptive, visual and auditory stimuli)
• However, all 23 of the patients with contraversive pushing in the study by Karnath et al displayed severe paresis of both the upper and lower contralesional extremities
• The severity of paresis of the hemiplegic extremities has not been shown to directly influence the presence of pushing or body orientation with respect to gravity while seated.

How to Distinguish?

• Active pushing with the nonparetic extremities : distinguish patients with pusher syndrome from patients with thalamic astasia and lateropulsion in Wallenberg's syndrome.
• When asked to sit up, patients with astasia typically grasp the side rail of the bed with the unaffected hand or with both hands and pull themselves up, rather than using the available power of the trunk.
• While patients with pusher syndrome extend the unaffected arm and using it to actively push away from the nonparetic side.
• Patients with Wallenberg’s syndrome display a tilt in subjective visual vertical but in pusher syndrome, it is intact.
• The tendency of patients with Wallenberg's syndrome is to fall sideways toward the side of the lesion, compared to patients with pusher syndrome who fall to the side opposite the lesion.
• Able to maintain correct head orientation toward vertical in the presence of severe lateral lean

• helps to differentiate patients with cerebral lesions in the posterior insula('vestibular cortex,‘),experience a perceived tilt of the subjective visual vertical

Location of Stroke Lesion.

1.  infarctions clearly centered on the posterolateral thalamus
2.  including the ventral posterior nucleus, lateral posterior nucleus(which seems to be critical in control of upright posture) .( Karnath et al,2002)
3.  In another study shows that thalamic and extra-thalamic lesion also can cause pusher syndrome
4.   Different types of imaging technology used to determine the structural damage as well as malperfused but structural intact tissue.
5. Study shows that thalamic lesions did not show a systematic involvement of dysfunctional brain areas in addition to the ones found to be structurally damage   And in extra-thalamic lesion, thalamus was neither structurally damaged nor malperfused 
6.    However, abnormality seen in these areas in extra-thalamic lesion in pusher syndrome’s patient.(inferior frontal gyrus, middle temporal gyrus, inferior parietal lobule, and parietal white matter.)
7. Thus, these extra-thalamic brain areas contribute to the network controlling upright body posture. (Luca Francesco Ticini, Uwe Klose Thomas Nägele and Hans-Otto Karnath, 2009)

Causes of Pusher Syndrome

1. results from a high-order disruption in the processing of somesthetic information originating in the contrale-sional hemibody.suspected that this could be gravi-ceptive neglect.
2. The patients perceive their body as oriented 'upright' when it is tilted an average of 18° to the ipsilesional side severe misperception of body orientation in relation to gravity
3. Pushing is a response of patients' unexpected experience of loss of lateral balance when trying to get up and sit upright in a vertically oriented room.

MEASURING CONTRAVERSIVE PUSHING
Scale for Contraversive Pushing (SCP)

3 criteria

(1) posture: symmetry of spontaneous posture while sitting and standing,

(2) extension: the use of the ipsilesional arm or leg to extend the area of physical contact to the ground while sitting and standing, and

(3) resistance: resistance to passive correction of posture while sitting and standing.

PHYSICAL THERAPY INTERVENTIONS and RECOVERY OF FUNCTION FOR PATIENTS WITH PUSHER SYNDROM

1. Some patients with pusher syndrome can 'learn' to balance in standing with their feet apart within a half-hour session.(Bohannon RW, 1996)
2. appropriate positioning over their feet, practicing and feedback to patients, they can achieve a short duration of independent static standing
3. 3 stage of practices:back against wall,without support, during movement .
4. Karnath et al, 2000 and Perennou, 2002 noted that patients able to align body axis with the use of visual cues from environment.
5. Using the upright orientation of surrounding objects and persons.
6. However, it is temporary. Thus, visual input alone not suffice to continuously control upright posture.
7. It may be an effective training tool when combined with conscious strategies for postural control.
8. It is believed that applying TENS by activating various afferent nerve fibers in the neck
   convey stimuli to the contralateral cerebral hemisphere, unmasking the patients' latent postural capabilities.
9. TENS as substitution stimulus to reactivates the damaged neural network devoted to body orientation with respect to gravity.
    and lower initial activities of daily living (ADL) function scores as measured by the Barthel Index
10. subjects with pusher syndrome had more severe strokes as expressed by lower neurological scores on the Scandinavian Stroke Scale
11. According to Pedersen and colleagues(1996), pushing should first diminish in the supine position, then in the sitting position, and finally in the standing position.However, no supportive evidence.
12. Pusher syndrome was found to slow the recovery process post-stroke,requiring an average of 3.6 weeks (63%) longer to reach highest ADL function

Conclusion

•  patients with pusher syndrome display a misperception of body orientation in space, believing that the upright position is approximately 18° tilted toward the ipsilesional side.
• suspected that is the result of 'graviceptive neglect' of signals originating in the contralesional trunk and pelvis
• Pushing may be an attempt to compensate for a mismatch between an intact perception of the visual vertical and an impaired perception of postural vertical
• Visual cues and cognitive strategies can be rehabilitation tool
• Slow recovery process has been found in patient with pusher syndrome
• Longer than average to reach independence ADL and ambulation

Wallahuallam...

Total Knee Replacement (OA Knee) Guideline

Total Knee replacement (Tukar Sendi lutut)

Bismillahirahmanirrahim..

sorry I am so busy around this month, so just want to share a short info regarding a total knee replacement when we have a chronic Osteoarthritis (OA) at knee

OA is a chronic disease causing deterioration of the joint cartilage and the formation of new bone (bone spurs) at the margins of the joints,

Risk factor for OA knee:

• - obesity
• - age
• -OA at other sites
• - Previous knee trauma or injury
• -Previous knee surgery
• - Sex ( female)

Sign and Symptom

•          -Pain
•          -Morning stiffness
•          -Reduced flexibility
•          -Reduced ms strength and stability
•          -Joint deformation ( genu valgum/ genu varus)
•          -Reduced aerobic capacity

Mx of OA

Early stage:

Treated with

• -nonsteroidal anti-inflammatory drugs (NSAIDs)
• Activity restrictions
• Exercise        
•  Bracing
•  Orthotics
•  Weight loss
•  Injections of hyaluronic acid or cortisone

Chronic stage:

Surgery-When conservative measures fail & arthritic symptoms limit functional activity

Types of Knee replacement

Non-constrained

     - most common type of artificial knee.

     - the artificial components inserted into the knee are not linked to each 

       other.

Semi-constrained

     - All the ligaments in knee will be removed during the surgery, this implant provides increasing stability for the knee.

Constraint or hinged

     - rarely used as a first choice of surgical options.

     - two components of the knee joint are linked together with a hinged

        mechanism.

     -This type of knee replacement is used when the knee is highly unstable

Unicondylar knee replacement

            - replaces only half of the knee joint. It is performed if the damage is

         limited to one side of the joint only with the remaining part of the knee

         joint being relatively spared.

What Is Plan Of treatment in Physiotherapy ?

• Mobility exs
• Stretching exercise
• Strengthening exs
• Circulatory exs
• Ambulation
• Pt’s education
• Discharge planning

Short Term Goals ( 1/52) (1 week)

- Improve ROM of Rt. LL. ( Rt. knee flexion at least 90⁰ )

- Improve ms power of Rt LL from 3/5 to 4/5.

- Reduce swelling of Rt ankle.

- Independent indoor ambulation with walking frame.

- Able to lift up both buttocks during bridging.

Long term goal ( 2/12) (2month)

-Maintain muscle strength of all limbs.

- Prevent hamstring tightness.

-Able to ambulate outdoor independently with aid.

wallahualam.