힘줄 질병의 이해 tenosynovitis, tendinopathy(tendinitis, tendinosis)의 구분

[문형철]

힘줄은 근육과 직렬로 연결되어 뼈에 힘을 전달한다. 

그 힘을 전달하는 과정에서 비정상적인 부하, 반복부하가 주어지거나

정상정렬을 잃어버린 형태, 구조 등에서 움직이면 질병이 발생한다. 

김송준 ....

예를들어 힘줄이 긴 "flexor hallucis longus tendon, peroneous longus tendon"은 건염이 잘 발생한다. 

힘을 많이 받는 힘줄(예를들어 아킬레서 건)에서 건염이 잘 발생한다. 

이러한 문제는 부정렬이나 환자의 움직임 습관에 의해서 과사용되는 힘줄에서 건염이 더 잘 발생한다. 

힘줄은 손목의 건처럼 tendon sheath로 둘러싸여 활액을 가진 형태와 아킬레스 건처럼 paratenon으로 둘러싸여 활액이 거의 없는 형태가 있다. 

거위발 점액낭염, 견봉하 첨액낭염처럼 힘줄아래 점액낭에 염증이 동반되는 경우를 잘 알아야 한다. 

점액낭염, 건막염, 건병증(건염 tendinitis, 건증 tendinosis) 등의 정확한 병리를 구분할 수 있어야 한다. 

osteotendinojunction(Sharpey's fibers), myotendinojunction등의 부위에 따른 병증을 구분할 수 있어야 한다. 

흔한 건막염, 건염, 건병증에 대해서 정리해보자.

극상근 건염, 테니스 엘보, 골퍼엘보, 손가락 건염, 햄스트 건염, 대퇴사두근건염, 슬개하 건염, 아킬레스 건염, 발목 건염 등

panic bird...

항상 solution이 중요하다. 

일단 deep friction massage를 잘 이해해야

모든 치료테크닉은 시간과 강도, 빈도수, 기간이 중요하다.

시간은 정해주기 어려움. 가장 길게는 10분이상.. 짧게는 1분이상은 시행하고

과도하게 시행했으면 반드시 얼음팩을 ...

hamstring strain injury.pdf

아킬레스 건염.pdf

대퇴사두근 건염, 슬개하 건염.pdf

극상근 건염.pdf

참고) paratenon, paratendon

loose connective tissue filling the interstices of the fascial compartment in which a tendon is situated and which allows it to move freely. Is not organized into discrete tendon sheaths.

The Achilles tendon is not encased in a true synovial sheath but is surrounded by paratendon composed of a single layer of cells. This tissue is richly vascularized and is responsible for much of the blood supply,4 which reaches the tendon through a series of transverse vincula that function as passageways for the vessels. The Achilles tendon also receives blood from vessels originating at the musculotendinous and osteotendinous junctions.

참고) Sharpey's fiber

Sharpey's fibers (bone fibers, or perforating fibres) are a matrix of connective tissue consisting of bundles of strong collagenous fibres connecting periosteum to bone. They are part of the outer fibrous layer of periosteum, entering into the outer circumferential and interstitial lamellae of bone tissue. Sharpey's fibres are also used to attach muscle to the periosteum of bone by merging with the fibrous periosteum and underlying bone as well. A good example is the attachment of the rotator cuff muscles to the blade of the scapula.

1. 건막염 tenosynovitis

Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon. Symptoms of tenosynovitis include pain, swelling and difficulty moving the particular joint where the inflammation occurs. When the condition causes the finger to "stick" in a flexed position, this is called "stenosing" tenosynovitis, commonly known as "trigger finger". This condition often presents with comorbid tendinitis.

Causes of tenosynovitis are unknown. Repeated use of hand tools can precede the condition, as well as arthritis or injury. Tenosynovitis sometimes runs in families and is generally seen more often in males than in females. The causes for children are even less well known and have a recurrence rate of less than 1-5% after treatment. 

Tenosynovitis is also linked to infectious arthritis caused by bacteria such as Neisseria gonorrhoeae.

