Features of the use of magnetic therapy for arthrosis of the knee joint

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February 18, 2019
Any joint disease is accompanied by pain - acute, incessant and unbearable. This forces you to drink packs of painkillers, which have a weak temporary effect, but negatively affect other systems and organs. There is a way out of the vicious circle. A painless and effective treatment method is magnetic therapy.

Magnetic therapy applies magnetic fields to specific parts of the body or the entire body, which have beneficial effects on health.

About this procedure, why it is recommended for the treatment of almost all joint pathologies, what effect it gives and to whom it is contraindicated - in today’s article.

Magnetic influence

Arthrosis of the knee and coxarthrosis of the hip joint are quite common diseases among people over 45 years of age. It is worth mentioning that certain circumstances may increase the risk of developing such a degenerative disease:

• frequent trauma to joints;
• congenital malformations;
• some types of endocrine disorders;
• autoimmune diseases;
• specific and nonspecific inflammation;
• disturbances in the functioning of the ligamentous apparatus.

There is no doubt that the listed indications are only predisposing factors to the development of arthrosis of various types - their absence cannot guarantee that a person will avoid degenerative processes in the joint. Accordingly, there is a certain degree of need to know which treatment methods can become additional means of curing the pathology.

Treatment using magnetic fields of different frequencies is a relatively recent direction in physiotherapeutic developments. The main point is that by influencing the affected part of the body with magnetic fields of varying degrees of intensity, a certain response is achieved from the internal systems.

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Moreover, during the procedure, the effect extends primarily to organic liquids. Due to this, blood, lymph and other body fluids receive an additional charge from the magnetic field. This allows you to increase blood circulation and speed up metabolic processes.

The method of using magnets refers to auxiliary means of treatment, but is used according to indications. This is due to the fact that statistical indicators are not sufficient to transfer magnetic therapy to the category of basic means. According to unofficial statistics, 60% of patients who used the described technique experienced a decrease in pain and an improvement in overall well-being. The remaining 40% of respondents suffering from arthrosis did not notice any tangible results.

History of magnetotherapy treatment

Magnets have been used for treatment since ancient times. Records of the use of magnets were found in Hippocrates, ancient Egyptian priests, and also in ancient China. Tibetan monks believed that magnetic fields had a beneficial effect on the brain and stimulated its work, so they tied magnets to the head.

It is known that the Queen of England, Elizabeth I, suffered from a severe form of arthritis and the court physician used magnets for treatment.

Today in Russia and the CIS countries, magnetotherapy treatment is recognized as official medicine. In the USA it is classified as alternative. This discrepancy occurs because they have conducted few studies that would fit into the framework of classical evidence-based medicine.

Application of magnetic therapy

The use of magnetic therapy can be carried out both at home through the use of devices and personal equipment, and under the supervision of qualified specialists.

The second option uses more advanced equipment, which accordingly can have a greater effect.

If we consider the treatment of a disease such as arthrosis, then it is possible to indicate the following effects:

1. Stimulation of muscle tissue activity in the area of ​​influence. This allows you to relieve spasm around the joint, respectively, reduce pain and increase the mobility of the joint.
2. Increasing blood flow in the area of ​​damage allows you to increase the metabolic rate and activate general cleansing, which has a positive effect on regeneration.
3. Inflammatory processes under the influence of a magnetic field gradually reduce activity. This also affects the improvement of general condition.

However, despite all the positive effects of magnetotherapy treatment, this technique has a fairly wide list of indications and contraindications for use.

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Symptoms of coxarthrosis

The initial stage of coxarthrosis is characterized by the periodic occurrence of pain after physical activity. As a rule, long walking, running, and jumping act as a provoking factor. The sensations are localized in the area of ​​the affected joint and can radiate to the hip or knee. After a short rest the pain goes away completely. Later, the intensity of pain increases; it occurs not only after exercise, but also at rest. At the same time, hip mobility is limited. A person cannot fully move a limb to the side. There is a feeling of stiffness in the joint, which occurs after a long period of rest. The patient begins to limp.

The final stages of coxarthrosis are manifested by constant pain, independent of the level of physical activity. At this point, the patient is forced to walk with a cane, since he is no longer able to fully rely on the affected leg. When moving, crunching and clicking sounds are heard; upon examination, a slight decrease in the length of the limb is detected; atrophy of the muscles of the thigh and buttocks may occur. While walking, a person tilts his torso on the affected side, which subjectively makes it easier to move, but puts even more strain on the affected area.

