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Ari Sudarsono, PT

PENGERTIAN DAN PENYEBAB


CIDERA OLAHRAGA
Cidera olahraga adalah cidera pada sistem integumen, otot
dan rangka yang disebabkan oleh kegiatan olahraga. Cidera
olahraga disebabkan oleh berbagai faktor antara lain
kesalahan metode latihan, kelainan struktural maupun
kelemahan fisiologis fungsi jaringan penyokong dan otot
(Bahr et al. 2003).
Penyebab Cidera Olahraga
1. Kesalahan Metode Latihan
Ini merupakan penyebab paling sering cidera pada otot dan sendi.
2. Kelainan Struktural.
3. Kelemahan Otot, Tendon & Ligamen.
DIAGNOSIS CIDERA OLAHRAGA AKUT
On field assessment
Tujuan dari pemeriksaan di lapangan (on field assessment) adalah
menegakkan patologi jaringan yang terkena cidera secara cepat dan tepat
dan memastikan apakah olahragawan tersebut dapat melanjutkan
permainan atau tidak. Asesmen yang dilakukan mengikuti prinsip
pemeriksaan pada umumnya yaitu pemeriksaan subyektif-obyektif-analisa-
rencana tindakan namun dalam fisioterapi olahraga dikenal pemeriksaan
dengan alur TOTAPS
Talk
Observe
Touch
Active movement
Passive movement
Skill test

Pemeriksaan di luar lapangan


Pemeriksaan di luar lapangan (Klinik) dapat dilakukan dengan lebih leluasa
secara waktu sehingga dapat diperoleh diagnostik yang lebih akurat.
Pemeriksaan juga dapat dilengkapi dengan pemeriksaan penunjang seperti
CT scan, MRI, artroskopi, elektromyografi dan foto rontgen dilakukan untuk
melengkapi informasi yang diperoleh dari anamnesis (wawancara dengan
penderita) serta pemeriksaan fisik. Pemeriksaan pada kasus cidera olahraga
biasanya didokumentasikan dalam format HOPS (History-Observation-
Palpation-Special Test
Cidera
Secara umum patofisiologi terjadinya cedera berawal
dari ketika sel mengalami kerusakan, sel akan
mengeluarkan mediator kimia yang merangsang
terjadinya peradangan. Mediator tadi antara lain
berupa histamin, bradikinin, prostaglandin dan
leukotrien. Mediator kimiawi tersebut dapat
menimbulkan vasodilatasi pembuluh darah serta
penarikan populasi sel sel kekebalan pada lokasi
cedera.
Secara fisiologis respon tubuh tersebut dikenal sebagai
proses peradangan. Proses peradangan ini kemudian
berangsur-angsur akan menurun sejalan dengan
terjadinya regenerasi proses kerusakan sel atau
jaringan tersebut (Van Mechelen et al. 1992).
Proses penyembuhan cidera
jaringan lunak
Semua cidera jaringan ikat lunak, apapun tingkat keparahannya,
harus menjalani proses penyembuhan yang sama yaitu terdiri
dari 4 fase (overlapping- interlinked); bleeding, acute
inflammation, proliferation, and remodeling
Begitu cidera, pembuluh darah yang rusak akan bleeding
menyebabkan hypoxia, sehingga jaringan yang cidera
mengandung sel-sel mati dan darah yang keluar dari pembuluh
(extravasated). Ini akan memicu respon inflamasi yang alami
namun penting, melibatkan respon vaskuler dan seluluer yang
sangat kompleks, hasilnya adanya exudates cairan, bengkak/
oedema dan aktifitas fagositik.
Secara umum treatment dan rehabilitation cidera jaringan lunak
tercakup dalam prinsip-prinsip ilmiah yang mendasari
penyembuhan jaringan
Secara tipikal, fase inflamasi akut berlangsung antara 4-6
hari, dan menyiapkan luka untuk fase proliferasi.
Inflamasi akut sebagai hasil dari vasodilatasi dan
vasopermeability dari pembuluh darah, diawali dan
dikontrol oleh susunan yang luas dari chemical mediators
yang dilepaskan oleh jaringan yang cidera.
Secara klinis, inflamasi akut manifestasinya adalah
bengkak, kemerahan, peningkatan temperatur, nyeri, yang
menyebabkan hilangnya fungsi. Pertama kali dinyatakan
oleh Celsus pada (30 BC 38 AD) menggunakan aksara
Latin; rubor, calor, tumor and dolor (18).
3 Phases of Tissue Healing
Inflammatory response phase

