스크랩 shoulder disorder 검사법. 크레이그 리벤슨 - 다시보자

[터사랑]

어깨의 뼈구조, 인대구조, 관절낭(capsule)구조, 근육구조와 기능을 완전하게 이해하지 못한 상태에서 

아래 글은 참 어렵구나!

어깨통증은 크게 3가지로 나누어 이해해야 

1. subacromial impingement, tendonitis 등(견봉하 점액낭염, 극상근 건, 극하근 건, 상완이두근 건염), tear 포함

2. adhesive capsulitis - limitation of shoulder

3. shoulder instability - SLAP lesion 등

통증 generator를 찾기

1. active ROM

2. passive ROM

3. 저항 검사

4. 기능적 검사

부정렬은 두가지

1. 정적인 자세의 poor posture

2. 동적인 움직임 faulty movement pattern

그리고 그것을 개선하기

여기서 가장 중요한 치료 핵심이 scapular의 neutral position 유지하기. 

Shoulder disorders—Part 2. Examination.pdf

SELF-MANAGEMENT: CLINICIAN SECTION

Shoulder disorders—Part 2: Examination ^☆

• Craig Liebenson, DC^, 

• 10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA

• Available online 26 September 2005.

loosed packed position/resting position

Glenohumeral 55-70 abduction, 30 horizontal adduction,neutral rotation

Ulnohumeral 70 flexion, 10 supination

Radiohumeral full extension, full supination

Proximal Radioulnar 70 flexion, 35 supination

Distal Radioulnar 10 supination

1st Metacarpophalangeal; 2-5 MCP slight flexion;slight flexion with ulnar deviation

PIP and DIP 10 degree flexion;30 degree flexion

Hip 30 flexion, 30 abduction, slight external (lateral) rotation

Tibiofemoral 25 flexion

Patellofemoral 25 flexion

Proximal tibfib 0 plantarflexion

Distal tibfib 0 plantarflexion

Talocrural 10 plantarflexion, neutral

Subtalar 10 plantarflexion, neutral

Midtarsal 10 plantarflexion, neutral

Metatarsophalangeal neutral

Interphalangeal slight flexion

Radiocarpal slight ulnar deviation

Vertebral Midway between flexion and extension

Temporomandibar jaw slightly open

sternoclavicular arm resting by side

acromioclavicular arm resting by side

어깨통증은 크게 네가지 분류

1. red flag

2. impingement - 대부분 회전근개 tendonitis는 impingement로 진행.

3. adhesive capsulitis - rom 제한. 

4. shoulder instability - SLAP lesion, hypermobile, recurrent dislocation발생. - apprehension sign positive. 

shoulder girdle complex 검사의 세가지 방향

1. Red flag 반드시 rule out해야

1) tumor

2) infection 

3) fracture or dislocation

2. Orthopedic examination

- pain generation 확인과 질병 상태진단(diagnose the condition)

3. functional examination

- 종종 무시되는데 사실은 가장 중요

- 통증의 원인이 되는 생체역학적인 과부하 원인을 찾는데 중요한 검사

shoulder girdle 질환 - faulty posture or motor control과 관련

1. muscle imbalance의 전형적인 패턴

- lower scapular fixator(전거근, 하부승모근)과 상부승모근, 견갑거근 단축에 의한 shoulder external rotator, shoulder internal rotator의 약화

참고) shoulder external rotator - deltoid 후방 섬유, infraspinatus, teres minor

참고) shoulder internal rotator -  teres major, latissimus dorsi, pectoralis major

overhead activity

- 어깨에 가장 격렬할 수 있는 동작이고, 특히 dyskinesis가 존재할때  반복적인 strain으로 손상을 촉발시킬 수 있다.

red flags

1) A Pancoast tumor, also called a pulmonary sulcus tumor or superior sulcus tumor, is a tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most Pancoast tumors are non-small cell cancers.

2) SC joint의 septic arthritis

3) fracture or dislocation

Functional orthopedic eval‎uation

1. basic rules of testing

- 모든 정형외과적, 기능적 테스트를 하는 동안 환자의 특징적인 통증을 야기하는 움직임과 자세를 확인하는 것이 중요함. 

- 어떤 특정한 움직임과 자세는 두가지 MS(mechanical sensitivity)와 AMC(abnormal motor control)유무를 확인하는 것이 중요

- 테스트에서 환자의 특징적인 증상이 야기되면 환자의 pain generator는 찾아진 것임(mechanical sensitivity).