Indications and contraindications for the use of magnets

When considering the use of magnetic therapy in the treatment of such common diseases as arthrosis of the knee and coxarthrosis of the hip joint, the main indications for using the magnetic field technique should also be mentioned. In general they are:

1. Congestion in the area of ​​the damaged joint.
2. Long-term inflammatory processes.
3. Swelling of nearby soft tissues.
4. Gradual atrophy associated with decreased mobility.
5. Reduced effectiveness of medications.
6. An auxiliary technique for an integrated approach to the treatment of arthrosis.

This is explained by the nuance that the combination of internal and external medications with magnetic influences leads to greater effectiveness of therapy.

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Important! The effectiveness of magnetic therapy used to treat joint pathologies such as arthrosis of the knees and coxarthrosis of the hip joint largely depends on the qualifications of the attending physician.

In addition, one should take into account the presence of contraindications in a person suffering from arthrosis of the knee or coxarthrosis of the hip joint. As such, it is possible to include the following list of contraindications:

1. Tumor diseases of a malignant nature or with the possibility of malignancy. This is due to increased blood flow, which in turn can accelerate the development of cancer and the release of metastases.
2. Blood clotting disorders (hemocoagulation). This pathology is present due to the influence of magnetic fields on blood flow - magnetic therapy is categorically contraindicated for people with poor clotting.
3. Severe disturbances in the functioning of the circulatory system. Especially for patients with heart pacemakers.
4. Presence of purulent lesions. Such a diagnosis, with increased blood flow, can develop into more severe forms - abscesses and gangrene.

Currently, a mandatory condition for the use of one or another physiotherapeutic method of treatment and rehabilitation in clinical practice is the presence of an evidence base in the form of previously conducted clinical studies that confirmed the effectiveness of this method using objective diagnostic methods [1].

The purpose of this article is to provide all interested clinical specialists with information about currently proven effective methods of treating patients with joint diseases using magnetic fields of various physical characteristics. This makes it possible to improve the effectiveness of complex treatment of patients with rheumatological and orthopedic problems using magnetic therapy (MT) methods, increase the level of their physical and social functioning during the rehabilitation process, prevent complications in the chronic course of the disease, and improve the quality of life of patients. To select an adequate physical method of treating a patient, it seems extremely important to analyze the available information on the effectiveness of various MT techniques.

Low-frequency MT is widely used in clinical practice both in the treatment and rehabilitation of patients after injuries, operations and vascular accidents. The mechanisms of action of this traditional physiotherapeutic method are quite well studied. A wide range of biotropic parameters makes it possible to change the characteristics of the magnetic field and cause various physiological effects in organs and tissues, which served as a rationale for the inclusion of MT in the complex treatment of degenerative-dystrophic and inflammatory diseases. The action of MT on the human body is based on primary physical and chemical processes associated with changes in the conformation and orientation of macromolecules, the rate of biochemical reactions and hydration of ions, the structure of water, an increase in the activity of metal-containing enzymes, etc. Under the influence of magnetic induction in biological tissues occurs action potential and electric currents of varying densities are formed. These induced low-frequency electric fields cause the movement of ions located near the charged surface of the membranes, which significantly affects bioelectrical and diffusion processes. Under the influence of low-frequency magnetic fields, the speed of action potentials along nerve conductors increases and their excitability increases. The primary interaction of the magnetic field with biological objects and the absorption of electromagnetic energy determine the physiological and therapeutic effects of MT [2].

MT is used in the complex treatment of patients with various joint diseases. Its anti-edematous, trophic, anti-inflammatory, and analgesic effects have been proven. Nevertheless, at present, issues of magnetobiology and MT contain many controversial and unresolved issues. Particularly acute in modern medicine are the issues of proving the effectiveness of a particular treatment method, and therefore the analysis and synthesis of scientific publications containing objective data on the results of randomized, placebo-controlled studies devoted to identifying the therapeutic possibilities of MT are highly relevant.

