Kelainan Tulang & Sendi

Terlokalisir
Humaryanto
Sendi bahu (shoulder)
 Shoulder Injuries
– Shoulder instability
• poor joint cavity
• poor ligament
• musculature
• Intracapsular pressure
• Concavity compression
• scapulohumeral
balance
 Shoulder Injuries
• Anterior Luxation
– mostly anterior when arm
is abducted, extended and
ext. rotated
– posterior forces
• Posterior luxation
– same mechanism
reverse
• Inferior luxation
 Shoulder Injuries
• Impingement
– glenohumeral joint:
abduction
– supraspinatus and bursae
• Categories
– Under 35 year: sports or
jobs with overhead
movement
– Older: degeneration
• Microtrauma-instability-
subluxation-aggravation
 Shoulder Injuries
• Rotator cuff impingements
– Extrinsic: structural factors
• hook acromion
• hypertrophy of
supraspinatus
– Intrinsic
• inflammation of the tissue
• Mechanism
– work of sports requiring
overhead movements
– Wheelchair (abductor
dominance)
 Shoulder Injuries
• Rupture Rotator cuff
– Chain of events:
• inflammation
• microtears
• partial or total rupture
• movement adaptations
– Supraspinatus rupture most
common
– Eccentric actions
• acceleration phase
• decceleratiom phase
 Rotator Cuff Tear
• Drop arm test: arm passively abducted at 90o,
patient asked to maintain  dropped arm
represents large rotator cuff tear
• Shrug sign: attempt to abduct arm results in
shrug only
 Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
• Calcific (calcareous)
tendonitis: hydroxyapatite
deposits in one or more
rotator cuff tendons
– Commonly
supraspinatus
• Sometimes rupture into
adjacent subacromial bursa
• Acute deltoid pain,
tenderness
 Calcific Tendonitis
Supraspinatus Tendonitis Subacromial
Bursitis
• Clinically similar: difficult to differentiate
• Rotator cuff: teres minor, supraspinatus,
infraspinatus, subscapularis
– Insert as conjoined tendon into greater
tuberosity of humerus
 Calcific Tendonitis
Supraspinatus Tendonitis Subacromial
Bursitis
Jobe’s sign, AKA “empty can test”
• Abduct arm to 90o in the scapular plane,
then internally rotate arms to thumbs
pointed downward
• Place downward force on arms: weakness
or pain if supraspinatus
 Calcific Tendonitis
Supraspinatus Tendonitis Subacromial
Bursitis
• Other tests: Neer, Hawkins
• Passively abduct arm to 90°, then passively
lower arm to 0° and ask patient to actively
abduct arm to 30°
 Calcific Tendonitis
Supraspinatus Tendonitis Subacromial
Bursitis
• If can abduct to 30° but no further, suspect
deltoid
• If cannot get to 30°, but if placed at 30° can
actively abduct arm further, suspect
supraspinatus
• If uses hip to propel arm from 0° to beyond
30°, suspect supraspinatus
 Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
• Subacromial bursa: superior
and lateral to supraspinatus
tendon
• Tendon and bursa in space
between acromion process and
head of humerus
• Prone to impingement
 Calcific Tendonitis / Supraspinatus Tendonitis /
Subacromial Bursitis
• Patient holds arm protectively against chest
wall
• May be incapacitating
• All ROM disturbed, but internal rotation
markedly limited
• Diffuse perihumeral tenderness
• X-ray: hazy shadow
 Shoulder Injuries
• Biceps tendon injuries
– tenosynovitis (repetition)
– dislocation (medial)
• abduction/ext. rotation
• falls outstretched arm
• lateral impact
• hyperextension
• anterior GH dislocation
• bicipital grove angulation
– rupture: tissue
degeneration
– SLAP
elbow
 Elbow Injuries
• Epicondylitis: repeated loading
causing microtrauma and tissue
degeneration leading to
inflammation and tissue
weakness
• Lateral epicondylitis
– tennis players 30-50 years old,
poor stroke mechanics,
excessive muscle contraction
– Overuse of extensor
mechanics, pinching and
grasping
 Lateral Epicondylitis
• Pain at insertion of extensor carpi radialis
and extensor digitorum muscles
• Radiohumeral bursitis: tender over
radiohumeral groove
• Tennis elbow: tender over lateral epicondyle
• History repetitive overhead motion: golfing,
gardening, using tools
• Worse when middle finger extended against
resistance with wrist and the elbow in
extension
• Worse when wrist extended against
resistance
 Medial Epicondylitis
• “Golfer's elbow” or
“pitcher’s elbow” similar
• Much less common
• Worse when wrist flexed
against resistance
• Tender medial epicondyle
 Bicipital Tendonitis
• Risk: repeatedly flex elbow
against resistance:
weightlifter, swimmer
• Tendon goes through
bicipital (intertubercular)
groove
• Pain with elbow at 90°
flexion, arm internally /
externally rotated
 Bicipital Tendonitis
• Range of motion: normal or restricted
• Strength: normal
• Tenderness: bicipital groove
• Pain: elevate shoulder, reach hip pocket, pull a
back zipper
 Bicipital Tendonitis
• Lippman test: "rolling"
bicipital tendon produces
localized tenderness