- mechanical sensitivity가 확인되면 환자의 치료, 환자의 상태, 회복의 점검, 방문등 추적검사의 시작

- 다양한 치료로 환자의 mechanical sensitivity가 감소된다면 치료는 care program은 올바른 방향

- abnormal motor control 검사는 mobilized or stabilized, strengthened or stretched 등 어떤 것이 먼저 필요한지 치료사의 의사결정을 안내하는 역할

- MS와 AMC 검사는 환자의 치료적 운동처방을 정확하게 하기 위해 필요함. 아래 테이블은 기능적 정형도수 검사임. 

table 1. functional orthopedic tests

1) active range of motion(ROM)

2) Passive ROM(including specific orthopedic tests such apprehension test)

3) passive accessory ROM

4) Resistance tests

5) functional/postural tests

6) palpation

- 검사를 통해 rotator cuff tendonitis or tears, shoulder impingement syndroem, shoulder instability, frozen shoulder를 감별

2. active range of motion(ROM)

- flexion, extension, abduction, adduction, internal rotation, external rotation하는 동안 환자의 pain, stiffness, crepitus등이 있는지 확인해야

Flexion(160~180도), Extesion(45~60도), Internal rotation(60~90도), External rotation(80~90도), Abduction(170~180도),  Adduction(45~75도)

- rom검사의 신뢰도는 100%는 아님. goniometric assessment는 믿을만함

- 연구에 의하면 어깨통증 환자는 25도 injured arm에서 90도 외전상태에서 내회전이 감소됨을 보고

-arm elevation(flexion, abduction)시 painful arc는 충돌증후군을 암시. mid range of motion에서 통증.

간단하고 실용적인 어깨움직임 검사는 wall angel test임

3. wall angel test

- simple and practical postural screen 검사법

검사방법

- 벽이 기대어 서서 어깨 90도 외전, 팔꿈치 90 굴곡, 손바닥 supinated, 발은 약간 앞으로

- 환자의 head와 buttock 벽에 닿아야하고 환자는 등을 flatten시키려고 노력해야

- chin in

- offer passive overprssure to aid cervico-cranial flexion testing

clinical pearl

- decresaed rom in external rotation, abduction and evevation : adhesive capsulitis

- decreased ROM in internal rotation and/or elevation(abduction, scapular, or flexion) is typical of impingement syndrome and rotator cuff problems.

- decreased ROM in horizontal adduction(scarf test) suggests acromio-clvicular joint dysfunction

4. passive ROM

- active ROM 평가에 이어서 바로 passive ROM검사를 시행해야

- 치료자는 어깨의 내회전, 외회전을 어깨 외전각도 0도, 45도, 90도에서 검사해야

- shoulder elevation(굴곡 또는 내전)의 끝에서 수동적인 overpressure와 함께 통증이 나타나는 것은 충돌증후군을 암시

Neer impingement sign

- arm이 내회전 상태에서 어깨 flexion할때 mechanical sensitivity가 있다면 positive sign

- 유튜브 동영상 http://www.youtube.com/watch?v=k21FNtBjQ14

Hawkins impingement test

- 어깨를 90도 elvation상태에서 arm 내전, 내회전할때 통증이 나타나면 positive sign

- 유튜브 동영상 http://www.youtube.com/watch?v=W0KnejfMtT0&feature=related

- excessive GH passive mobility는 glenohumeral joint가 불안정함을 암시

- 예를들어 어깨 외회전 105도를 넘어가거나 통증으로 불안을 보이면 GH joint instability

apprehension test, ant-post humeral glides, sulci test, hyper-abduction test

- GH 관절의 불안정성을 찾기 위한 흔한 검사

apprehension relocation test

- 유튜브 동영상 http://www.youtube.com/watch?v=qKqJRrms4u8

inferior sulcus test

- 유튜브 동영상 http://www.youtube.com/watch?v=taN04xR4iAs

posterior capsule tightness검사

- 어깨 90도 외전상태에서 내회전 제한일때 pos

- 심한 제한은 frozen shoulder, impingement 의심

- frozen shoulder는 외회전, 굴곡, 외회전 90도이하의 극단적인 제한 상태

- impingement는 내회전 제한, 외전 또는 굴곡과 관련하여 90도 넘어가면서 제한이 있을때

GH joint의 불안정성

- passive rom을 시행하여 105도 이상의 과도한 외회전, apprehension test pos일때 GH joint의 불안정성

upper crossed syndrome

- Janda's concepts에 의하면 치위생사 연구결과 상부승모근과 견갑거근의 tightness, 대흉근 하부섬유 tighteness

- muscle felxibility deficit : suboccipital, SCM, 대소흉근, 대원근, 견갑하근, 견갑거근, 상부승모근, 광배근