방아쇠 무지와 드퀘르방 질병이 대표적인 예

참고) tendinopathy

Tendinopathy refers to a disease of a tendon. More specifically, it can refer to:

• Tendinitis - tendon injuries that involve larger-scale acute injuries accompanied by inflammation
• Tendinosis - chronic tendon injury with damage to a tendon at a cellular level

Tendon injury arise from a combination of intrinsic and extrinsic factors; acute tendon injuries may be predominantly caused by extrinsic factors, whereas in overuse syndromes as in the case of tendinopathy it may be caused by multifactorial combinations of both intrinsic and extrinsic factors. 

건의 손상은 내인 요소와 외인 요소의 조합에 의해서 발생

급성 건 손상은 과사용과 같은 외인 요소에 의해서 발생. 

An example of an intrinsic factor for tendinopathies are: poor biomechanics such as limb malaligments and hyperpronation that may cause increased traction loads acting on the foot and ankle that may increase the incidence of Achilles, flexor hallucis longus muscle, and tibialis posterior muscle tendinopathies.

건병증의 내인요소는 사지 부정렬과 같은 나쁜 생체역학적 자세가 문제가 됨. 예를들어 발목 과회내는 아킬레스 건, 장무지굴근, 후경골근건에 비정상적인 생체역학적 과부하를 초래하여 건병증을 야기함. 

The exact etiology of tendinopathies has not been fully elucidated and different stresses may induce varying responses. There are multifactorial theories such as tensile overload, tenocyte related collagen synthesis disruption, tendon load induced ischemia, neural sprouting, thermal damage, and histological adaptive compressive responses seen as some of the causative factors that give rise to activity disruption and disability due to tendinopathies.

건병증의 원인들

장력의 과부하, 건섬유아세포와 연관된 콜라겐 합성의 붕괴, 건과부하에 의한 허혈, 신경발화, 온열손상, 조직학적 압박반응 등

 Also, the role of environmental factors, such as diet and smoking, must not be overemphasized. The deleterious effect of smoking involve noxious effects of both nicotine, which cause vasoconstriction and decreased delivery of oxygen to tissues, and carbon monoxide, which decrease cellular oxygen tension levels.^[1] The most commonly accepted cause for this condition however is seen to be an overuse syndrome in combination with intrinsic and extrinsic factors leading to what may be seen as a progressive interference or the failing of the innate healing response.

건병증의 환경적 요인

식이와 흡연

2. 건염 tendinitis

Tendinitis (also tendonitis), meaning inflammation of a tendon, is a type of tendinopathy often confused with the more common tendinosis, which has similar symptoms but requires different treatment.^[1] (The suffix -itis denotes diseases characterized by inflammation.) The term tendinitis should be reserved for tendon injuries that involve larger-scale acute injuries accompanied by inflammation. Generally tendinitis is referred to by the body part involved, such as Achilles tendinitis (affecting the Achilles tendon), or patellar tendinitis (jumper's knee, affecting the patellar tendon).

Tendinitis injuries are common in the upper and lower limbs (including the rotator cuff attachments), and are less common in the hips and torso. Individual variation in frequency and severity of tendinitis will vary depending on the type, frequency and severity of exercise or use; for example, rock climbers tend to develop tendinitis in their fingers or elbows, swimmers in their shoulders. 

Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping, while Patellar tendinitis is a common among basketball and volleyball players owing to the amount of jumping and landing.^[2] A veterinary equivalent to Achilles tendinitis is bowed tendon, tendinitis of the superficial digital tendon of the horse.

Symptoms can vary from aches or pains and local joint stiffness, to a burning that surrounds the whole joint around the inflamed tendon. In some cases, swelling occurs along with heat and redness, and there may be visible knots surrounding joint. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiff the following day as muscles tighten from the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms. If the symptoms of tendinitis last for several months or longer it is probably tendinosis.