Fibroblastic-repair phase

Maturation-remodeling phase

Healing process is a continuum and phases overlap


one another with no definitive beginning or end
points
Inflammatory-Response Phase
After injury, healing process begins immediately
Destruction of tissue produces direct injury to cells of
various soft tissue
Characterized by redness, swelling, tenderness and
increased temperature
Critical to entire healing process
Inflammatory-Response Phase
Leukocytes and other phagocytic cells delivered to
injured tissue
Dispose of injury by-products through phagocytosis
Inflammatory-Response Phase
Vascular reaction Chemical mediators
Blood coagulation and Released from damaged
growth of fibrous tissue, white blood cells
tissue occurs and plasma
First 5-10 minutes
Histamine, leukotrienes
vasoconstriction
occurs and cytokines assist in
Best time to
limiting exudate/swelling
evaluate Amt of swelling directly
Followed by related to extent of vessel
vasodilation damage
Effusion of blood
and plasma last 24
to 36 hours
Inflammatory Response Cont
Formation of Clot Chronic inflammation
Platelets adhere to Acute phase does not
collagen fibers and respond sufficiently to
create sticky matrix eliminate injury agent
Platelets and
and restore tissue to
leukocytes adhere to normal physiologic state
matrix to form plug
Damage occurs to
Clot formation occurs
12 hours after injury connective tissue and
and is complete w/in prolongs healing and
48 hrs repair process
Set stage for Response to overuse and
fibroblastic phase overload
Inflammatory Response Cont
Entire phase last 2-4 days
Greater tissue damage longer inflammatory
phase

NSAIDS may inhibit inflammatory response


thus delaying healing process
Will assist with pain and swelling
Fibroblastic-Repair Phase
Proliferative and regenerative activity leads to scar
formation
Begins w/in 1st few hours after injury and can last as long
as 4-6 weeks
Signs and Symptoms of inflammatory phase subside
Increased O2 and blood flow deliver nutrients essential
for tissue regeneration
Fibroblastic-Repair Phase
Break down of fibrin clot forms connective tissue
called granulation tissue
Consist of fibroblast, collagen and capillaries
Fills gap during healing process
Unorganized tissue/fibers form scar

Fibroblast synthesize extracellular matrix consisting of


protein fibers (Collagen and Elastin)
Day 6 7 collagen fibers are formed throughout scar

Increase in tensile strength increases with rate of collagen


synthesis
Fibroblastic-Repair Phase
Importance of Collagen
Major structural protein that forms strong, flexible
inelastic structure
Type I, II & III
Type I found more in fibroblastic repair phase
Holds connective tissue together and enables tissue to resist
mechanical forces and deformation
Direction of orientation of collagen fibers is along lines of
tensile strength
Fibroblastic-Repair Phase
Importance of Collagen
Mechanical properties
Elasticity
Capability to recover normal length after elongation

Viscoelasticity
Allows slow return to normal length and shape after
deformation
Plasticity
Allows permanent change and deformation
Maturation-Remodeling Phase
Long term process that involves realignment of
collagen fibers that make up scar
Increased stress and strain causes collagen fibers to
realign to position of maximum efficiency
Parallel to lines of tension
Gradually assumes normal appearance and function
Usually after 3 weeks a firm, contracted, nonvascular scar exist
Total maturation phase may take years to be totally
complete
Maturation-Remodeling Phase
Wolfs law/Davies Law
Bone and soft tissue will respond to physical demands
placed on them
Remodel or realign along lines of tensile force
Critical that injured structures are exposed to progressively
increasing loads throughout rehab process
As remodeling phase begins aggressive active range of motion
and strengthening
Use pain and tissue response as a guide to progression
Maturation-Remodeling Phase
Controlled mobilization vs. immobilization
Animal studies show Controlled mob. Superior to
Immobilization for scar formation
However, some injuries may require brief period of immob.
During inflammatory phase to facilitate healing process
Factors that impede healing
Extent of injury Hemorrhage
Microtears vs. Bleeding causes same neg.
effect as edema
macrotears
Poor vascular supply
Edema
Tissues with poor vascular
Increased pressure supply heal at a slower rate
causes separation of Failure to deliver phagocytic
tissue, inhibits neuro- cells and fibroblasts for scar
muscular control, formation
impedes nutrition,
neurological changes
Factors that impede healing
Separation of tissue Corticosteroids
How tissue is torn will In early stages shown to
effect healing inhibit healing
Smooth vs. jagged
Keloids or hypertrophic
Traction on torn tissue,
separating 2 ends scars
Ischemia from spasm Infection
spasm Health, Age and
Atrophy nutrition
Healing Process-Ligament Sprains
Tough, relatively inelastic band of tissue that connects
bone to bone
Stability to joint
Provide control of one articulating bone to another
during movement
Provide proprioceptive input or sense of joint position
through mechanoreceptors
3 Grades of lig. tears
Healing Process-Ligament Sprains
Physiology
Inflammatory phase-loss of blood from damaged vessels
and attraction of inflammatory cells
During next 6 weeks-vascular proliferation with new
capillary growth and fibroblastic activity
Immediately to 72 hours
If extraarticular bleeding in subcutaneous space