5. accessory mobility. end feel

- AC joint는 hypermobile and unstable되기 쉬운 관절

- 떨어지는 사고, 스포츠 부상등에서 흔하게 sprain

- passive accessory motion으로 앞뒤, 뒤앞의 방향으로 gliding시켜 불안정성을 확인

- 의사는 흉곽출구 증후군으로 ac joint가 immobilized되어 나타나는 문제를  passive accessory motion을 검사할 뿐 아니라 상지 부상, 수술로 인해 immobilized되는 경우도 검사해야 함.

anterior slide test 

- 특히 superior labrum의 손상을 검사하는 방법

- 환자 앉아서 손을 허리에 대고 검사자는 환자 뒤에 서서 한 손으로 환자의 견갑골과 쇄골을 고정. 다른 손으로 검사자는 anterosuperior force at the upper arm near the elbow. 

- 만약 labrum이 torn되었다면 통증이 발생하고 crack소리와 함께 humeral head가 slide

- 유튜브 동영상 http://www.youtube.com/watch?v=scYaTo7N11A

6. resistance test

- 저항검사는 회전근개 건염, 파열을 확인하는데 가장 중요한 검사

- passive motion 검사는 joint나 인대와같은 비수축성 구조문제를 평가하는 검사

- active movement는 muscle length 평가

- active resisted test는 muscle strength평가

저항검사로 mechanical sensitivity가 발생하면 muscle isolated 테스트로 tendonitis로 판단

- external rotation 저항검사로는 수축구조인 극상근과 극하근 회전근개의 손상을 판단

- 외회전 저항검사로 통증이 있으면서 weak가 보인다면 GH joint의 neutral position 상태에서 다시 검사하여 회전근개 손상, 건염을 진단함

- 외회전 저항검사로 통증이 없으면서 weak가 보인다면 c5 nerve, suprascapular nerve문제를 의심해야 

- Burkhart의 연구에 의하면 어깨 환자의 72%가 외회전근육인 극하근, 소원근이 약해져 있다는 사실

- Wilk에 의하면 외회전 근력은 내회전 근력의 최소한 65%는 되어야 한다고 

empty can test

- 극상근 isolated test

- scapular plane에서 90도 elevate하고 상지 내회전한 상태에서 저항

- http://www.youtube.com/watch?v=iyDkts_4URA

speed's test

- biceps muscle isolated test

- 환자의 상지 외회전 후 들어올릴 때 저항

A recent paper demonstrated that a comprehensive functional/orthopedic examination including the combination of the Hawkins–Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for impingement syndrome (Park et al., 2005)

7. Functional tests

Poor posture and/or faulty movement patterns are typical kinetic chain dysfunctions which cause 

biomechanical overload. Such repetitive strain irritates pain sensitive structures and can be a key perpetuating factor of pain. Movement patterns are important to assess because classic muscle tests eval‎uate strength, but

not the quality of movement (Janda, 2006; Liebenson et al., 1998). A number of muscles participate in any movement pattern.

- poor posture and/or faulty movement patterns는 인체 움직임 사슬 기능부전에 의한 mechanical overload의 가장 흔한 요인

-  classic muscle test 는 근력을 평가하는 방법이기 때문에 근력이 중요한 것이 아니라 functional test에서는 movement pattern검사가 가장 중요

 Poor scapulohumeral rhythm coordination is related to shoulder disorders (i.e. impingement) (Babyar, 1996; Yamaguchi et al.,2000). This stereotypical movement pattern screens for functional pathology during tasks involved with prehension (Kamkar et al., 1993; Kibler and McMullen, 2003). Inadequate fixation of the scapulae from below will overstress both the cervical spine and shoulder joint complex. This is eval‎uated during reaching and carrying tasks. Co-activation of the upper and lower scapular fixators maintain a ‘‘neutral’’ position of the scapulae during arm movements.

- umeral rhythm coordination 이 어깨충돌증후군 등 어깨질환과 연관성 있음.

-  Inadequate fixation of the scapulae from below는 경추와 견갑대에 overstres를 야기할 수 있음

- Co-activation of the upper and lower scapular fixators는 arm움직임 동안 견갑골의 중립자세를 유지.

Arm abduction test

Procedure (see Fig. 8):

- Arm at side, elbow bent 90도, and wrist in neutral position, slowly raise arm (abduction).

