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2. Plantar Facitis

PLANTAR FASCITIS

Oleh Dr H. Subagyo  SpB - SpOT

 Plantar Fascia, Dibaca  "plantar fash-ee-a"

Plantar berarti "Kaki", Fascia berarti "Band"

I.         PENDAHULUAN

Hampir seluruh penduduk dunia, pernah mengalami sakit yang satu ini yaitu rasa nyeri pada telapak kaki yang tidak menimbulkan kematian akan tetapi sangat mengganggu setiap aktifitas sehari-hari, mulai dari bangun tidur, berdiri, berjalan bahkan berlari, sehingga penderita tersebut akan memaksakan diri untuk memeriksakan ke dokter, agar dapat sembuh dari penderitaannya. Penderita biasanya mengetahui dari dokter spesialis ortopedi bahwa penyakit yang dideritanya adalah “fasciitis plantaris” atau “plantar fasciitis). Penyakit ini merupakan urutan nomor 3 setelah penyakit pinggang (low back pain) dan penyakit sendi lutut (osteo artritis).

Penyebab tersering rasa sakit pada telapak kaki terutama pada tumit adalah fasciitis plantaris. Biasanya hal disebabkan ketidakseimbangan biomekanik yang menyebabkan tekanan sepanjang fascia plantaris. Diagnosis ditegakkan dengan anamnesis dan pemeriksaan fisik termasuk lokasi rasa sakit. Terapinya berupa obat antiinflamasi, kompres dingin, dan pereganggan. Injeksi kortikosteroid dan balutan gips dapat dicoba. Operasi fasciotomy atau EPF (endoscopic plantar fasciotomy) metoda Dr. Barrett (1993) dapat dilakukan pada pasien yang tidak bisa dilakukan dengan pengobatan konservatif. Rasa sakit dapat berasal dari neurologi, trauma, atau sistemik.1

Fasciitis plantaris merupakan penyebab utama sakit pada tumit, mempunyai gejala klinis berbeda-beda. Walaupun rasa sakit berada sepanjang fascia plantaris, biasanya terbatas pada medial inferior calcaneus pada processus medial tubercel calcaneus. Tulang yang menonjol merupakan bagian insersio fascia plantaris centralis dan abductor hallucis brevis, flexor digitorum brevis.1

Fasciitis plantaris atau disebut juga “Heel spur syndrome”. Tapi penamaan ini tidak tepat. Spur dalam hal ini bukan penonjolan tulang pada calcaneus inferior yang merupakan penyebab sakit, bukan hanya penonjolan yang radiografik. Tidak ada hubungan antara rasa sakit dan ada/tidaknya penonjolan tulang, dan eksisi spur bukan merupakan bagian dari operasi pada fasciitis plantaris. Fasciitis plantaris terjadi pada pria dan wanita, tapi lebih sering pada usia tua. Angka kejadian dan keparahan berhubungan dengan obesitas.1

 

II.     ANATOMI      

Kerangka Kaki terdiri atas 3 bagian yaitu :

                  - Tarsal,

                  - Metatarsal dan

                  - Falang

Calcaneus merupakan bagian dari tulang tarsal yang paling besar dan terletak pada bagian belakang kaki untuk menahan berat badan seseorang

Calcaneus mempunyai 6 permukaan

Calcaneus berartikulasi dengan dua tulang tarsal lainnya yaitu talus di atasnya dan tulang cuboid kearah kaki bagian tengah.

Bagian posterior-bagian belakang dari calcaneus adalah tuberositas calcaneus, besar, “non-articulating process”, dan merupakan titik insersi tendon calcaneus (tendon Achilles).

Fungsi Calcaneus à Tumpuan utama dari komplek muskulus gastrocnemius dan muskulus soleus.

Tulang ini memberikan fondasi atau menyokong berat badan seseorang.

 

Fascia plantaris merupakan suatu serabut kaku yang berasal dari bawah tumit dan melebar sepanjang telapak kaki sampai ke jari-jari kaki. Fascia plantaris dapat gampang ditemukan dibawah kaki, terutama ketika jari-jari kaki dorsofleksi (keatas). Fascia plantaris terdiri dari 3 bagian; medial, central, dan lateral. Bagian medial dari fascia plantaris merupakan serabut yang paling sering menimbulkan keluhan pada kasus faciitis plantar.2

Gambar 1. Permukaan plantar dan medial kaki, asal dan insersio fascia plantaris dan lokasi nervus pada proksimal tumit.1.

 

              Heel (tumit)           Fascia plantaris            insersi di Toe (jari kaki)

Gambar 2.  Bagian medial dari fascia plantaris merupakan serabut yang paling sering menimbulkan keluhan pada kasus faciitis plantar

 

III. ETIOLOGI

Pasien yang menderita fasciitis plantaris umumnya terjadi pada:

-          72% wanita

-          74% overweight

-          87% berumur diatas 30 tahun

-          43% pekerja yang berdiri lebih dari 6 jam sehari atau berjalan

-          Baru mulai olahraga setelah beberapa tahun tidak olah raga (mendadak).

Berdasarkan penelitian oleh Martin RL, Irrgang JJ, Conti SF. Dalam jurnalnya berjudul Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int 1998;19:803-11 , pasien dengan fasciitis plantaris mempunyai lapisan bagian tumit yang lebih tipis dan overpronasi saat berjalan3 dan penyebab penyakit tersebut:

-          36% tidak diketahui

-          15% oleh karena berjalan

-          12% oleh karena berlari

-          10% oleh karena perubahan aktivitas

-          5% terjadi saat kecelakaan

-          4% oleh karena sepatu

-          7% oleh karena overweight

-          16% oleh kerena obese (kegemukan)

Penyebab fasciitis plantaris dapat diakibatkan karena:

-          Terlalu lama berdiri yang bila bergerak terjadi peningkatan tekanan yang besar secara tiba-tiba pada telapak kaki sehingga dapat menyebabkan stress atau injuri pada fascianya.

-          Pada pekerja kantor karena telalu lama duduk dapat menyebabkan berkurangnya fleksibilitas otot betis.

-          Pada yang banyak bergerak menggunakan kaki seperti perawat, tukang pos, dan guru.

-          Pada pekerja yang berdiri atau berjalan selama berjam-jam tanpa sepatu yang baik (dengan permukaan yang keras).

Menurut heelspurs.com (salah satu website komunity terbesar mengenai plantar fasciitis ) di USA, kelebihan berat badan merupakan penyebab utama faciitis plantaris (heel spurs), terutama pada wanita. Pada sebuah jurnal (An October 4, 2000 an article in JAMA by the CDC 20 using 1999) melaporkan orang obese dengan body mass index (BMI>30) memungkinkan 5,6 kali terkena fasciitis plantaris dari pada yang tidak overwight (BMI<25). Wanita yang overweight 6 kali lebih besar menderita fasciitis plantaris dari pada pria overweight. Wanita dengan berat badan normal atau underweight 2,4 kali lebih besar menderita sakit tumit dibandingkan pria dengan berat badan normal atau underweight.3,4

 

IV. PATOFISIOLOGI

Sebagian besar fasciitis plantaris disebabkan ketidakseimbangan biomekanik yang menyebabkan pronasi abnormal. Contoh pasien dengan pes varus flexible dapat terjadi pada struktur kaki yang awalnya normal, tapi dengan berat badan yang besar, dapat menunjukan pronasi yang hebat. Saat pasien berdiri plantar akan fleksi dan adduksi, calcaneus akan menekan. Pronasi akan meningkatkan tekanan pada fascia plantaris. Bagian terlemah fascia plantaris adalah insersio fascia plantaris, bukan serabutnya (karena kekuatan tertinggi peregangan berada pada serabut fascia).4

Ketika berdiri dan semua berat badan bertumpu pada kaki, telapak kaki datar, dan fascia plantaris menjadi tegang. Fasciitis plantaris terjadi ketika berat badan yang disokong kaki, sangat besar sehingga fascia plantaris bergerak menjauhi tulang tumit. Rasa sakit pada fasciitis plantaris tidak menggambarkan berapa tajam spur tumit, tapi menggambarkan tekanan yang sangat besar pada fascia plantaris saat berdiri (menahan berat badan). Fascia plantaris yang sangat tegang yang dapat menyebabkan robekan dari bawah tumit.5

Saat membicarakan biomekanik heel spur syndrome, penting untuk mengerti definisi dari ’berat mekanikal’ (berat badan + berat barang yang dibawa).