A fairly large number of studies have been conducted to evaluate the therapeutic effectiveness of MT in the treatment of patients with joint diseases. Thus, according to the results of a prospective, randomized, placebo-controlled, double-blind study conducted in clinics in Moscow and Kazan, it was found that in patients with gonarthrosis (GA) treated with a pulsed magnetic field (PMF) with an induction of 20 mT and a frequency of 6, 24 Hz, more significant positive dynamics of clinical symptoms were revealed, according to the EQ-5D (Euro-Quality of Life) questionnaire, as well as a decrease in joint volume compared to patients receiving placebo effects. Moreover, in the main group ( n

=75) a decrease in the “pain and discomfort” indicator by 57.3% was obtained, while in the placebo group (
n
=95) it was only by 37.9%. At the same time, no significant changes were detected in such functional indicators as “angle of flexion and extension of the affected joint”, “walking short distances” [3].

According to the results of a prospective, randomized, placebo-controlled, double-blind study (75 patients with HA), it was found that low-frequency MT for 6 weeks caused more significant changes in clinical indicators on the WOMAC scale (Western Ontario and McMaster Universities Arthrose index - severity rating scale). osteoarthritis) and EQ-5D in contrast to the placebo group. Thus, after MT the data on the WOMAC scale were: total score - p

=0.018, pain -
p
=0.065, disability -
p
=0.019, on the EQ-5D scale -
p
=0.001. No statistically significant changes were detected in the control group. The authors of the publication conclude that further research is necessary to identify the effectiveness of MT using different parameters and types of magnetic fields, differentiated treatment protocols on different patient populations [4].

The effectiveness of pulsed electromagnetic fields in the treatment of osteoarthritis (OA) is also evidenced by data from a meta-analysis of 9 randomized clinical trials (RCTs), including 483 patients with HA; favorable effects on the clinical manifestations of HA were revealed (weighted mean difference (WMD) 0.4; 95 % confidence interval (CI) 0.05—0.8; p

=0.029) and the level of household activity of such patients (HRV 0.8; 95% CI 0.2-1.4;
p
=0.014). The analyzed studies used different MT protocols, but no statistically significant differences in treatment effectiveness were identified [5].

Two systematic reviews provide compelling evidence of the analgesic effect of UTIs, which reduces locomotor dysfunction in patients with OA [6, 7]. Similar conclusions are drawn from the results of RCTs that proved significant benefits in the group of patients with OA who received BMI compared to the placebo group [8, 9].

A randomized, double-blind study in patients with knee OA showed a decrease in pain and an increase in joint mobility under the influence of a course of MT with an induction of 105 mT, a frequency of 8 Hz, and an exposure of 5 minutes. The procedures were carried out over 18 days [10].

Along with the improvement of clinical symptoms and locomotor function of the knee joints, some studies have shown an improvement in blood circulation under the influence of a magnetic field (MF) with an induction of 2 to 10 mT [11].

A number of authors propose thermographic research as one of the objective criteria for the effectiveness of MT. Thus, in a double-blind, placebo-controlled study in 57 patients with GA, along with differences in the clinical picture of the disease, more pronounced positive dynamics were established according to thermography data in patients who received UTI effects against the background of basic drug treatment. Thus, in the main group, the decrease in skin temperature in the area of ​​the affected joints during a course of treatment with MT was 2 °C, while in the control group it was significantly less (0.8 °C) [12].

The effectiveness of MT was also shown in patients with primary and post-traumatic coxarthrosis in an open RCT ( n

=102). In patients of the main group who received low-frequency pulsed MT procedures against the background of basic treatment (taking meloxicam at a dose of 15 mg/day and therapeutic exercises), more pronounced positive dynamics were revealed on the visual analogue scale and the Lequesne index, while the analgesic effect persisted for 30 days after completing a course consisting of 15 procedures [13].

Attention should be paid to the fact that a number of foreign studies have shown a fairly high efficiency of small induction MP, while the procedures were carried out over a long course. Thus, 1 high-quality RCT in patients with OA showed a significant difference in the study results in the study and control groups. When assessed on 6 clinical parameters (general pain; difficulty with daily activities; worst discomfort in the past week; pain caused by ADLs; pain on movement and tenderness) differences were found to be 4-fold. Methodology M.T. differed in a small induction - 0.2 mT, frequency 30 Hz. The procedures were carried out for 1 month for 30 minutes [14].