Treatment of tendon injuries is largely conservative. Use of non-steroidal anti-inflammatory drugs (NSAIDs), rest, and gradual return to exercise is a common therapy. Resting assists in the prevention of further damage to the tendon. Ice, compression and elevation are also frequently recommended. Physical therapy, Occupational therapy, orthotics or braces may also be useful. Initial recovery is typically within 2 to 3 days and full recovery is within 4 to 6 weeks.^[3]Tendinosis occurs as the acute phase of healing has ended (6–8 weeks) but has left the area insufficiently healed; Treatment of tendinitis helps reduce some of the risks of developing tendonosis, which takes longer to heal.

Steroid injections have not been shown to have long term benefits but have been shown to be more effective than NSAIDs in the short term.^[4]

In chronic tendinitis or tendonosis laser therapy has been found to be better than conservative treatment at reducing pain; however, no other outcomes were assessed.^[5] Both prolotherapy and PRP injections are being used more frequently with good clinical short and long term outcomes in tendonosis - research has been only slightly positive for these treatment modalities due to the poor design of many of the completed studies.

3. 건증 tendinosis

Tendinosis, sometimes called chronic tendinitis, tendinosus, chronic tendinopathy, or chronic tendon injury, is damage to a tendon at a cellular level (the suffix "osis" implies a pathology of chronic degeneration without inflammation). It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.^[1] Classical characteristics of "tendinosis" include degenerative changes in the collagenous matrix, hypercellularity, hypervascularity, and a lack of inflammatory cells which has challenged the original misnomer "tendinitis".^[2]

Swelling in a region of micro damage or partial tear may be detected visually or by touch. Increased water content and disorganized collagen matrix in tendon lesions may be detected by ultrasonography or magnetic resonance imaging.

Symptoms can vary from an ache or pain and stiffness to the local area of the tendon, or a burning that surrounds the whole joint around the inflamed tendon. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain, which may contribute to the symptoms.

Tendons are very slow to heal if injured. Partial tears heal by the rapid production of disorganized type-III collagen, which is weaker than normal tendon.^{[citation needed]} Recurrence of injury in the damaged region of tendon is common.

Physical therapy, rest, and gradual return to the activity in which tendinosis was experienced is a common therapy. There is evidence to suggest that tendinosis is not an inflammatory disorder; anti-inflammatory drugs are not an effective treatment,^[3] and inflammation is not the cause of this type of tendon dysfunction.^[4] There is a variety of treatment options, but more research is necessary to determine their effectiveness. Initial recovery is usually within 2 to 3 months, and full recovery usually within 3 to 6 months. About 80% of patients will fully recover within 12 months.^[5] If the conservative therapy doesn't work, then surgery can be an option. This surgery consists of the excision of abnormal tissue. Time required to recover from surgery is about 4 to 6 months.^[6]

Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach.^[7] Other treatments for which research is on-going includes vitamin E, vitamin B6, nitric oxide, and stem cell injections.

Vitamin E[edit]

Vitamin E has been found to increase the activity of fibroblasts, leading to increased collagen fibrils and synthesis, which seems to speed up the regeneration and increase the regenerative capacity of tendons.^[8][9]

Nitric oxide[edit]

Nitric oxide (NO) also appears to play a role in tendon healing^[10] and inhibition of its synthesis impairs tendon healing.^[11] The use of a nitric oxide delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was tested in three clinical trials for the treatment of tendinopathies and was found to significantly reduce pain and increase range of motion and strength.^[12]

Soft tissue mobilization[edit]

Augmented Soft Tissue Mobilization (ASTM) is a form of manual therapy that has been shown in studies on rats to speed the healing of tendons by increasing fibroblast activity.^[13][14] One case study showed ASTM resulting in full recovery in the case of an athlete suffering from chronic ankle pain and fibrosis, after an unsuccessful course of surgery and conventional physical therapy.^[15]

Eccentric loading[edit]

A promising line of therapy involves eccentric loading exercises involving lengthening muscular contractions.^[16]

Inflatable brace[edit]

The use of an inflatable brace (AirHeel) was shown to be as effective as eccentric loading in the treatment of chronic Achilles tendinopathy. Both modalities produced significant reduction in pain scores, but their combination was no more effective than either treatment alone.^[17]