• Yergason test: pain along

bicipital groove when
patient attempts supination
of forearm against
resistance, holding elbow
flexed at 90° against side of
body
 Olecranon Bursitis
• “Student's” or “barfly elbow”
• Most frequent site of septic bursitis
• Aseptic: motion at elbow joint complete and
painless
• Septic: all motion usually painful
Wrist, hand
 Ganglion Cysts
• Swelling on dorsal wrist
• ~60% of wrist and hand soft tissue tumors
• Etiology obscure
• Lined with mesothelium or synovium
• Arise from tendon sheaths or near joint
capsule
 Cubital Tunnel Syndrome
• Ulnar nerve passes through cubital tunnel just
behind ulnar elbow
• Numbness and pain small and ring fingers
• Initial treatment: rest, splint
 Carpal Tunnel Syndrome
• Median nerve compression
in fibro-osseous tunnel of
wrist
• Pain at wrist that sometimes
radiates upward into forearm
• Associated with tingling and
paresthesias of palmar side
of index and middle fingers
and radial half of the ring
finger
 Carpal Tunnel Syndrome
• May be idiopathic
• Known causes: rheumatoid arthritis
pregnancy, diabetes, hypothyroidism,
acromegaly
 Carpal Tunnel Syndrome
• Patient wakes during night with burning or
aching pain, numbness, and tingling
• Positive Tinel sign: reproduce tingling and
paresthesias by tapping over median nerve at
volar crease of wrist
 Carpal Tunnel Syndrome
• Positive Phalen test: flexed wrists held against
each other for several minutes in effort to
provoke symptoms in median nerve
distribution
 de Quervain’s Disease
• Chronic teno-synovitis due to narrowed
tendon sheaths around abductor policis
longus and extensor pollicis brevis muscles
 Trigger Finger
• Digital flexor tenosynovitis
• Stenosed tendon sheath
– Palmar surface over MC head
• Intermittent tendon “catch”
• “Locks” on awakening
• Most frequent: ring and middle
 Trigger Finger
• Tendon sheath walls lined with synovial cells
• Tendon unable to glide within sheath
• Initial treatment: splint, moist heat, NSAID
• Steroid for recalcitrant cases
Hip, pelvis
 Trochanteric Bursitis
• Second leading cause of
lateral hip pain after
osteoarthritis
• Discrete tenderness to
deep palpation
• Principal bursa between
gluteus maximus and
posterolateral prominence
of greater trochanter
 Trochanteric Bursitis
• Pain usually chronic
• Pathology in hip abductors
• May radiate down thigh, lateral or posterior
• Worse with lying on side, stepping from curb,
descending steps
 Trochanteric Bursitis
• Patrick fabere sign (flexion,
abduction, external rotation,
and extension) may be negative
• Passive ROM relatively painless
• Active abduction when lying on
opposite side  pain
• Sharp external rotation  pain
 Ischiogluteal Bursitis
• Weaver's bottom / tailor’s
seat: pain center of buttock
radiating down back of leg
• Often mistaken for back
strain, herniated disk
• Pain worse with sitting on
hard surface, bending
forward, standing on tiptoe
 Ischiogluteal Bursitis
• Tenderness over ischial tuberosity
• Ischiogluteal bursa adjacent to ischial
tuberosity, overlies sciatic / posterior femoral
cutaneous nerves
knee
 Prepatellar Bursitis
• Housemaid’s knee / nun’s knee:
swelling with effusion of
superficial bursa over lower pole
of patella
• Passive motion fully preserved
• Pain mild except during extreme
knee flexion or direct pressure
Prepatellar Bursitis
• Pressure from repetitive
kneeling on a firm
surface: rug cutter's knee
• Rarely direct trauma
• Second most common
site for septic bursitis
 Baker’s Cyst
• Pseudothrombophlebitis
syndrome
• Herniated fluid-filled sacs of
