Penatalaksanaan Kfr Pada Tendinitis
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Transcript of Penatalaksanaan Kfr Pada Tendinitis
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PENATALAKSANAAN KFR PADA
TENDINITIS
dr.Hendi IndiarsaSupervised :
dr.Tertianto Prabowo,SpKFR
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TENDON• A tendon (or sinew) is a tough band of fibrous
connective tissue that usually connects muscle to bone.
• Tendons are similar to ligaments and fasciae as they are all made of collagen .
• Except that ligaments join one bone to another bone, and fasciae connect muscles to other muscles.
• Tendons and muscles work together and can only exert a pulling force.
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Tendon
Fungsi Tendon :Mentransmisikan gaya antara
otot dan tulangStore elastic energy
To provide & maintain body structure
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Struktur Tendon
Tendon terdiri dari sel dan matrix extraseluler
(ECM)
Lokasi Tendon dibagi menjadi 3,yaitu :
Muscle tendon junction (MTJ)
Bone-tendon junction (BTJ)
Tendon Midsubstance
Pada BTJ, tdpt 4 zone yg dibagi berdasarkan
komposisi bahannya (over a distance of about 1 mm) : tendon, fibrocartilage,
mineralized fibrocartilage, tulang.
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Tendon structure Composed of
fasicles derived from smaller fibrilso Surrounded by
epitendono Separated by
endotendon
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Tendon structure• Consist of fibroblasts and collagen arranged in
parallel rows
• Contain relatively few cells and therefore has low metabolic activity
• Fibroblasts produce Type I collagen o (85% of dry weight of
tendon)
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Tendon Types• 2 types:
o Paratenon covered tendons• Rich vascular supply• Better healing potential
o Sheathed tendons• Tendon segments supplied by vinculae
and osseous insertion• Avascular areas receive nutrition via
diffusion from vascularised segments
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Tendinitis & Tenosynovitis
• Tendinitis and tenosynovitis are the painful inflamation of a tendon (Tendinitis) or a tendon sheath (Tenosynovitis).
• Tendinitis is inflamation of a tendon, the fibrous cord that attaches a muscle to a bone.
• Tenosynovitis is inflamation of the sheath of tissues that surrounds a tendon.
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Tendinitis & Tenosynovitis
• These two conditions usually occur together.• Tendons around the shoulder, elbow, wrist,
fingers, thigh, knee, or back of the heel are most commonly affected.
• Both condition be caused by injury of a particular tendon, or rarely, by an infection.
• Inflamation of the achilles tendon between the heel and the calf may be the result of a sport injury or of wearing ill-fitting shoes.
• Tenosynovitis may be associated with RA.• In some cases, the cause is unknown.
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Symptoms • Pain and/or mild swelling.• Stiffness and restricted movement in the affected
area.• Warm, red skin over the tendon.• A tender lump over the tendon.Particularly during movement in the affected area, and sometimes may feel a crackling sensation (crepitus).
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General Principles of Tendinopathy Treatment• Identify & remove negative external forces/factors• Establish stable baseline treatment• Determine tensile load starting point• Use symptoms to guide loading program• Control pain• Address use of whole kinetic chain• Employ specificity• Use maximum loading• Load progression
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Rehabilitation• Early controlled mobilisation can:
o Reduce scar adhesionso Facilitate healing by stimulating remodelling
• Excessive loading will:o Disrupt the repair tissue
• Thus optimal healing requires:o Surgical apposition and mechanical
stabilisationo Minimal soft tissue damageo Optimal mechanical environment for healing
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Tendon healing• Occurs through extrinsic and intrinsic
processes
• Divided into 3 phaseso Inflammation (Day 0-7)o Repair (Day 3-60)o Organisation and remodelling (Day 28-180)
• Under action of cytokines:o PDGF (Chemotaxis)o TGFß (Collagen type)
(Transforming growth factor β)
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Variables that influence healing
TRAUMA
Cell & Matrix damage
HEALING
Inflammation -> Repair->
Remodelling
RESULT
Restoration of original tissue
Scar
Excessive repair
Failure of healing
INJURY
Type
Intensity
Duration
PATIENT
Age
Comorbidity
Medication
TREATMENT
Apposition
Stabilisation
Loading & Motion
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Inflammation (0-7 days)
• Inflammatory cells migrate from:o Epitendinous tissues (sheath, periosteum, soft
tissues) o Epitendon and endotendon
• Defect rapidly filled with granulation tissue, haematoma and tissue debris
• Fibronectin laid down as scaffolding for collagen synthesis
• Extrinsic response outweighs intrinsic response
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Inflammation (0-7 days)
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Inflammation (0-7 days)
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Inflammation (0-7 days)
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Inflammation (0-7 days)
PDGF
PDGF
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Repair (3-60 days)• Fibroblast migrate to zone of injury and
begin to synthesise collagen by day 5
• Initially collagen type 3 produced which is laid down in a random orientation
Healing tendon
Normal tendon
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Repair (3-60 days)• During 4th week intrinsic fibroblasts
proliferate and these cells take over the healing process both synthesising and reabsorbing collageno “Tendon Callus”
• Switch to production of Type 1 Collagen which is increasingly orientated along line of force
• Vascular ingrowth via collagen/fibronectin scaffolding
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Repair (3-60 days)
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Repair (3-60 days)
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Repair (3-60 days)
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Organisation (28-180 days)
• Final stability acquired during this phase by the normal physiological use of the tendon
• Accompanied by cross linking between fibrils further increasing tendon tensile strength
• Complete regeneration never achievedo Defect remains hypercellularo Thinner collagen fibrils
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Summary• Tendon healing:
o Weakest at 7-10 dayso Regain most of original strength by 21-28 dayso Achieve maximum strength by about 6 months
• Early mobilisation: o Increases ROM but can decrease tendon repair
strength if excessive stress placed on repairo Immobilisation leads to increase tendon
substance strength at expense of ROM.
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THANK YOU