Besarnya tekanan pada permukaan kaki, frekuensi terpaparnya, dan lama terpaparnya, membedakan tingkat fasciitis plantaris. Awal terkenanya fasciitis plantaris masing-masing berbeda-beda pada setiap orang. Contohnya pada pelari jarak jauh, frekuensi terpaparnya berat dan tekanan pada permukaan kaki merupakan penyebab utama yang menyebabkan fasciitis plantaris. Untuk pekerja pabrik, lamanya berdiri, durasi terpaparnya berat merupakan penyebab utama terjadinya fasciitis plantaris. Biasanya orang yang menderita fasciitis plantaris tidak hanya memiliki satu penyebab saja.5

Gambar 3. Plantar fasciitis.6

 

V. GEJALA KLINIK

Gejala fasciitis plantaris klasik. Gejala berkembang pelan-pelan dan semakin sakit dalam seminggu sampai 2 tahun. Rasa sakit semakin berat, rasa sakit semakin terfokus dibawah tumit. Pasien mengatakan rasa sakit yang sangat berat di bawah tumit terutama ketika berdiri dari bangun tidur pagi hari atau mencoba berdiri setelah istirahat. Rasa sakit sesudah istirahat sangat tajam dan berkurang setelah 5-10 menit (85%). Rasa sakit pada tuberkulum calcaneus medialis. Rasa sakit bisa perlahan-lahan, tanpa riwayat trauma akut.  Rasa sakit terjadi 24 jam sehari atau ketika berjalan atau berdiri (82%). Rasa sakit saat ditekan oleh jari (lebih dari 70%). Rasa sakit setelah berjalan minimal 100 yard (58%). Rasa sakit biasanya pada tumit, tapi biasa juga berubah-ubah dengan alasan yang tidak diketahui atau rasa sakit diseluruh bagian bawah telapak kaki.7

Pasien mengatakan rasa sakit yang semakin berat seiring berjalannya hari. Rasa sakit tumpul. Rasa sakit biasanya berada di bawah tumit tapi dapat juga didalam tumit. Gambar 4 menggambarkan lokasi sakit pada fasciitis plantaris. Area warna merah, di bawah tumit merupakan daerah dimana fascia plantaris meradang yang terletak tepat di bawah medial calcaneus. Ini merupakan lokasi sakit saat berdiri setelah istirahat atau ketika berdiri saat bangun tidur pagi hari. Pada gambar juga terdapat lokasi rasa sakit yang dirasakan yang sedikit berbeda dari masuknya nervus tibialis, plantar medialis dan cabang medial dan lateral calcaneal ke tumit. Garis putus-putus warna merah menggambarkan bagian dari nervus tibia posterior. Nervus tibia posterior masuk ke kaki, dibagi menjadi beberapa macam yang berfungsi motorik otot kaki dan sensoris dibawah kaki. Terjepitnya nervus tibia posterior dapat menyebabkan tarsal tunnel syndrome atau Baxter’s nerve entrapment.1

Gejala Klinik Umum: Dengan menyaring data dari banyak artikel, dapat disimpulkan bahwa gejala klinik yang paling umum terjadi adalah rasa sakit yang meningkat dengan drastic pada area jaringan telapak kaki (fascia plantaris) umumnya terjadi pada waktu pagi hari disaat penderita berjalan beberapa langkah awal. Ada beberapa kondisi yang dapat menyebabkan hal ini, tapi plantar fasciitis adalah yang kondisi factor yang paling umum. Penderita menyampaikan bahwa rasa sakit terjadi sepanjang hari (dalam 24 jam) atau saat berjalan atau berdiri. Rasa sakit juga terjadi bila telapak kaki ditekan dengan jari tangan.


Gambar 4. Lokasi sakit fasciitis plantaris.1

 

 

 

 VI. DIAGNOSIS

Test dapat dipakai untuk mendukung diagnosis:

  1. Penggunaan Tape. Jika penggunaan tape (gambar 6a) secara langsung mengurangi rasa sakit, menunjukkan bukti bahwa tekanan pada fascia adalah penyebab dari rasa sakit.
  2. Pemakaian bantalan kertas setebal 1 inci pada tumit (atau merengangkan otot betis) dapat menghilangkan rasa sakit, hal ini menunjukan kurangnya fleksibilitas pada otot betis sebagai penyebab tekanan yang kuat pada fascia plantaris.
  3. Pemakaian bantalan lunak bisa mengurangi rasa sakit, diagnosis masih bisa mengarah ke plantar fasciitis, namun penyebabnya bisa juga berupa tekanan fracture atau jaringan heep pad atrophy yang kurang  menopang.
  4.  Langkah berikut bisa mengurangi rasa sakit dan memperkuat arah kesimpulan diagnosis bahwa tekanan pada plantar fascia adalah penyebab utama rasa sakit.
  1. Menekan jempol kaki kebawah ketika berjalan (Membagi tekanan dari fascia ke tendons dan otot calf).
  2. Mengarahkan kaki kearah dalam menuju kaki lain ketika berjalan.
  3. Berjalan menggunakan ujung telapak kaki.

Jika dilakukan kompresi menggunakan telapak tangan atau diberikan anti-inflamasi selama 2 menit dapat mengurangi rasa sakit, maka menunjukkan tanda-tanda ada inflamasi yang menyebabkan rasa sakit.

Pemeriksaan penunjang lain: Scanning tulang menunjukan peredaran darah yang tinggi pada fascia yang ke tumit, terutama jika rasa sakit memburuk. Jika scanning tulang positif, hal ini menandakan stress fraktur, infeksi, atau perlukaan operasi. Jika scanning tulang negatif, hal ini bukan menandakan stress fraktur, kemungkinan penyebab lain adalah terlukanya saraf atau fasciitis plantaris. Pemeriksaan laboratorium dapat digunakan untuk mencari kemungkinan arthritis, tapi tidak dapat dipakai sebagai pembuktian sebagai arthritis. MRI digunakan untuk membantu konfirmasi fasciitis plantaris tapi bisa juga tidak digunakan untuk konfirmasi fasciitis plantaris. Pada MRI ditemukan penebalan fascia. MRI merupakan standar untuk mengetahui adanya fraktur, ruptur fascia plantaris atau infeksi. Ultrasound dapat digunakan sebagai alat diagnosis untuk melihat ketebalan fascia. Pada penelitian ditemukan fascia yang menebal 2 kali lipat (5,2 mm) pada pasien dengan sakit tumit dibandingkan dengan kontrol (2,6 mm).4,9


Gambar 6a. Penggunaan Tape

 

Diagnosis fasciitis plantaris ditegakkan dari anamnesis, pemeriksaan fisik, dan pemeriksaan penunjang.. Palpasi pada tuberkulum calcaneus medial biasanya menimbulkan rasa sakit (gambar 6). Rasa sakit biasanya berada pada insersi serabut fascia plantaris centralis, dengan rasa sakit yang tidak jelas saat penekanan calcaneus dari medial ke lateral. Foto roentgen proyeksi lateral dan anteroposterior menggambarkan kaki bagian belakang dan depan, juga menggambarkan kelainan tulang seperti fraktur, tumor, atau rheumatoid arthritis di calcaneus. Radiografi ditunjukan untuk menunjang diagnosis klinik.1,8

 

Gambar 6. Palpasi tuberkulum calcaneus medialis yang menimbulkan rasa sakit pada pasien dengan fasciitis plantaris.