If intraarticular bleeding occurs in inside joint capsule


Healing Process-Ligament Sprains
Essential that 2 ends of ligament be reconnected
by bridging of clot
Collagen fibers initially random woven pattern with
little organization
Failure to produce enough scar and of ligament to
reconnect 2 reasons ligaments fail
Maturation
May take 12 months to complete
Realignment/remodeling in response to stress and
strains placed on it
Healing Process-Ligament
Factors that effect healing
Sprains
Surgery or non surgical approach
Surgery of extraarticular ligaments stronger at first but
may not last over time
Non surgical will heal through fibrous scarring , but may
also have some instability
Immobilization
Long periods of immobilization may decrease tensile
strength weakening of insertion at bone
Minimize immobilization time
Surrounding muscle and tendon will provide stability
through strengthening and increased muscle tension
Healing Process-Cartilage
Cartilage
Rigid connective tissue that provides support
Hyaline cartilage: articulating surface of bone
Fibro cartilage: interverterbral disk and menisci. Withstands
a great deal of pressure
Elastic cartilage: more flexible than other types-auricle of ear
and larynx
Healing Process-Cartilage
Physiology of healing
Relatively limited healing capacity
Dependant on damage to cartilage alone or subchondral bone.
Articular cartilage fails to elicit clot formation or cellular
response
Subchondral bone can formulate granulation tissue and
normal collagen can form
Healing Process-Cartilage
Articular cartilage repair
Patients own cartilage can be harvested and implanted
into damages tissue to help form new cartilage
Promise for long term results
Fibrocartilage/Menisci
Depends on where damage occurs
3 zones of various vascularity
Greater that blood supply better chance of healing on own
Healing Process-Bone
Similar to soft tissue healing, however
regeneration capabilities somewhat limited
Bone has additional forces such as torsion, bending
and compression not just tensile force
After 1 week fibroblast lay down fibrous collagen
Chondroblast cells lay down fibrocartilage creating
callus
At first soft and firm, but becomes more firm and
rubbery
Osteoblast proliferate and enter the callus
Form cancellous bone and callus crystallizes into bone
Healing Process-Bone
Osteoclasts reabsorb bone fragments and clean up
debris
Process continues as osteoblast lay down new bone and
osteoclasts remove and break down new bone
Follow Wolfs law-forces placed on callus-changes size, shape
and structure
Immobilization longer 3 to 8 weeks depending on the bone
Healing Process-Muscle
Similar to other soft tissue discussed
Hemorrhage and edema followed by phagocytosis to
clean up debris
Myoblastic cells from in the area and regenerate new
myofibrils
Active contraction critical to regaining normal tensile
strength according to Wolff's Law
Healing time lengthy-Longer than ligament healing
Return to soon will lead to re-injury and become very
problematic
6-8 weeks?
Healing Process-Tendon
Not as vascular as muscle
Can cause problems in healing
Fibrous union required to provide extensibility and
flexibility
Abundance of collagen needed to achieve good tensile
strength
Collagen synthesis can become excessive can result in
fibrosis: adhesions from in surrounding structures
Interfere with gliding and smooth movement

Tensile strength not sufficient to permit strong pull for 4


to 5 weeks
At risk of strong contraction pulling tendons ends apart
Healing Process-Nerve
Nerve cell is specialized and cannot regenerate
once nerve cell dies
Injured peripheral nerve- nerve fiber can regenerate
if injury does not affect cell body
Regeneration is very slow 3-4 mm /day
Axon regeneration obstructed by scar formation
Damaged nerve within CNS regenerate poorly compared
to peripheral nervous system
Lack connective tissue sheath and nerve cells fail to
proliferate
What Does This Mean for Treatment ?
Excessive bleeding should be discouraged
Inflammation is normal and essential, though
when acute and continues, can cause problems.
Early gradual mobilisation (active rest) orientates
scar tissue in the line of stress, similar to normal
tissue plus early movement helps breaks down
adhesions
Remodelling is helped by gradual return to full
physical stress - rehabilitation programme
Soft Tissue Injury Approach
Facilitate / promote normal tissue repair
(Immobilization and) Early mobilization
Enhance sequence of events
Promote normality
Appropriate therapy to influence the process in a
positive way

DO NOT FOLLOW RICE..... Why?