One of the most important criteria for the effectiveness of MT is the quality of life of patients with OA. High-quality RCTs showed significant differences in the study and control groups in the results of the WOMAC scale, visual analogue scale and quality of life assessment using the EQ-5D questionnaire. The technique was also distinguished by low induction (0.05 mT) and low frequencies (3 and 7.5 Hz) [15].

It seems important that against the background of the therapeutic effect of MP in patients with OA, the need for taking non-steroidal anti-inflammatory drugs and analgesics decreased. This was shown, in particular, in a randomized, placebo-controlled study in which 83 patients with GA took part. In the main group, patients received low-induction effects for 2 hours a day for 6 weeks [16].

A review of 9 RCTs examining the effectiveness of MTX in 636 patients with OA found that MTX reduced pain severity, but did not significantly change the quality of life of patients [17]. At the same time, many researchers note a statistically significant improvement in the indicators of medical and psychological testing in patients with rheumatoid arthritis and OA after a course of general MT [18, 19].

Foreign sources contain references to 2 RCTs, the purpose of which was to study the effectiveness of BMI in osteochondrosis of the cervical spine [20, 21]. The results obtained convincingly indicate a decrease in pain and muscle spasms after a course of exposure to magnetic fields.

There are few RCTs devoted to identifying the effectiveness of MT in post-traumatic tendonitis [22, 23], chronic epicondylitis [24], temporomandibular syndrome [25], and osteoporosis [26]. High-quality RCTs have proven a significant improvement in bone tissue metabolism (based on the level of biochemical markers) and joint function under the influence of MT (magnetic induction value 4 mT, frequency 30 Hz, exposure 60 min) in patients with osteoporosis due to hemophilia A [27] . It should be noted that in domestic physiotherapy, hemophilia is an absolute contraindication for the prescription of any physical influence, including MT.

In an RCT of 28 patients with osteonecrosis of the knee joint, it was found that exposure to an electromagnetic field with an induction of 1.5 mT and a frequency of 75 Hz with a 6-hour exposure for a long time (up to 3 months) helped reduce pain and improve the functional state of the knee joints, as well as stimulation of osteogenic activity of osteoblasts [28].

Studies were conducted in patients with unstable hip joint endoprostheses who received long-term low-intensity magnetic influences for 6 months. Impact of M.P. decreased the Harris scale scores by 6 times compared to the placebo group, which made it possible to delay joint revision [29].

In another RCT, the authors showed that in patients who underwent total knee arthroplasty, anti-edematous, anti-inflammatory effects of MP with an induction of 1.5 mT were detected, which allows accelerating the time of functional recovery of patients after surgery [30].

The anti-inflammatory and analgesic effects of MT have been confirmed in patients with patellofemoral pain syndrome. MP parameters were characterized by a low induction of 1.5 mT, a frequency of 75 Hz, and large exposures were used - 4 hours per day for 6 weeks [31].

Mixed results have been obtained from studies examining the clinical effectiveness of constant magnetic field (CMF). A meta-analysis, taking into account the results of the use of PMP for pain relief according to 21 RCTs (15 of them of good quality), concluded that the use of MT for pain syndromes associated not only with inflammatory diseases of the musculoskeletal system and fibromyalgia, but also with neuropathies, as well as in the postoperative period [32].

Another RCT with double-blind control studied the effectiveness of PMP with different induction in patients with chronic lumbar radicular pain. The primary endpoint of the study was mean daily leg pain scores (scale 0–10). Significant differences in the level of pain were established depending on the level of magnetic field intensity. Better results were obtained with a magnetic induction value of 20 mT compared to 5 mT. Within 5 weeks, there was a gradual decrease in pain in 86% of cases [33]. Other authors come to similar conclusions [34].

The use of PMP (magnetic insoles) for a shorter period of time (8 weeks, 4 hours per day) did not cause significant changes in pain in the lower extremities according to a moderate quality RCT [35]. Also, in a placebo-controlled RCT in patients with fibromyalgia for 6 months, there were no differences in the severity of pain compared with the placebo group [36].

At the same time, in another multicenter (48 centers) high-quality RCT, when studying the effect of PMP on pain syndrome (375 subjects with diabetic polyneuropathy II-III degrees), it was found that constant wearing of magnetic insoles for 3-4 months with induction 45 mT significantly reduces the burning sensation ( p<

0.05), numbness and tingling (
p
<0.05), as well as pain in the leg (
p
<0.05).
Moreover, the identified significant differences also concerned patients with initial severe pain, in whom pain decreased no earlier than 4 months (main group - 41%, placebo group - 21%; p
<0.01), numbness and tingling (main group - 32 %, placebo group - 14%;
p
<0.01) [37].