articular synovial membrane
that extend into popliteal fossa
• Causes: trauma, rheumatoid
arthritis, gout, osteoarthritis
• Pain worse with active knee
flexion
 Baker’s Cyst
• Can mimic deep venous
thrombosis
• Ultrasound eseential
• Many resolve over weeks
• May require surgery
• Steroid injections not
performed: risk of
neurovascular injury
 Anserine Bursitis
• Cavalryman's disease /
pes bursitis / goosefoot
bursitis: obese women
with large thighs,
athletes who run
• Anteromedial knee,
inferior to joint line at
insertion of sartorius,
semitendinous, and
gracilis tendon
 Anserine Bursitis
• Abrupt knee pain, local
tenderness 4 to 5 cm
below medial aspect of
tibial plateau
• Knee flexion exacerbates
 Iliotibial Band
Syndrome
• Lateral knee pain
• Cyclists, dancers,
distance runners,
football players
• Pain worse climbing
stairs
• Tenderness when
patient supine, knee
flexed to 90o
ankle
 Peroneal Tendonitis
• Peroneal tendons cross
behind lateral malleolus
• Running, jumping, sprain
• Holding foot up and out
against downward pressure
causes pain
 Peroneal Tendon Rupture
• Torn retinaculum
• Have patient dorsiflex and plantar flex with
foot in inversion
• Feel for “snapping” behind lateral malleolus
 Retrocalcaneal Bursitis
• Ankle overuse: excessive
walking, running, or jumping
• Heel pain: especially with
walking, running, palpation
• Haglund disease: bony ridge
on posterosuperior calcaneus
• Treatment: open heels (clogs),
bare feet, sandals, or heel lift
 Plantar Fasciitis
• Policeman's heel / soldier's
heel: associated with heel spurs
• Degenerated plantar fascial
band at origin on medial
calcaneous
• Heel pain worse in morning and
after long periods of rest
• May be relieved with activity
 Plantar Fasciitis
• Microtears in fascia from overuse?
• Eliminate precipitators, rest, strength and
stretching exercises, arch supports, and night
splints
• Sometimes need steroid injection
• Risk of plantar fascia rupture and fat pad
atrophy
 Tarsal Tunnel Syndrome
• Between medial malleolus and
flexor retinaculum
• Vague pain in sole of foot: burning
or tingling
• Worse with activity, especially
standing, walking for long periods
• Tender along course of nerve
 Tarsal Tunnel Syndrome
• Between medial malleolus and flexor
retinaculum
• Vague pain in sole of foot: burning or tingling
• Worse with activity, especially standing,
walking for long periods
• Tender along course of nerve
Muscle Injuries
 Acute Muscle Injuries
• Contusions
• Strains
• Tendon Injuries
• Cramps/spasms
• Overexertional problems
 Contusion
• Bruise • Hematoma (blood
• Sudden traumatic blow tumor): formation
to body (severe caused by pooling of
compression force) blood and fluid w/in a
• Not penetrate skin tissue space
• Usually injury to blood • Speed of healing
vessels depends on tissue
damage and internal
• Superficial, deep, or bleeding
hemorrhage
 Contusion
• Symptoms:
– Swelling
– Point tenderness
– Redness
– Ecchymosis
• Treatment: PRICE,
stretch
• Complication: myositis
ossificans—calcification
of the muscle to bone
 Strains
• Stretch, tear, or rip in the muscle or adjacent
tissue (fascia or muscle tendon)
• Severe tension force
• Common sites:
– Hamstring
– Quadriceps
– Hip flexor
– Biceps
– Latissimus dorsi
 Strains
• Grade 1
– Some muscle fibers stretched or torn
– Some tenderness/pain with AROM
• Grade 2
– Number of muscle fibers torn
– Active contraction of muscle extremely painful
• Grade 3
– Complete rupture of muscle (MTJ)
– Significant impairment or total loss of movement
 Strains