Score:

- During the ‘‘setting phase’’, 1st 601, the shoulder should  not elevate.

 The lower and middle trapezius can also be assessed in the prone postion (see Figs. 9–11). In each of these tests strength, symmetry, and AMC is assessed. The chief dysfunction noted is typically the inability to maintain a depressed scapular position. Impaired muscle performance of the scapular adductors and upward rotators—serratus anterior, middle and lower trapezius—are also commonly present.

- 하부승모근, 중부승모근은 아래 그림처럼 누운자세로 평가할 수 있음.

- 각각의 검사동안 근력, 양측균형, Abnormal motor control을 측정함

- 전형적으로 문제가 되는 것은 견갑골 하강이 유지가 안되는 것

- 또 흔하게 존재하는 문제는 견갑골 내전근육과  upward rotator근육(전거근, 중부,하부 승모근)의 impaired muscle performance

Push-up test

Procedure (See Fig. 12):

_ In a push-up position from toes or knees,

_ slowly lower and then raise the trunk up.

ARTICLE IN PRESS

Shoulder disorders—Part 2: Examination

Score:

_ Fail if:

J scapulae retract,

J scapulae wing,

J shoulders shrug.

Burkhart et al. (2000) describe two important functional tests. The scapular assistance test (SAT) and scapular retraction test (SRT). The SAT is positive if it gives relief of impingement, clicking or rotator cuff weakness. The SAT is performed by manually stabilizing the upper medial scapula border and rotating the inferior medial border as the arm is actively abducted and adducted by the patients. The SRT is a similar test involving retraction.

scapular assistance test 

- 유튜브 동영상 http://www.youtube.com/watch?v=I9Dzze57EWM

- SAT 검사시 impingement, clicking or rotator cuff weakness가 relief되면 positive sign

scapular retraction test

- 유튜브 동영상 http://www.youtube.com/watch?v=Tm_q2ipA0_o

Palpation

Palpation is important to provide further information about the rotator cuff, biceps tendon and/or subacromial/subdeltoid bursa. The seated position is ideal for the supraspinatus tendon. Have the

patient place the hand behind their buttock. The arm can also be extended. The long head of the biceps can best be palpated either seated or supine in the bicipital groove. The subscapularis muscle is challenging to palpate. The scapula must be abducted from the rib cage. This is best performed in either supine or side lying positions. The

infraspinatus and teres minor muscles can be palpated with the patient prone.

- 극상근 건 촉진을 위해 손을 엉덩이에 두기

- 상완이두근건 촉진은 bicipital groove에서 

- subscapularis 촉진은 rib cage를 외전

- 극하근, 소원근 촉진은 엎드려서

Imaging

Imaging such as X-ray, magnetic resonance image (MRI), etc. is often indicated in trauma, the elderly, or unresponsive patients. However, not all positive imaging findings are confirm‎atory of symptom

producing abnormalities. In fact, there is a surprisingly high rate of false positive test results in asymptomatic individuals.

- 엑스레이, mri등은 trauma, 나이든 경우, 치료에 반응하지 않는 환자의 경우에서 적응증

- 하지만 positive finding이 증상을 야기하는 확정적인 질병은 아님. 많은 비율에서 false positive

Ultrasound showed a complete rupture of the supraspinatus tendon in 6% of 212 patients from 56 to 83 years of age (mean: 67 years) (Schibany et al.,2004). MRI confirmed a complete rupture of the supraspinatus tendon in 90%. 

- 초음파 진단의 경우 극상근 완전파열 212명중(평균나이 67세) 6명만 진단

- mri는 극상근건 완전파열의 90%를 확진

All patients reported no functional deficits, although strength was significantly lower in the patient group with

complete supraspinatus tendon tear (Po0:01). There is a higher preval‎ence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living. MRI of the shoulders of 96 asymptomatic individuals were eval‎uated to determine the preval‎ence of findings consistent with a tear of the rotator cuff (Sher et al., 1995). The over-all preval‎ence of tears of the rotator cuff in all age-groups was 34%. There were fourteen full-thickness tears (15%) and nineteen partial-thickness tears (20%). The frequency of full-thickness and partial-thickness tears increased significantly with age (Po0:001 and 0.05, respectively). Twenty-five (54%) of the 46 individuals who were more than 60-year old had a tear of the rotator cuff: 13 (28%) had a full-thickness tear and 12 (26%) had a partial-thickness tear. 