 

Gambar 7. Plantar heel spur. Sisi bagian lateral calcaneus. Panah menunjukan spur di inferior calcaneus.2

               

VII. DIAGNOSA BANDING

Penyebab lain rasa sakit pada tumit adalah sciatica, tarsal tunnel syndrome, entrapment of the lateral plantar nerve, rupture of plantar fascia, calcaneal stress fracture dan apophysitis calcaneal (Sever’s disease).3

 

 

TABLE 1
Diagnosa Banding  


 

Penyakit

 

Fitur perbandingan klinik

  1. 1.     Neurologic causes (entrapment syndromes)

 

Radiating burning pain, numbness and tingling, especially at night

-          Tarsal tunnel syndrome

 

Diffuse symptoms over plantar surface

-          Medial calcaneal branch of the posterior tibial nerve entrapment

 

Medial and plantar heel symptoms

-          Abductor digiti quinti nerve entrapment

 

Burning pain in heel pad area

2.   Skeletal causes

 

Bony point tenderness

-          Calcaneal stress fracture activity

 

Pain with weight-bearing; worsens with prolonged weight-bearing

-          Paget's disease

 

Bowed tibias, kyphosis, headaches

-          Tumor

 

Deep bone pain; constitutional symptoms late in the course

-          Calcaneal apophysitis (Sever's disease)

 

Posterior heel pain in adolescents

3.    Soft tissue causes

 

 

-          Fat pad syndrome

 

Atrophy of heel pad

-          Heel bruise

 

History of acute impact injury

-          Bursitis

 

Usually retrocalcaneal; swelling and erythema of posterior heel

-          Plantar fascia rupture

 

Sudden acute, knife-like pain, ecchymosis

-          Tendonitis

 

Pain with resisted motions

-          Plantar fasciitis

 

See text.

 

 

TARSAL TUNNEL SYNDROME

 

Gbr.8

Keterangan:

  1. Tibial Nerve Entrapment adalah terjepitnya syaraf tibialis dibelakang maleolus medialis dibawah flexor retinaculum, dan biasa disebut dengan Tarsal tunnel syndrome. Evaluasi dengan EMG / NCS sangat membantu, dan merupakan indikasi untuk dilakukan operasi. Juga dapat dijelaskan tepitan distal cabang pertama syaraf plantaris lateralis yang mempersyarapi otot adductor digiti quinti.
  2. Medial Plantar Nerve Entrapment adalah titik persilangan antara otot flexor digitorum longus dengan otot flexor hallucis longus dinamai “Knot of Henry” dan disebabkan umumnya oleh karena pemakaian Orthotic, dan biasanya disebut dengan Jogger’s foot, dan penanganannya berhasil  baik secara konservatif.

Tarsal tunnel syndrome disebabkan kompresi nervus tibialis posterior yang berasal dari malleolus medial bagian posterior melewati anteromedial menuju calcaneus. Canal struktur fibro-osseous terdiri dari flexor retinaculum medial, bagian posterior talus dan calcaneus lateral, dan melleolus anterior medial. Tendon tibialis posterior, flexor digitorum longus dan musculus flexor hallucis longus, nervus tibialis posterior, berserta arteri dan vena masuk ke dalam rongga tersebut. Kompresi nervus tibialis posterior dapat menimbulkan rasa terbakar.3

Kondisi ini dapat disebabkan kompresi nervus tibialis posterior oleh massa jaringan lunak, callus dari fraktur malleolus medial, inflammasi tendon yang melewati canal tarsal dengan pronasi berlebihan akan menyebabkan tekanan pada tendon tibia posterior dan nervus yang bersangkutan. Pasien mengatakan bahwa rasa sakit seperti rasa baal sekitar plantar dan bagian medial tumit. Tarsal tunnel syndrome juga disebut posterior tibial nerve neuralgia. Rasa sakit tidak berkurang dengan istirahat, juga dirasakan baal pada jari-jari kaki. Nervus tibialis posterior berperan dalam mempersarafi sensoris, dan pasien biasanya kesulitan dalam menunjukan lokasi spesifik bagian yang sakit pada tumit. Berbeda dibandingan pasien dengan rasa sakit pada fasciitis plantaris, pada tarsal tunnel syndrome rasa sakit yang semakin berat saat berdiri dan berjalan setelah istirahat dalam waktu yang lama dan tidak menunjuk secara spesifik rasa sakit pada insersio serabut fascia plantaris medialis.3

Pemeriksaan fisik seperti palpasi nervus tibia posterior dari proksimal kebagian distal malleolus medial melewati bagian anterior calcaneus. Pasien mengatakan rasa tidak nyaman seperti terbakar yang menjalar dari proksimal betis (Valleix sign) atau distal jari-jari kaki (Tinel’s sign). Pemeriksaan terhadap struktur telapak kaki yang dapat menyebabkan gangguan biomekanik. Gaya berjalan yang abnormal dapat menyebabkan tekanan yang besar pada isi dari terowongan tarsal posterior, sehingga terjadi iritasi nervus tibia posterior. Pemeriksaan kecepatan hantaran saraf dan test electromyographic dapat mendukung diagnosis tarsal tunnel syndrome. Terapi konservatif seperti mengurangi berjalan, NSAID, terapi peregangan, dan pengunaan orthotoc dapat mengurangi gejala. Pasien yang tidak ada respon terhadap terapi konservatif dapat dilakukan tindakan operasi dekompresi canal tarsal.3

 

  • ENTRAPMENT OF THE LATERAL PLANTAR NERVE

Terjepitnya cabang pertama nervus plantar lateral, yang mempersarafi musculus abductor digiti, menyebabkan rasa sakit pada plantar tumit medial. Lokasi terjepitnya saraf berada antara musculus abductor hallucis, musculus plantaris quadratus, menimbulkan sensasi terbakar pada plantar tumit yang timbul saat aktifitas dan tetap saat istirahat. Palpasi pada area ini dapat menimbulkan rasa sakit, dengan sensasi baal. Pengobatan konservatif tersebut untuk fasciitis plantaris tersebut sangat efektif untuk mengatasi kondisi ini.3

  • RUPTUR FASCIA PLANTARIS

Ruptur fascia plantar merupakan penyebab yang jarang yang menimbulkan rasa sakit pada plantar. Rasa sakit yang berat pada arkus medial karena trauma fisik. Beberapa pasien salah didiagnosis sebagai fasciitis plantaris dan tidak sukses diterapi dalam beberapa bulan dengan injeksi steroid. Pemeriksaan fisik dengan palpasi didapatkan berkurangnya fascia plantaris atau berkurangnya area bagian distal fascial. Rasa sakit yang berat saat palpasi fascia plantaris terasa sangat signifikan pada distal processus medial dari tuberositas calcaneus. Cara jalan yang pincang yang menunjukan ekstremitas yang terkena. Penanganan berupa imobilisasi dengan tidak boleh menumpu berat pada tungkai bawah dan NSAID. Imobilisasi selama 4 sampai 6 minggu.3