Why Ice Delays Recovery?
March 20, 2014 by Gabe Mirkin, MD

When I wrote my best-selling Sportsmedicine Book in 1978, I coined


the term RICE (Rest, Ice, Compression,Elevation) for the treatment of
athletic injuries (Little Brown and Co., page 94). Ice has been a
standard treatment for injuries and sore muscles because it helps to
relieve pain caused by injured tissue. Coaches have used my RICE
guideline for decades, but now it appears that both Ice and complete
Rest may delay healing, instead of helping.
In a recent study, although cooling delayed swelling, it did not hasten
recovery from this muscle damage (The American Journal of Sports
Medicine, June 2013). A summary of 22 scientific articles found almost
no evidence that ice and compression hastened healing over the use of
compression alone, although ice plus exercise may marginally help to
heal ankle sprains (The American Journal of Sports Medicine, January,
2004;32(1):251-261).
Healing Requires Inflammation
Damage tissue heal by using immunity (inflammation).
When muscles and other tissues are damaged, our
immunity sends inflammatory cells to the damaged tissue
to promote healing. The response to both infection and
tissue damage is the same.
Inflammatory cells rush to injured tissue to start the
healing process (Journal of American Academy of
Orthopedic Surgeons, Vol 7, No 5, 1999).
The inflammatory cells called macrophages release a
hormone called Insulin-like growth Factor (IGF-1) into the
damaged tissues,
However, applying ice to reduce swelling actually delays
healing by preventing the body from releasing IGF-1.
The authors of one study used two groups of mice, with
one group genetically altered so they could not form the
normally expected inflammatory response to injury. The
other group was able to respond normally.
The scientists then injected barium chloride into muscles
to damage them. The muscles of the mice that could not
form the expected immune response to injury did not heal,
while mice with normal immunities healed quickly.
The mice that healed had very large amounts of IGF-1 in
their damaged muscles, while the mice that could not heal
had almost no IGF-1.
(Federation of American Societies for Experimental Biology,
November 2010).
Ice Keeps Healing Cells from Entering Injured Tissue

Applying ice to injured tissue causes blood vessels


near the injury to constrict and shut off the blood
flow that brings in the healing cells of
inflammation
(Knee Surg Sports Traumatol Arthrosc, published online Feb 23, 2014).

The blood vessels do not open again for many


hours after the ice was applied. This decreased
blood flow can cause the tissue to die from
decreased blood flow and can even cause
permanent nerve damage.
Inflammation is the first physiological process to the repair and remodeling
of tissue. We can not have tissue repair or remodeling without
inflammation. Ice constricts blood flow and impedes the inflammatory cells
from reaching injured tissue. The blood vessels do not open again for many
hours after ice is applied.
Inflammatory cells are designed to release a hormone known as Insulin-like
Growth Factor (IGF-1). IGF-1 is a primary mediator of the effects of growth
hormone and a stimulator of cell growth and proliferation, and a potent
inhibitor of programmed cell death. The application of ice inhibits the
release of IGF-1.
Swellinga byproduct of the inflammatory processmust be removed
from the injured area. Swelling does not accumulate at an injured part
because there is excessive swelling, rather it accumulates because lymphatic
drainage is slowed. The lymphatic system does this through muscle
contraction. Ice has been shown to reverse lymphatic flow.
Ice impedes cellular signaling and inhibits the proper development of new
cells. The processes of mechanobiology and cellular signaling take
progenitor cellsinfant cells who do not know what they are going to be
and makes them into rebuilding cells like myocytes, osteocytes, tenocytes,
chondrocytes, etc.
RECOMENDATION
Manual Lymphatic Drainage & Kinesiotaping
Reduce Swelling & control pain
(start from Bleeding phase)

Gradual Exercise (Early Mobilization)


(start from inflammatory phase)
50
Lymphatic drain area (R & L)