These data from foreign researchers are of practical interest, since it is well known that PMP is significantly inferior in effectiveness to alternating magnetic fields, IMP, and in domestic physiotherapy this method is used extremely rarely for the treatment of pain syndromes. It should be noted that all the evidence provided for the effectiveness of PMP was obtained with long-term daily exposure to PMP and courses of at least 3 months.

MT occupies an important place in the rehabilitation of patients after joint surgery, since this method does not cause disruption of adaptation systems and is well tolerated even by weakened patients. A few RCTs have been devoted to identifying the effectiveness of BMI in patients with interbody fusion [38] and after arthroscopy [39]. 92% of patients who underwent spine surgery achieved a significant improvement after a course of BMI, while in the placebo group only 65% ​​achieved a therapeutic effect ( p

<0.001). Conducting M.T. after arthroscopy requires additional evidence.

Two high-quality RCTs established the effectiveness of BMI in the rehabilitation of patients after long bone fractures [40, 41]. At the same time, for scaphoid fractures, there was no statistically significant difference in the severity of the treatment effect in patients receiving BMI and placebo [42].

A systematic review that analyzed the results of 4 RCTs (125 subjects with slow-healing or non-union long bone fractures) showed positive results of the use of BMI to accelerate osteoregeneration in 3 RCTs, in 1 case there was no convincing evidence of the effectiveness of MT [43].

The analysis of scientific publications allows us to draw a conclusion about the feasibility of using MT in arthrological practice. Foreign reviews most often analyze the results of a course of exposure to low-induction MP, with exposures of at least 30 minutes per procedure recommended [44-46]. In domestic physiotherapy, factual material has been accumulated confirming the effectiveness of MT in the range of 10-75 mT with an exposure of 15-20 minutes. The method of general MT, which uses an induction of 1.5-3 mT, is rarely used for joint diseases, although the experience accumulated by foreign researchers allows us to hope for the prospects for the development of this area of ​​physiotherapy. It should be noted that the largest number of scientific publications that meet the requirements of evidence-based medicine are devoted to studying the effect of UTIs on clinical symptoms, the functional state of joints, microcirculation processes and inflammation. Thus, despite significant differences in methodological approaches, there is currently quite strong evidence of the effectiveness of the use of MT in patients with diseases and consequences of joint injuries based on the identified reduction in pain, increased daily activity, improved psycho-emotional state and generally improved quality of life .

Conflict of interest.

The authors declare that there is no conflict of interest related to the publication of this article.

The authors declare no conflicts of interest.

Information about authors

Konchugova T.V. - Doctor of Medical Sciences, Prof.; https://orcid.org/0000-0003-0991-8988; e-mail

Kulchitskaya D.B. - Doctor of Medical Sciences, Prof.; https://orcid.org/0000-0002-7785-9767; eLibrary SPIN: 2674-6371; e-mail

Ivanov A.V. — https://orcid.org/0000-0001-5961-892X

Konchugova Tatyana Venediktovna - Doctor of Medical Sciences, Professor; https://orcid.org/0000-0003-0991-8988; e-mail

Konchugova T.V., Kulchitskaya D.B., Ivanov A.V. The effectiveness of magnetic therapy methods in the treatment and rehabilitation of patients with joint diseases from the perspective of evidence-based medicine. Issues of balneology, physiotherapy and therapeutic physical culture.

2019;96(4):63-68. https://doi.org/10.17116/kurort201996041

How does magnetotherapy work?

When a magnet is applied to the affected joint, various physical and chemical processes occur. The non-invasive treatment is believed to cause:

• Vibration of water molecules;
• Changing the amount of sodium and protein;
• Destruction of hydrogen bonds;
• Electron transfer and much more.

To date, there is no general theory that would explain the entire process of the influence of such a field on the joint. There is an opinion that this technique is ineffective and has nothing to do with the treatment of ailments.