  • STRESS FRAKTUR CALCANEUS

Rasa sakit pada tumit yang akut karena stress fraktur calcaneus hampir sama seperti fasciitis plantaris. Rasa sakit yang tiba-tiba muncul pada aktifitas sehari-hari. Rasa sakit saat kompresi  calcaneus lateral dan medial (gambar 10). Rasa sakit fraktur dimulai dari awal aktifitas dan selama aktifitas. Rasa sakit seperti itu jarang ada pada pasien fasciitis plantaris. Pengobatan konservatif seperti edukasi pasien untuk membatasi aktifitas karena akan memperburuk rasa sakit. Pasien disarankan mengunakan sepatu athletic (untuk mengurangi tekanan pada tumit).3

FRACTURE CALCANEUS

Anatomi

 

Gbr. 9

KLASIFIKASI FRAKTUR CALCANEUS (Palmer (1948) dan Essex Lopresti (1952))

  • Fraktur calcaneus Ekstra-artikular
  • Fraktur calcaneus Intra-artikular (2 Tipe)
  • Fraktur calcaneus kominutif
  • Fraktur avulsi tuberositas calcaneus

Terdapat 6 metode yang umumnya digunakan untuk penatalaksanaan fraktur calcaneus dengan gangguan pada sendi subtalar yaitu:

  1. Metode traksi
  2. Dengan pembalutan kompresif dan mobilisasi segera
  3. Immobilisasi dengan plaster cast (Pembalut gips)
  4. Reduksi dengan fiksasi internal dengan atau tanpa        ”Bone Graft”
  5. Metode Essex-Lopresti
  6. Artrodesis sendi subtalar segera

Campbell operatif dalam penanganan fraktur dan dislokasi kaki.

Essex-Lopresti merekomendasikan penatalaksaan untuk fraktur calcaneus sebagai berikut ;

  1. Terapi konservatif untuk semua fraktur yang tidak terdapat pergeseran tanpa melihat apakah sendi subtalar ikut terganggu atau tidak, tetapi dengan penekanan untuk mobilisasi segera sendi yang berdekatan.
  2. Fiksasi aksial dengan pin metalik untuk fraktur calcaneus tipe ”Tongue Depression”
  3. Reduksi terbuka dan fiksasi internal (ORIF) untuk fraktur calcaneus tipe ”Joint Depression”

 

TEKNIK FIKSASI AKSIAL (Essex-Lopresti)

  1. Dilakukan tindakan anestesi spinal, pasien dalam posisi supine (terlentang) dengan kepala sedikit diturunkan
  2. Dilakukan asepsis dan antisepsis lapangan operasi, dipersempit dengan duk steril
  3. Dilakukan insisi mulai dari kutis, subkutis pada bagian posterior kaki kemudian diperlebar dengan hak sehingga calcaneus terlihat dan terexpose semua.
  4. Dilakukan fiksasi dengan clamp bone/calcaneus clamp/tulang reduction clamp
  5. Kemudian dilakukan pengeboran dan pin/wire sebanyak 5 buah dipasang untuk fiksasi. Setelah itu dipasang Tension Bend Wiring.
  6. Perdarahan dirawat dan luka operasi ditutup lapis demi lapis
  7. Operasi selesai.

 

Gambar: Reduksi Fraktur Calcaneus dengan Manipulasi dan Fixasi Pin

Dorsal dan diilustrasikan sebagai fraktur umum dalam intra artikular fraktur dari calcaneus.

A. Dorsal :

  1. Fraktur sagittal melalui permukaan posterior.
  2. Dinding lateral fraktur
  3. Garis fraktur memisahkan sisa dari calcaneus melalui fragment sustentaculum
  4. Fraktur transverse melalui sinus tarsi.
  5. Pelebaran fraktur ke calcaneocuboid.

B. Plantar

  1. Dinding fraktur medial dimana fragment tuberositi berpindah dengan medial.
  2. Fragment tuberosity memiliki variabel fraktur

Pengobatan pada fraktur calcaneus merupakan dilemma, ada yang dilakukan secara konservatif atau dengan operatif tergantung dari jenis frakturnya.

Pengobatan pada fraktur tertutup intraarticuler calcaneus menggunakan casting (gips), bisa dengan elastik band dan segera mobilisasi.

Dapat menggunakan traksi fiksasi, manipulasi menurut Böhler dan dapat juga menggunakan pin fiksasion menurut Essex-Lopresti.

Menurut Essex-Lopresti

  1. Konservatif; bila fraktur non displaced atau minimal displaced (minimal bergeser) dan segera dilakukan mobilisasi.
  2. Operatif;  Axial fixation dengan menggunakan metallic pin untuk fraktur tipe ‘tongue’.
  3. ORIF (open reductin internal fixation) untuk fraktur sendi depress.

Technik yang digunakan pada ORIF adalah:

  • Medial approach (Mc Reynolds, Burdeaux)
  • Kombinasi medial & lateral approach (Stephenson, Romash)
  • Lateral approach saja (Benirsckke dan Sangeorzan)
  • Juga beberapa ahli diikuti dengan melakukan arthrodesis

Tujuan utama pengobatan fraktur calcaneus adalah:

  1. Mengembalikan joint ke kondisi yang kongruen (facet port dan sendi subtalar)
  2. Mengembalikan ketinggian dari os calcaneus
  3. Mengembalikan ketebalan dari os calcaneus
  4. Dekompresi celah subtalar untuk dilewati otot peroneal
  5. Perbaiki aligment (keselurusan) pada posisi valgus
  6. Perbaiki sendi calcaneocuboid bila terjadi fraktur

Faktor yang mempengaruhi pada pengobatan fraktur calcaneus:

  1. Umur; sering terjadi pada umur 50-55 tahun
  2. Status kesehatan; apakah ada DM atau Neuropathy
  3. Jenis frakturnya; apa tipe I, II atau III
  4. Kerusakan jaringan lunak sebagai penyokong.
  5. Pengalaman Operatornya sendiri; mahir atau sudah terbiasa melakukan tindakan tsb

Hasil ORIF

  • Ditangani segera dalam waktu 12-24 jam pertama maka hasilnya akan baik
  • Dilakukan atara hari ke 10-14 maka jaringan akan bengkak sehingga akan tegang dan agak kesukaran dalam approximasi / mendekatkan kulit
  • Dilakukan setelah 3 minggu maka operasi akan sulit
  • Dilakukan setelah 4-6 minggu maka dilakukan primary arthrodesis

Bila dilakukan pemasangan Pin maka pin akan diangkat setelah 4-6 minggu, dan weight bearing (menopang) dimulai setelah 8-10 minggu setelah operasi.