Signs & Symptoms Prevention

• Localized swelling • Proper warm-up
• Cramping • Stretch
• Inflammation • Proper mechanics
• Loss of function • Proper cool-down/
stretch
• Pain
• Proper nutrition &
• General weakness
hydration
• Discoloration
 Strains
• Treatment
– Reduce swelling & pain
– NSAIDs
• Severe—
– Hard cast
– Surgery
 Tendon Injuries—
Anatomy of a Tendon
• Extension of muscle
– Musculotendinous junction
• Contains wavy parallel collagenous fibers
organized in bundles surrounded by
gelatinous material that decreases friction
• Connects muscle to bone
– Concentrates pulling forces in limited area
• Not as elastic
• May run through sheath
 Tendon Injuries
• Tears commonly at • Tendonitis:
muscle belly, inflammation of
musculotendinous tendon-muscle
junction, or bony attachments, tendons,
attachment or both
– Tendon double strength
muscle it serves
• Tenosynovitis:
inflammation of
synovial sheath
surrounding tendon
 Tendonitis
• Signs & Symptoms • Prevention
– Pain & inflammation – Slowly increase intensity
– Worse with movement & type of exercise
– Worse at night – Don’t try to do more
than ready for
• Treatment
– Proper warm-up &
– PRICE stretch
– NSAIDs
– Ultrasound therapy
– Rehabilitation
 Cramps/Spasms
• Cramp: painful • Spasm: reflex reaction
involuntary contraction caused by trauma of
of a skeletal muscle or musculoskeletal system
muscle group

→ Can lead to muscle

and tendon injuries
 Overexertion Muscle
Injuries
Soreness Stiffness
• Muscular pain from • Occurs when muscles
strenuous muscular exercise worked hard for long period
• DOMS of time
• Preventative • Fluids that collect in muscle
• Treatment during/after activity
absorbed in bloodstream
slowly
• Result in swollen, shorter,
thicker muscle that resist
stretching
 Chronic Musculotendinous
Injuries
• Myositis: inflammation of muscle tissue
• Fasciitis: inflammation of muscle fascia
– Fascia supports and separates muscle
• Tendinitis
• Tenosynovitis
 Chronic Musculotendinous
Injuries
Ectopic Calcification Atrophy
• Myositis ossificans • Wasting away of muscle
– Occur in muscle directly tissue
overlies bone – Immobilization of body part;
loss of nerve simulation
Contracture
• Abnormal shortening of
muscle tissue
• Resistance to passive
stretch
– Associated with joint
developed resisting scar
tissue
Nerve entrapment syndrome
 Obtaining the History
• Pain questions- location, duration, type, etc.
• Presence and location of numbness and
paresthesias
• Exertional fatigue and/or weakness
• Subjective muscle atrophy
• Symptom onset- insidious or post-traumatic
• Exacerbating activities
 History (continued)
• Changes in exercise duration, intensity or frequency

• New techniques or equipment

• Past medical history and review of systems

– Diabetes
– Hypercoaguable state
– Depression/anxiety
– Nutritional deficiencies
– Thyroid disease
 Physical Exam
• Spinal ROM, tenderness and provocative tests
– Spurling’s, Hoffman’s, etc.
• Extremity ROM, tenderness, swelling,
temperature changes, discoloration,
sensation, pain with resisted movements,
sensation deficits
• Muscle weakness and atrophy
 Exam (continued)
• Anatomic malalignments
• Biomechanical abnormalities
• Provocative testing
– Tinel’s (reproduction of symptoms by tapping over
the nerve; compared to unaffected side)
– Diagnosis specific (i.e., carpal tunnel tests)
• Post-exercise testing
 Diagnostic Testing
• Plain radiographs
• MRI, CT or bone scan
– Of all imaging, MRI most likely to be diagnostic
– Others often more “exclusionary”
– Vascular studies- ABI, MRA, angiography
• Labs- glucose, HgbA1C, thyroid, sed rate, CRP,
CPK, B12/folate, rheumatologic studies, etc.
 Electromyography and
Nerve Conduction Studies
• May be helpful but not always diagnostic even if a neuropathy
present
• Testing at rest could produce a false negative
• Often 3 weeks of pathology required before EMG/NCS
abnormalities can be detected
• An unrelated neuropathy may be detected
• Choose your specialist wisely- someone familiar with
athletically-related neuropathies and someone who performs
these on a frequent basis
 Treatment
• Highly variable depending on the specific pathology, etiology,
degree of pain and disability and proven methods of
correction

• 3 R’s- rest, rehab and/or referral

• NSAIDS, corticosteroids (oral or injectable)

• Improvements in muscle strength, flexibility, posture

• Correction of biomechanical abnormalities and/or errors in

technique
 Surgical Treatment
• Nerve decompression
• Neurolysis
• Neuroma excision
• Nerve resection
• Nerve repair
• Nerve or muscle transfer