Before magnetotherapy, the doctor examines the affected joint

Clinics that provide such therapy assure that the procedure produces a different effect on the body:

• Increasing the speed of recovery processes;
• Cells begin to transport more useful substances;
• The electrical potential of nerve cells changes, which significantly increases the conductivity of the nerve impulse;
• Relieving swelling by reducing tissue permeability;
• Blood clotting is reduced, which reduces the risk of blood clots.

Two types of fields are used for physiotherapy:

• Osteoarthritis of the hip joint: degrees, symptoms and treatment

1. Permanent. Significantly improves blood circulation, stimulates the immune system, relieves inflammation, and also enhances reparative processes. The device is used to treat ailments such as arthritis, arthrosis and inflammation of the ligaments.
2. Variable. Improves blood circulation, reduces vascular tone, stimulates the endocrine system, and also prevents the growth of tumors. A magnetic device is used to treat osteochondrosis and other pathologies.

There is a significant difference between statistical and electromagnetic fields. In the first case, there is no magnetic field.

Using a magnet, swelling is eliminated and pain is reduced. That is why it is widely used for acute diseases of the joints, such as coxarthrosis, gonarthrosis and others. Of course, the effectiveness of non-invasive therapy has not been proven.

Useful properties of a magnet for joints

If you follow all the rules and recommendations, then magnetic therapy will not cause harm. Magnet treatment has many beneficial properties. It is believed that pseudotherapy can have the following effect on the body:

• Relieving swelling and eliminating joint pain;
• Improving blood supply to small vessels;
• Acceleration of metabolism in cartilage tissue;
• Elimination of bacterial development;
• Stimulation of the immune system;
• Strengthening drug therapy.

Of course, it is impossible to cure a hip, ankle or shoulder joint with a magnet alone. In the fight against the disease, doctors recommend using traditional methods of treatment. This is due to the fact that non-invasive treatment is ineffective and is only a way to siphon money from patients.

Important! Before carrying out therapy, it is necessary to take into account the indications and all contraindications.

The device has a different design

What is magnetic therapy?

Procedures with magnetic effects have the effect of dilating blood vessels, relieve pain, relieve inflammation, relax and promote the regeneration of body cells. With the help of individual magnetic therapy sessions, many positive physiological results are achieved:

• Treatment of headaches and elimination of dizziness;

• Normalization of blood pressure levels;

• Activation of blood supply to the vessels of the brain and heart;

• Elimination of neurotic disorders;

• Stimulates collagen production and increases skin elasticity;

• Increased lymph outflow;

• Elimination of pain and activation of restoration of bone structures in case of fractures;

• Strengthening the immune system and activating metabolic processes.

Contraindications

Before referring for physical therapy for coxarthrosis of the hip joints, doctors conduct a thorough examination of the patient. This is due to the fact that this method is contraindicated for certain diseases. If you neglect this rule, then various complications are possible as a result of therapy. The main contraindications include:

• Hypotension;
• Low blood pressure;
• High blood clotting;
• Acute infectious diseases;
• Purulent processes;
• Pregnancy;
• Acute heart attacks;
• Presence of a pacemaker or pacemaker;
• Bionic prostheses.

In the presence of such contraindications, treatment of arthrosis of the knee joint with magnets is extremely undesirable. Otherwise, physiotherapy will cause significant harm to human health. This is especially true for patients who have installed electrical devices. The formation of a field can disrupt their operation or completely disable them. As for bionic prostheses, they are removed before the procedure, which helps protect them from damage.

Diagnosis and treatment of ankle arthrosis

For diagnostic purposes, the patient may be referred for radiography, computed tomography, MRI, ultrasound, scintigraphy, or puncture. Consultations with related specialists (rheumatologist, endocrinologist, neurologist) may be required.

Treatment goals for ankle arthrosis:

• pain relief;
• relieving inflammation;
• regeneration of cartilage tissue;
• increased mobility in the joint;
• improvement of metabolism in the articular joint and adjacent structures.

In the treatment of arthrosis of the ankle joint, the following can be used:

• drug therapy;
• physiotherapy;
• kinesitherapy;
• massage;
• physiotherapy;
• surgical intervention.

Patients are also advised to adjust their diet and lifestyle (reduce body weight, avoid long walking and standing).

However, surgical treatment is associated with risks and significant financial costs, and taking medications provides only a temporary effect and does not eliminate the cause of the disease. The Innovative Medical Center uses an effective method of treating degenerative-dystrophic lesions of the ankle - kinesitherapy.