Komplikasi

  • Problem luka; infeksi
  • Retracting soft tissue à full thickness flaps
  • Drain
  • Suture
  • Pre Op antibiotic
  • CALCANEAL APOPHYSITIS

Calcaneal apophysitis (Sever’s disease) biasanya terdapat pada anak laki-laki usia 6-10 tahun, terutama yang obesitas dan melakukan aktifitas berat. Rasa sakit berada pada bagian posterior calcaneus dan rasa sakit bertambah berat setelah aktifitas olah raga. Palpasi pada posterior calcaneus sekeliling insersio tendon Achilles biasanya menimbulkan rasa sakit local. Tendon Achilles tegang dengan kemampuan dorsifleksi yang terbatas, yang menyebabkan pasien berjalan dengan bertumpu pada jari-jari kaki untuk mengurangi rasa sakit. Penanganannya berupa pijat dengan es dan NSAID, diikuti dengan latihan peregangan untuk mencapai kemampuan dorsifleksi maksimal. Imobilisasi dengan orthotic digunakan pada pasien aktif dan tidak patuh terhadap pengobatan.3

  • SCIATICA

Rasa sakit pada tumit berasal dari sciatica karena tekanan pada nervus L5-S1, yang mempersarafi tungkai bawah bagian posterior, dan gluteal, kaki kaki bagian anterior, posterior, dan lateral, juga tumit. Nervus ini berperan dalam reflek ankle patellar reflex (APR). Rasa sakit tajam yang menjalar dari bawah pantat dan posterior tungkai bawah dan distal tumit.3

 

Gbr.

PENYAKIT SISTEMIK

Rasa sakit pada sendi dapat terjadi pada berbagai macam kondisi inflamasi sistemik, seperti rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, gout, dan systemic lupus erythematosus. Gonorrhea dan tuberculosis juga dapat menyebabkan rasa sakit pada tumit, walau jarang terjadi. Sebagian besar pasien dengan penyakit sistemik disertai sakit sendi dan inflamasi pada bagian lain, tapi gejala biasanya awalnya berasal dari tumit. Anamnesis dan pemeriksaan fisik dapat menyimpulkan suatu penyakit arthritis. Contohnya, seorang laki-laki muda yang mengatakan rasa sakit tumit bilateral dan mempunyai riwayat konjungtivitis atau urethritis lebih dari 1 bulan, mengambarkan Reiter’s disease.

 Rasa sakit tumit pada pasien dengan riwayat psoriasis dan rasa sakit yang asimetris pada sendi interfalang distal pada jari tangan dan kaki, menunjukan kemungkinan psoriatic arthritis. Jika rasa sakit berasal dari sistemik, pengobatan awal harus ditujukan untuk penyakit primernya. Radiografi pada pasien inflamasi sistemik dapat mengambarkan posterior atau plantar exostoses, tapi penemuan ini tidak penting.3

VIII. PENATALAKSANAAN FASCIITIS PLANTARIS

Penanganan fascitis plantar dibagi dua, yaitu konservatif dan operatif. Sebelum diputuskan melakukan tindakan operasi sebaiknya dilakukan tindakan konservatif terlebih dahulu. Hampir sebagian besar, rasa sakit pada fasciitis plantaris dapat dihilangkan dengan pengobatan konservatif. Sebagian lagi memerlukan tindakan operatif. Walau tidak semua rasa sakit dapat hilang pada pengobatan konservatif.

KONSERVATIF

Pengobatan konservatif fasciitis plantaris ditujukan untuk mengatasi komponen inflamasi yang menyebabkan ketidaknyamanan dan faktor biomekanik yang menyebabkan gangguan. Edukasi pasien sangat penting. Pasien harus mengerti penyebab dari rasa sakit termasuk faktor biomekanik.

Langkah-langkah penanganan konservatif dapat dikategorikan sebagai berikut:

  • Teknik penggunaan taping,
  • Penggunaan sepatu athletic
  • Stretching (Peregangan) dan Straigthening (Pelurusan)
  • Penunjang Arch (bentuk kaki)  dan Orthotics
  • Night Splints
  • Anti-Inflammatory Agents
  • Iontophoresis
  • Corticosteroid Injections

Teknik penggunaan taping

Penggunaan teknik taping untuk mengurangi rasa sakit akibat fasciitis plantaris. Rasa sakit secara signifikan dapat dikurangi dengan perlindungan pembatasan pergerakan kaki.

Langkah 1

 

Penempatan tape strip ukuran 1-1/2 inch. Putari metatarsal, tutupi areal medial dan  pinggiran kaki lateral.

Langkah 2

 

Gunakan tape ukuran 1 inch. Mulai dari metatarsal kepala ke lima, diikuti dengan sekeliling lateral kemudian putari calcaneous dan silangi ke posisi mula-mula

Langkah 3.

 

Ulangi langkah diatas, mulai dan akhiri pada kepala metatarsal pertama

Langkah 4

 

Alternatif bentuk silang 3 kali setiap posisi.

Langkah 5

 

Tutup permukaan plantar dengan 1-1/2 inch tape.

Langkah 6

 

Akhiri dengan menutupi seluruh permukaan tape dengan 2 lapis tape lagi.

Penggunaan sepatu athletic

Penggunaan sepatu yang tepat juga dapat membantu mengurangi rasa sakit. Pada penderita yang memiliki telapak kaki rata, sepatu khusus untuk mengatur pergerakan atau sepatu yang lebih lebar longitudinalnya bisa membantu. Beberapa pasien menggunakan sepatu yang kekecilan, yang bisa mengakibatkan gejala-gejala sakit pada kaki.

Pasien disarankan untuk merubah aktifitas sehari-hari, seperti memakai sepatu athletic yang sesuai dengan lengkung medial ketika berjalan. Pasien diberikan bantalan logitudinal metatarsal pada kunjungan pertama, tebalnya 1-4 inchi, yang diukur dari distal tuberkel calcaneus medial sampai 0,5 cm proksimal dari ujung metatarsal. Bagian yang medial dibuat lebih tebal dibanding lateral. Bantalan ini berguna untuk mengurangi pronasi.6,7

Stretching (Peregangan) dan Straigthening (Pelurusan)

Peregangan tendon achilles berguna sebagai terapi tambahan pada fasciitis plantaris. Cara pertama dengan meletakan papan diatas sebuah batu-bata. Cara kedua dengan mendorong dinding, yaitu meletakan kaki pertama 6 inchi dari dinding dan kaki yang lainnya setinggi 2 feet dari dinding, dan kemudian gerakan kedepan dinding sambil mempertahankan kedua tumit berada pada lantai. Ketiga dengan Prostretch. Keempat dengan night splint.

                                  

Gambar 10. Latihan mendorong dinding untuk stretching (peregangan) otot Gastrocnemius kanan dan otot Soleus kiri.

                                                                            

Gambar 11. Naik tangga                                                              Gambar 12. Berdiri di Papan miring

Gambar 13. Menggunakan 2-3 Inci untuk stretching otot Intrinsik kaki

 

Gambar 14. Menggunakan alat stretching yang dinamis (berputar)

 

Gambar 15. Menggunakan 2 jari untuk pijat diatas fascia plantaris

Gambar 16. Menggunakan Handuk untuk stretching otot-otot fleksor kaki

 

Night Splints

Penggunaan night splints pada gambar 20 (orthosis) pada malam  hari dan mempertahankan kaki pada sudut 90 derajat atau lebih dari pergelangan kaki telah digunakan sebagai terapi tambahan pada fasciitis plantaris. Balut gips ini mencegah kontraksi fascia plantar saat pasien tidur. Berdasarkan penelitian  pada pasien yang diterapi dengan balut gips, 83% pasien mengatakan rasa sakitnya menghilang. Faktor biomekatik yang menyebabkan gerakan pronator abnormal yang menekan bagian medial fascia plantar harus dihilangkan. Latihan peregangan dilakukan pada kedua kaki selama 6-8 minggu, lalu dievaluasi kembali.6,7

                                   

Gambar 17. Menggunakan batu bata.5      Gambar 18. Prostretch.5

                                             

Gambar 19. Mendorong dinding.5

     

Gambar 20. Night splints.5

 Anti-Inflammatory Agents

Setiap malam selama 10-14 hari, pasien mengkompres tumit  dengan es selama 15 sampai 20 menit sebelum tidur. Alternatif lain berupa pijat fascia plantar dengan es selama 15 menit per hari dalam 2 minggu. Bila pasien tidak mempunyai kontraindikasi nonsteroidal antiinflamasi (NSAID) , NSAID dapat diberikan selama 6-8 minggu

Iontophoresis

Iontophoresis  adalah penggunaan kejutan listrik dari stimulasi galvanic bervoltase rendah, berguna untuk merubah corticosteroids menjadi lebih lunak.