51
Left Lymph duct, Thracic duct
& Cysterna chyli

52
Vena Subklavia kanan & kiri

53
54
55
Evidence Based Practice
What the research DOES support about
kinesiotaping:
Decreased inflammation / edema
Tsai, 2009
Bialoszzewski, 2009
Osterhues, 2004

56
Gradual Exercise
(Using PNF Concept)
Inflamatory Phase
Maintain muscle physiology (contractility, length-tension rel.)
Use philosophy Positive Approach
Use Basic principle Irradiation & Reinforcement
Pattern
Use PNF Technique Rythmic Initiation
Combination of Isotonic
Proliferation Phase
Increase strength, ROM and propriocetion
Use philosophy Positive Approach
Use Basic principle Irradiation & Reinforcement
Pattern
Use PNF Technique Rythmic Initiation
Combination of Isotonic
Dynamic Reversals
PNF Philosophy (5)
1. Positive approach: no pain, achievable tasks, set up for success,
direct and indirect treatment, strong start.
2. Functional Approach : Highest functional level, ICF, include
treatment on body structure level and activity level.
3. Mobilize Reserves: Mobilize potential by intensive training:
active participation, motor learning, self training.
4. Consider the total whole person: Total human being with
his/her environmental, personal, physical, and emotional
factors.
5. Use of motor control and motor learning principles: repetition
in a different context; respect stages of motor control, variability
of practice.
PNF in practice 2007
BASIC PRINCIPLES (10)
Exteroceptor stimuli
Tactile Stimulation
Visual Stimulation
Auditory Stimulation
Proprioceptor stimuli
Resistance
Traction & Approximation
Stretch
Body Position & Mechanics
Timing
Pattern
Irradiation & Reinforcement
TECHNIQUE (10)
Agonist Technique
Rythmic Initiation
Combination of Isotonics/ Agonist Reversal
Repeated Stretch from begining of range
Repeated Stretch through range
Replication
Relaxation and/ or Stretching techniques
Contract Relax
Hold Relax
Antagonist Technique
Dynamic Reversals
Stabilizing Reversals
Rythmic Stabilization
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed
Inflammation is the first physiological process to the repair and remodeling of
tissue. You cannot have tissue repair or remodeling without inflammation. Ice
constricts blood flow and impedes the inflammatory cells from reaching
injured tissue. The blood vessels do not open again for many hours after ice is
applied.
Inflammatory cells are designed to release a hormone known as Insulin-like
Growth Factor (IGF-1). IGF-1 is a primary mediator of the effects of growth
hormone and a stimulator of cell growth and proliferation, and a potent
inhibitor of programmed cell death. The application of ice inhibits the release
of IGF-1.
Swellinga byproduct of the inflammatory processmust be removed from
the injured area. Swelling does not accumulate at an injured part because there
is excessive swelling, rather it accumulates because lymphatic drainage is
slowed. The lymphatic system does this through muscle contraction and
compression. Ice has been shown to reverse lymphatic flow.
Gabe Mirkin, MDthe physician who coined the term RICEhas since said he
was wrong. Coaches have used my RICE guideline for decades, but now it
appears that both Ice and complete Rest may delay healing, instead of helping.
Gabe Mirkin, MD, March 2014
In a National Athletic Trainers Association position statement (the review of
many scientific papers) on the management of ankle sprains (2013) found that
ice therapies had a C level of evidence, meaning little or poor evidence exists. In
an interview, the author of that article said: I wish I could say that what we
found is what is really being done in a clinical setting. Maybe our European
colleagues know something we dontthere is very little icing over there.
Ice does not facilitate proper collagen alignment. Diagnostic imaging of chronic
tendon injuries like Achilles tendinopathy, jumpers knee, runners knee, and
plantar fasciitis show poor collagen arrangement of connective tissue. Study
shows that exercise (especially eccentric loading) helps align collagen.
Ice impedes cellular signaling and inhibits the proper development of new cells.
The processes of mechanobiology and cellular signaling take progenitor cells
infant cells who do not know what they are going to beand makes them into
rebuilding cells like myocytes, osteocytes, tenocytes, chondrocytes, etc.
Ice slows nerve firing and interferes with the strength, speed, and coordination
of muscle. A search of the medical literature found 35 studies on the effects of
cooling and most reported that immediately after cooling, there was a decrease
in strength, speed, power and agility-based running.
Ice does control pain, but that pain relief lasts only 20-30 minutes and as
evidenced above, has detrimental side effects to healing.