Ankle pain (발목 통증)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
KEYWORDS:
..Common cause of Ankle pain
i. Ankle sprain(85%) (usually, inversion injury)
ii. Fracture(<5%), including stress fractures : tibia, fibula, talus, calcaneus,
fifth metatarsal
iii. Peroneal tendonitis/subluxation/ dislocation
iv. Arthritides : rheumatoid, degenerative joint disease, gout, pseudogout,
ankylosing spondylitis, Reiter's syndrome, psoriatic
v. Anterior/posterior impingement
vi. Complex regional pain syndrome
vii. Osteochondritis dissecans
▶ Ligaments of the ankle
1. Description of pain :
- acute onset pain with no trauma?
→ stress fracture
- Early morning stiffness?
→ arthritis
- Pain with extreme dorsi-/ plantar flexion?
→ anterior/posterior impingement
- Pain out of proportion to injury?
Ankle pain
Key questions
Tibia
Anterior talo-fibular
Calcaneus Calcaneo-fibular ligament
Fibula
Posterior
talo-fibular
ligament
- Vasomotor disturbances +/- edema?
→ complex regional pain synd.
2. Injury mechanism if injured
3. Previous foot or ankle injury?
4. Occupational or athletic history
5. Mechanical symptoms : popping or snapping? (peroneal tendon dysfunction) :
locking or instability of ankle? (osteochondritis dissecans)
1. Anterior drawer test 2. Talar tilt test
3. Ankle AP/lat/oblique view
if fracture suspected
4. CT/MRI : >80% sensitive and specific in detecting soft tissue damage
5. Bone scan for suspected stress fracture
..의사가 환자의 발을 잡고, 수동 족저굴곡(plantarflexion), 내번(inversion)을 할
때 외측부 통증이 증가하면 inversion injury (anterior talofibular ligament)의 손
상을 강력히 시사한다.
..Instability 정도가 손상 정도를 가장 잘 시사하며, 부종이나 통증이 심하다고
반드시 손상이 심각한 건 아니며 손상된 한 발로 체중부하를 하지 못할 때
심각한 손상을 고려해야 한다.
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The Root of ambulatory care
Key tests
▶ Drawing the calcaneus and talus
anteriorly while stabilizing the tibia,
3~14mm indicates grade 2 sprain ;
> 15mm indicates grade 3 sprain
▶ Stressing the ankle laterally (inversion)
and medially (eversion) while stabilizing
the patient’s leg, 5~10degree
difference between ankles indicates
grade 2 sprain ; > 10degree difference
indicates grade 3 sprain
..
→
Key treatments
Key treatment of
Ankle sprain
Ankle pain
RICED
1. Rest from pain-producing activities
2. Ice for 20minutes several times a day while area is swollen
3. Compression with padding and a wrap
4. Elevation above level of heart to reduce edema
5. Drug : NSAIDs (e.g., Ibuprofen 400~800mg tid-qid & Acetaminophen 650mg
every 4~6hours until edema and pain subside)
Physical therapy(PT) aimed at improving motion, strength, flexibility and proprioception
분류 통증
전방전위검사
instability End point
Grade 1 (+) (-) (+)
1~2주 정도 단순 압박붕대 혹은 테이핑 고정
Grade 2 (+) (+) (+)
3~4주 정도 functional splint
Grade 3 (+/-) (+) (-)
4~6주 정도 석고 고정
Red flags signs-referral decisions (ankle sprain)
- fractures of the foot and ankle
- tears or subluxation of the peroneal tendons
- nerve injury
- a history of repeated giving way (chronic instability)
- failure to improve in 6 weeks with apporopriate treatment
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The Root of ambulatory care
Medication Relative potency Onset Duration
Hydrocortisone 1 Fast Short
Prednisolone terbutate 4 Fast Intermediate
Methylprednisolone acetate 4 Slow Intermediate
Triamcinolone acetonide 5 Moderate Intermediate
Triamcinolone hexacetonide 5 Moderate Intermediate
Betamethasone 25 Fast Long
Dose Anatomic site
5 to 10mg Phalangeal joints
20 to 30mg Wrist
20 to 30mg Elbow and ankle
40 to 80mg Shoulder, hip, or knee
참고 문헌
James R. Barrett : Ankle and Foot pain, in Saunders Manual of Medical Practice, 2nd ed, Robert E.
Rakel(ed). Philadelphia, Saunders, 2000, P 988-991
이홍수 : 발목염좌, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1543-1548
양윤준 : 발목, 발 통증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1182-1189
Walter B. Greene, M.D.(ed) : Ankle Sprain,in Essentials of Musculoskeletal Care. R osemont,
American Academy of Orthopaedic Surgeons, 2001, P 422-424
Richard B. Birrer, M.D. : Ankle Injuries, in A Lange clinical manual Family Medicine Ambulatory Care
& Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed). United States of America,
The McGrwa-Hill Companies, Inc., 2005, P 24-30