Sebuah studi oleh Gudeman (ref 27) menyatakan bahwa penggunaan iontophoresis menunjukan kemajuan yang berarti setelah penerapan dalam 2 minggu tapi tidak ada perubahan setelah penerapan di minggu ke-6.

 

Gbr. 21

Corticosteroid Injections

Injeksi kortikosteroid harus dihindari pada awal terapi fasciitis plantaris. Kortikosteroid hanya digunakan sebagai terapi tambahan pada fasciitis plantaris kronik. Setelah melakukan kontrol biomekanik. Injeksi ini dapat menyebabkan hilangnya lapisan lemak jika digunakan tidak benar. 3 ml NSAID yang dicampur dengan 1% lidokain, 0,5% marcaine, dan 1 ml triamcinolone (40 mg per mL) diinjeksikan sekitar processus medual tuberositas calcaneus.Pengunaan radiographic digunakan sebagai alat bantu untuk mengetahui tempat injeksi.8

Injeksi kortikosteroid diberikan kepada pasien yang tidak berespon terhadap program peregangan dan/atau memakai sepatu yang cocok atau orthosis.7,8

  • Berdasar penelitian, injeksi intralesi kortikosteroid lebih efektif dan harganya lebih efektif daripada terapi extracorporeal shockwave yang telah diberikan dalam waktu lebih dari 5 minggu (Porter, 2005).
  • Injeksi kortikosteroid disuntikan dengan jarum ukuran 22, panjang 1,5 inchi (3,8 cm) untuk menyuntikan 4 mL anestesi local (contohnya lidokain) dan 1 ml (40 mg) kortikosteroid (contoh methylprednisolone).
  • Palpasi bagian anterior tuberkel calcaneus plantar medial dan masukan jarum pada sisi ini. Masukan jarum sampai mencapai bagian anterior distal dari tuberositas calcaneus medial plantar, lalu injeksikan. Jangan menyuntikan pada bagian superfisial pada bagian subkutan, karena injeksi kortikosteroid pada lapisan lemak superfisial dapat menyebabkan nekrosis dan atrofi, menyebabkan telapak kaki tidak dapat merasakan tekanan.
  • Hambatan nervus pada injeksi steroid digunakan untuk mengurangi rasa sakit pada injeksi dan meningkatkan hasil terapi, tanpa komplikasi (Govindarajan, 2003).
  • Perdarahan atau memar biasanya dapat terjadi pada pasien dengan gangguan perdarahan atau mengkonsumsi antikoagulan.
  • Infeksi pada tempat injeksi jarang, tapi dapat terjadi. Jadi harus dijaga sterilitasnya.
  • Pada pasien dengan diabetes, terjadi peningkatan kadar glukosa darah setelah injeksi kortikosteroid.
  • Reaksi alergi dapat terjadi walau jarang.
  • Penyuntikan intravaskular dapat menyebabkan disfungsi jangtung, karena toksisitas anestesi lokal.
  • Disfungsi nervus perifer dapat terjadi jika anestesi lokal diinjeksikan dekat atau di nervus plantar medial pada nervus tibia cabang calcaneus.
  • Berdasar penelitian, 25 pasien yang mendapatkan injeksi fasciitis plantaris menunjukan gejala yang menghilang.

               

OPERASI

Terapi konservatif yang telah dijelaskan harus dilakukan selama beberapa bulan sebelum dilakukan operasi. Tidak bijaksana bila melakukan tindakan operasi pada pasien dengan tidak mencoba melakukan terapi konservatif dengan baik dan tidak memperbaiki penyebab. Operasi diindikasikan pada pasien yang gagal dengan pengobatan konsevatif dan pasien yang masih merasakan sakit setelah terapi. Pada operasi dapat dilakukan plantar fasciotomi tanpa exostectomi inferior calcaneus (gambar 15). Endoskopi plantar fasciotomi dapat dilakukan dengan tindakan invasif minimal. Endoskopi plantar fasciotomi kurang traumatik daripada operasi terbuka.9 

 

Gambar 22. Lokasi plantar fasciotomi.3

 

Gbr. 23

Fascia dibebaskan, sehingga tekanan diatas fascia dikurangi (prinsip dekompresi)

Operasi biasanya tidak diperlukan untuk fasciitis plantaris. Rasa sakit pada sebagian besar pasien (95%) dengan fasciitis plantaris dapat sembuh dengan terapi non operasi. Operasi dipertimbangkan setelah terapi non bedah selama minimal 6 bulan tapi tidak membaik dan rasa sakit yang membatasi aktifitas sehari-hari. Operasi meliputi pemotongan (pelepasan) bagian fascia plantar ligament untuk mengurangi tekanan dan meredakan inflamasi. 70-80% rasa sakit pada pasien fasciitis plantaris dapat diatasi dengan tindakan operasi.9

Endoscopy Plantar Fasciotomy (EPF)

Endoscopic plantar fasciotomy adalah teknik surgery yang mengutamakan ketepatan tinggi, tapi tidak sulit dilakukan apabila semua parameter diikuti dengan benar.

Lokal anastesi diperlukan karena proses operasi hanya singkat saja (kira-kira memakan waktu 10-15 menit). Hematosis secara komplit diperlukan sebelum prosedur dilakukan, hal ini dapat diperoleh dengan menggunakan Esmarck bandage dan ankle tourniquet.
Penempatan  cannular secara benar adalah intisari dari prosedur ini, Proyeksi radiograph bisa diambil tanpa pemberat tumit.

Penempatan cannula ditandai dengan 1-2mm distal, atau anterior dari inferior cancaneal exotosis, atau medial calcaneal tubercle bila tidak ada rasa sakit. 

Penempatan ini dapat diukur dengan 2 arah. Dari posterior ke anterior, dan dari inferior ke superior dari ujung kulit yang bersangkutan.

 

Gbr.24

5mm insisi permukaan dilakukan dengan blade 15 pada posisi yang ditandai.

Insisi harus dilakukan dengan efektif agar kemungkinan perpindahan dari medial calcaneal dapat dihindari.

Dengan menggunakan gunting kecil yang tumpul untuk memisahkan lemak medial subcutaneous akan membuat portal arthroscopy. Gunakan fascial elevator menembus ke inferior fascia untuk membuat area untuk obturator/cannula.

Gbr.25

Pada tahap ini, 2 area konflik akan dirasakan, kira-kira 1/3 aspek plantar dari telapak dan juga pada 2/3 permukaan kaki. 