Shock-wave therapy[edit]

Shock-wave therapy (SWT) may be effective in treating calcific tendinosis in both humans^[18] and rats.^[19] In rat subjects, SWT increased levels of healing hormones and proteins leading to increased cell proliferation and tissue regeneration in tendons. Another study found no evidence that SWT was useful in treating chronic pain in the Achilles tendon.^[20]

Tendon bioengineering[edit]

The future of non-surgical care for tendinosis is likely bioengineering. Ligament reconstruction is possible using mesenchymal stem cells and a silk scaffold.^[21] These same stem cells were capable of seeding repair of damaged animal tendons.^[22] Autologous tenocyte implantation is currently being tested for tendinosis. There is a large randomized, double-blind, placebo controlled trial being conducted in the Netherlands to test the safety and efficacy of tenocyte therapy. Results from the trial are expected by April 2013.

참고) Repetitive strain injuries 

Repetitive strain injuries (RSIs) are "injuries to the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression, or sustained or awkward positions".^[1] RSIs are also known as cumulative trauma disorders, repetitive stress injuries, repetitive motion injuries or disorders, musculoskeletal disorders, andoccupational or sports overuse syndromes.

Repetitive strain injury (RSI) and cumulative trauma disorders are umbrella terms used to refer to several discrete conditions that can be associated with repetitive tasks, forceful exertions, vibrations, mechanical compression, or sustained/awkward positions.^[1][2] Examples of conditions that may sometimes be attributed to such causes include edema, tendinitis, carpal tunnel syndrome, cubital tunnel syndrome, De Quervain syndrome, thoracic outlet syndrome,intersection syndrome, golfer's elbow (medial epicondylitis), tennis elbow (lateral epicondylitis), trigger finger (so-called stenosing tenosynovitis), radial tunnel syndrome, and focal dystonia.^[1][2]

While the recent preval‎ence of upper extremity RSIs has focused awareness on injuries to the fingers, hands and arms, they can occur in any body part and frequently affect the trunk, back and legs.^[3]

[장은석]

★ 힘줄 질병의 이해

- Tenosynovitis / 건막염
건 주위 활액막(synovium)의 염증으로 pain, swelling, difficulty moving을 호소
ex) trigger finger

- Tendinopathy / 건병증 (Tendinitis, tendinosis)
tendinitis / 건염
염증과 함께 나타나는 tendon의 광범위한 급성 손상
tendinosis, -sus / 건증
세포단위에서 나타나는 건의 만성 손상(염증 없이 나타나는 만성 degeneration)

건병증은 내인, 외인의 작용으로 인해 나타남
(내인 = malalignment / 외인 = overuse)

[09정문권]

힘줄은 (근육과 직렬로 연결..)뼈에 힘을 전달! 전달과정에서 비정상적 부하, 반복부하, 비정상정렬..등이 발생하면 질병발생
힘줄이 길거나, 힘을 많이 받거나(ex.아킬레스건), 과사용되는 힘줄.. 건염이 더 잘 발생한다.

건막염 tenosynovitis
-tendon으로 둘러싸인 synovium(액체로 차있는 sheath)의 염증
-pain, 부종, 움직임장애
-발생시에 방아쇠 손가락처럼 됨(also called, stenosing, tenosynovitis, trigger finger)

cf) tendinopathy : 다음을 포함하는 tendon의 질병을 말함 >> tendinitis(염증을 동반한 급성 tendon 손상), tendinosis(세포단위에서의 tendon의 손상을 동반하는 만성손상)

[09정문권]

건염 tendinitis
-tendon의 염증, 염증을 동반하는 큰 scale의 급성 손상을 동반하는 것을 의미
-대표적 예로 아킬레스건염은 돌진하거나 점프하는 등의 스포츠상황하에서의 흔한 손상이다.

건증 tendinosis
-만성의, 염증을 동반하지 않는, 세포레벨에서의 tendon손상을 의미한다.