Obturator dan cannula bisa dilakukan dengan cara yang sama seperti diterangkan diatas untuk pengangkatan fascial. Ketika ujung dari obturator dimasukan kedalam lateral dermis, assisten dapat melakukan insisi vertical diatas permukaan kulit sehingga obturator dapat menembus kulit

Gbr.26

Obturator dapat diangkat dari cannula. Endoscope kemudian dapat dimasukan, juga alat potong. Ada banyak variasi teknik operasi, adalah penting untuk melakukan prosedur dari medial ke lateral .

Surgery dinyatakan selesai bila pemisahan fascial dapat dilihat dari otot intrinsic dibawahnya. Ujung fascial harus terlihat untuk memisahkan dorsiflexion dari kaki.

Penempatan Posisi Cannula

Seperti terlihat pada gambar cannula, ada 2 penandaan (marking) yang menempatkan posisi medial investment. Kedua tanda ini berada pada 9mm dan 11 mm dari medial dermis. Dengan memulai fasciotomy menggunakan hook blade pada kedua tanda tersebut dan berlanjut sehingga ke tanda selanjutnya akan mencegah pemotongan yang terlalu berlebihan. Tanda-tanda tersebut adalah rata-rata dari cadaveric dissections dan hanya digunaakan sebagai panduan. Penampakan kasat mata dari anatomi cannula adalah teknik penempatan yang terbaik.

 

Gbr.27

Komplikasi operasi pada fasciitis plantaris adalah :9

  • Terlepasnya fascia plantaris yang besar

Pada operasi dilepaskan 30-50% fascia plantar. Lepasnya fascia plantar yang berlebih selama operasi menyebabkan bentuk telapak kaki datar karena kehilangan lengkung telapak kaki.

  • Terlukanya nervus kaki

Terdapatnya saraf-saraf kecil sepanjang fascia plantar. Saraf-saraf ini walau dilindungi, akan rusak selama operasi dalam melepaskan fascia plantaris. Sebagian kecil pasien akan mengeluh sakit atau baal pada lokasi tersebut setelah operasi fasciitis plantaris.

  • Infeksi

Infeksi merupakan komplikasi yang mungkin terjadi setelah operasi. Sehingga diperlukanoperasi yang baik dan diberikan antibiotik yang adequat untuk mencegah terjadinya infeksi.

Post-Operative

Seperti terlihat pada MRI scan berikut, terlihat perbedaan panjang plantar.

Pasien harus beristirahat atau mengurangi aktivitas fisik selama 6-8 minggu untuk memperbolehkan fascia melewati proses re-fibrose.

Membuat keputusan untuk melakukan operasi pada fasciitis plantaris9

 

Alasan melakukan operasi

Alasan untuk tidak melakukan operasi

-          Pasien telah melakukan terapi non operasi minimal 6 bulan, dan tidak ada perbaikan rasa sakit.

-  Sakit tumit mengganggu aktifitas atau alasan sebagai atlit atau program latihan.

-  Pasien tidak dapat atau merasa tidak sanggup melakukan tindakan non operasi selama 6 sampai 12 bulan.

- Pekerjaan atau hobi pasien yang mengharuskan pasien dalam waktu yang cukup lama.

-          Terapi non operasi berhasil memperbaiki rasa sakit.

-          Pasien telah berhasil dengan melakukan tindakan non operasi dalam waktu kurang dari 6 bulan.

-          Pasien bersedia dan sanggup untuk melakukan tindakan non operasi dalam 6 sampai 12 bulan dan melihat hasilnya dapat mengatasi rasa sakit atau tidak

-          Pekerjaan atau hobi pasien tidak berpengaruh terhadap rasa sakit tumit.

-          Status kesehatan pasien berisiko terhadap tindakan operasi dan anestesi.

Dalam membuat keputusan operasi pada fasciitis plantaris harus mempertimbangkan beberapa hal, seperti keparahan kondisi pasien, kesuksesan terapi sebelumnya, dan keterbatasan dalam membatasi pekerjaan atau aktifitas olahraga.9

  • Setiap pasien tidak harus dilakukan operasi. Hanya sekitar 5% pasien dengan fasciitis plantaris yang melakukan operasi. Para ahli menyarankan untuk mencoba melakukan tindakan non medis minimal 6 bulan sebelum diputuskan operasi.
  • Operasi mungkin dapat dilakukan jika pasien merasa putus asa terhadap pengobatan non operatif yang dilakukan dalam 6 sampai 12 bulan atau jika rasa sakit pada tumit mempengaruhi aktifitas bekerja atau dalam kegiatan olah raga.
  • Operasi dapat mengurangi rasa sakit. 75 dari 100 pasien yang melakukan operasi, menunjukan rasa sakit yang berkurang.
  • Operasi tidak menjamin akan mengurangi rasa sakit. 25 dari 100 pasien yang melakukan operasi, menunjukan rasa sakit yang menetap.

IX. REHABILITASI MEDIK

Definisi Rehabilitasi Medik (WHO 1981) adalah semua upaya yang bertujuan mengurangi dampak dari keadaan yang dapat menimbulkan disabilitas dan handicap, serta memungkinkan penderira cacat berperan aktif dalam lingkungan keluarga dan masyarakat.

Jika seseorang menderita sakit atau Gangguan permanent/tidak permanent dari anatomi, fisiologi, psikologi orang tersebut (Impairment) atau Keterbatasan fungsi-fungsi badan (Disabilitas) atau Gangguan penderita pada tingkat sosial, sehingga tidak dapat bersosialisasi dengan baik (Handicap).

Tujuan dari Rehabilitasi Medik adalah mencegah kecacatan; mengembalikan kelainan fungsi dan mental pasien seoptimal mungkin; melatih pasien menggunakan fungsi yang masih tersisa semaksimal mungkin.

Program Rehabilitasi Medik antara lain meliputi: .

  • Fisioterapi: menggunakan modalitas fisik (terapi panas, dingin, arus listrik, air), massage, latihan terapeutik, manipulasi.
  • Okupasi Terapi: terapi kerja atau terapi latihan mengerjakan sasaran yang terseleksiyang bertujuan agar pasien mandiri melakukan aktifitas kegiatan sehari-hari dan
  • melakukan tugas sesuai fungsinya.
  • Ortotik & Prostetik: membuat alat bantu untuk anggota badan yang lemah (Ortotik) atau membuat alat ganti/ palsu untuk bagian tubuh yang hilang (Prostetik); dan juga
  • membuat alat bantu jalan seperti kursi roda, tongkat, walker, dsb.
  • Speech terapi : membantu melatih bicara, menelan dan komunikasi bagi penderita yangmengalami gangguan.  
    Biasanya penderita datang mengeluh nyeri pada telapak kaki; kemungkinan suatu radang pada jaringan lunak di telapak kaki (Fasciitis Plantaris). Penyakit ini mempunyai gejala seperti: nyeri pada telapak kaki pada waktu pagi hari dan nyeri tekan pada daerah tumit. Hal ini biasanya disebabkan antara lain: pergerakkan kaki yang berlebihan (banyak jalan/ lari), sepatu yang tidak cocok/ nyaman dipakai, kegemukkan, atau adanya kelainan pada telapak kaki (adanya perkapuran pada tulang calcaneus atau bentuk kaki ceper/ kaki rata). Untuk penanganan masalah tersebut yang paling baik adalah menghilangkan penyebabnya. Ada beberapa saran yang dapat dilakukan untuk mengurangi rasa nyeri pada penderita Fasciitis Plantaris:
    • Kontras bath (bak air hangat dan air dingin): rendam kaki yang sakit pada air hangat dan air dingin secara bergantian untuk jangka waktu 3-5 menit setiap hari.
    • Hindari berjalan kaki/ berlari yang berlebihan.
    • Kurangi berat badan yang berlebihan.
    • Hindari berjalan tanpa alas kaki.
    • Pilih sepatu/ sandal yang nyaman dan enak dipakai, disarankan untuk menggunakan sepatu / sandal dengan alas yang lunak.
    • Dapat juga menggunakan sepatu dengan hak tinggi (high heel) 3-5 cm untuk mengurangi tekanan pada daerah tumit.
    • Modifikasi sepatu dengan “Heel Cap” untuk daerah tumit, atau bagi mereka yang mempunyai kaki ceper perlu diberikan “Medial Weidge”.

 

IX. PROGNOSIS

Pasien yang tidak membaik setelah pengobatan konservatif selama 9 sampai 12 bulan, disarankan operasi. Kegagalan operasi dalam menanggulangi penyakit ini adalah 2% sampai 35%. Kegagalan ini ditandai dengan memburuknya rasa sakit dalam satu tahun terakhir. Rasa sakit pada tumit menetap. Sebagian pasien mengeluhkan rasa sakit yang tidak  berkurang setelah operasi mungkin disebabkan komplikasi seperti infeksi dan lain-lain.9

 

XI.  TINJAUAN  PUSTAKA

  1. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998;19:91-7.
  2. Barret SL, O’Malley R. Plantar Fasciitis and Other Causes of Heel Pain. American Family Physician (serial online) 1999 April 15th (cited 2007 June 20th). Available from URL: HYPERLINK http://aafp.org
  3. Batt ME, Tanji JL, Skattum N. Plantar fasciitis: a prospective randomized clinical trail of the tension night splint. Clin J Sports Med 1996;6:158-62.
  4. Benton-Weil W, Borrelli AH, Weil LS, Weil LS. Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis. J Foot Ankle Surgery 1998;37:269-72.Crenshaw AH. MD. 1992.
  5.  Fracture and Dislocations of Foot (Fractures of Calcaneus). In: Campbell’s Operative Orthopaedics. 2nd Vol. 8th ed. Mosby Year Book. Toronto; Chapter 44.
  6. Culley J. Plantar Fascia Release. Orthopedics (serial online). Available from URL: HYPERLINK http://www.orthopedics.about.com
  7. Daly PJ, Kitaoka HB, Chao YS. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle 1992;13: 188-95.
  8. Frank H. Netter, M.D., Anatomy, Physiology, and Metabolic Disorders, The Ciba Collection of Medical Illustrations, Musculoskeletal System, Part 1, Volume 8,  1987, hal: 105, 502, 503
  9. Foye PM, Stitik TP. Plantar Fasciitis. Emedicine (serial online) 2006 Dec 21th (cited 2007 June 25th). Available From URL: HYPERLINK: http://www.emedicine.com
  10. Furey JG. Plantar fasciitis. The painful heel syndrome. J Bone Joint Surg 1975;57:672-3.
  11. Gill LH, Kiebzak GM. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int 1996;17:527-32 [Published erratum appears in Foot Ankle Int 1996;17:722].
  12. Gudeman SD, Eisele SA, Heidt RS, Colosimo AJ, Stroupe AL. Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. Am J Sports Med 1997;25:312-6.
  13. Kane D, Greaney T, Bresnihan B, Gibney R, FitzGerald O. Ultrasound guided injection of recalcitrant plantar fasciitis. Ann Rheum Dis 1998;57:383-4.
  14. Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed 2000;28:38-48.
  15. Kwong PK, Kay D, Voner RT, White MW. Plantar fasciitis. Mechanics and pathomechanics of treatment. Clin Sports Med 1988;7:119-26.
  16. Leach RE, Seavey MS, Salter DK. Results of surgery in athletes with plantar fasciitis. Foot Ankle 1986;7:156-61.
  17. Lohrer H, Alt W, Gollhofer A. Neuromuscular properties and functional aspects of taped ankles. Am J Sports Med 1999;27:69-75
  18. Lynch DM, Goforth WP, Martin JE, Odom RD, Preece CK, Kotter MW. Conservative treatment of plantar fasciitis. A prospective study. J Am Podiatr Med Assoc 1998;88:375-80.
  19. Manfroy PP, Ashton-Miller JA, Wojtys EM. The effect of exercise, prewrap, and athletic tape on the maximal active and passive ankle resistance of ankle inversion. Am J Sports Med 1997;25:156-63.
  20. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int 1998;19:803-11.
  21. McCarthy D. Nonsteroidal anti-inflammatory drug-related gastrointestinal toxicity: definitions and epidemiology. Am J Med 1998;105:3S-9S.
  22. McFarland EG, Cosgarea A, Krabak BJ. Sports Medicine & Shoulder Surgery. Johns Hopkins Medicine. Available from URL: HYPERLINK http://hopkinshospital.org
  23. Meyer HR. The female foot. Foot Ankle Int 1996; 17:120-4.
  24. Miller M.D., Review of Orthopaedics, Secon Edition,W.B. Saunders Company, Philadelphia, 1996, hal: 181
  25. Mizel MS, Marymont JV, Trepman E. Treatment of plantar fasciitis with a night splint and shoe modification consisting of a steel shank and anterior rocker bottom. Foot Ankle Int 1996;17:732-5.
  26. Oster JA. Plantar Fasciitis. My Foot Shop (serial online) 2007 June 6 (cited 2007 June 10). Available from: URL: HYPERLINK http://www.myfootshop.com
  27. Plantar Fasciitis Organization. Plantar Fasciitis, Heel Spur, Heel Pain. Available from URL: HYPERLINK: http://www.plantar-fasciitis.org
  28. Powell M, Post WR, Keener J, Wearden S. Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study. Foot Ankle Int 1998;19:10-8.
  29. Quillen WS, Magee DJ, Zachazewski JE. The process of athletic injury and rehabilitation. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic injuries and rehabilitation. Philadelphia: Saunders, 1996:3-8.
  30. Reid DC. Sports injury assessment and rehabilitation. New York: Churchill Livingstone, 1992.
  31. Roberts S. Plantar Fasciitis and Heel Spurs. Scoot’s Book on Plantar Fasciitis, Heel Spurs, and Heel Pain (serial online) 2004 Augst 25th (cited 2007 June 20th). Available from URL: HYPERLINK http://www.heelspurs.com
  32. Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1994; 15:376-81.
  33. Singh D, Angel J, Bentley G, Trevino SG. Plantar fasciitis. BMJ 1997;315:172-5.
  34. Stanley KL, Weaver JE. Pharmacologic management of pain and inflammation in athletes. Clin Sports Med 1998;17:375-92.
  35. Stephen L. Barrett, D.P.M.F.A.C.F.A.S., F.A.C.F.O.Endoscopic Plantar Fasciotomy (EPF) Decompression Intermetatarsal Neuroma (EDIN-2) Gastrocnemius Recession (EGR)
  36. Sollitto RJ, Plotkin EL, Klein PG, Mullin P. Early clinical results of the use of radiofrequency lesioning in the treatment of plantar fasciitis. J Foot Ankle Surg 1997;36:215-9,256. [1]
  37. Wapner KL, Sharkey PF. The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle 1991;12:135-7.
  38. Wikipedia. Plantar Fascia. Available from URL: HYPERLINK http://www.wikipedia.org
  39. Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int 1994;15:97-102

 

 

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