- 극상근건 파열로 근력이 심각하게 떨어져 있을지라도 모든 환자가 기능적 장애를 보이지는 않음

- 예를들어 96명 증상이 없는 사람들을 대상으로 한 연구에 의하면 나이든 그룹의 34%가 극상근 건 파열

- 15%(14명)이 full-thickness tear, 20%(19명)이 partial-thickness tear

- 나이가 많은수록 극상근 건 파열 비율은 높아짐

- 60세가 넘은 46명환자 중 극상근 건 파열이 있는 환자는 54%(25명).  full-thickness tear는 28%(13명),  partial-thickness tear는 26%(12명)

참고) Tears of the rotator cuff tendon are described as partial thickness tears, full thickness tears and full thickness tears with complete detachment of the tendons from bone.

• Partial thickness tears often appear as fraying of an intact tendon.

• Full thickness tears are through-and-through tears. These can be small pin-point tears or larger button hole tears or tears involving the majority of the tendon where the tendon still remains substantially attached to the humeral head and thus maintains function.

• Full thickness tears may also involve complete detachment of the tendon(s) from the humeral head and may result in impaired shoulder motion and function may be significantly affected.

Of the 25 individuals who were 40–60-year old, one (4%) had a full-thickness tear and six (24%) had a partialthickness tear. Of the 25 individuals who were 19–39-year old, none had a full-thickness tear and

one (4%) had a partial-thickness tear. 

- 40-60세 25명을 대상으로 한 연구에서는 4%(1명)이  full-thickness tear,  24%(6명)은 partial-thickness tear

- 19-39세 25명을 대상으로 한 연구에서는  full-thickness tear는 없고, 4%(1명)만  partial-thickness tear

MRI identified a high preval‎ence of tears of the rotator cuff in asymptomatic individuals. These tears were increasingly frequent with advancing age and were compatible with normal, painless, functional activity. The results of the present study emphasize the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention in the absence of associated clinical findings. Additionally, it is possible in symptomatic individuals that the MRI findings are merely coincidental. 

- mri로 극상근 건 파열이 있는 환자가 통증이 있는 것은 우연의 일치일 수 있음. 

Fourteen completely asymptomatic patients and 32 patients with residual symptoms were or retears were detected in three (21%) and bursitis-like abnormalities in 14 (100%) of the 14 asymptomatic patients. Fifteen (47%) residual

defects or retears and 31 (97%) bursitis-like abnormalities were diagnosed in the 32 patients with residual symptoms. The size of the residual defects/retears was significantly smaller in the asymptomatic group (mean 8 mm, range 6–11 mm) than in the symptomatic group (mean 32mm, range 7–50mm) (t-test, P ¼ 0:001). The extent of the bursitis-like subacromial abnormalities did not significantly differ (t-test, P40:05) between asymptomatic (mean 28_3 mm) and symptomatic patients (mean 32_3 mm).

- 무시

Thus, small residual defects or re-tears (<1 cm) of the rotator cuff are not necessarily associated with clinical symptoms. Subacromial bursitis-like MR abnormalities are almost always seen after rotator cuff repair even in patients without residual complaints. They may persist for several years after rotator cuff repair and appear to be clinically irrelevant.

- Subacromial bursitis-like MR abnormalities are almost always seen after rotator cuff repair even in patients without residual complaints

Detailed MRI scans of asymptomatic dominant and nondominant shoulders of elite overhead athletes were obtained (Connor et al., 2003). Images from a surgical control group were intermixed to assess accuracy and control for observer bias. A 5-year follow-up interview was performed to determine whether MRI abnormalities found in

the initial stage of the study represented truly clinical false-positive findings or symptomatic shoulders in evolution. Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had MRI evidence of Bennett’s lesions compared with none (0%) of the nondominant shoulders. None of the athletes

interviewed 5 years later had any subjective symptoms or had required any eval‎uation or treatment for shoulder-related problems during the study period. 

Thus, MRI alone should not be used as a basis for operative intervention in this patient population. For chronic shoulder pain of non-traumatic origin it does not appear MRI is a front line diagnostic test (Bradley et al., 2005). In total, 41% of 101 consecutive patients had a shoulder MRI prior to specialist eval‎uation by an orthopedic fellowshiptrained shoulder specialist. There were no statistically significant differences in age, sex, affected

shoulder, insurance status, mechanism of injury, comorbid conditions, range of motion, treatment, initial outcome parameter assessments, or improvement of outcomes between the patients who had pre-eval‎uation MRI and those who did not.

Summary

Thorough eval‎uation of patients with shoulder problems should classify patients into discreet diagnostic groups—red flags, impingement syndrome, adhesive capsulitis, shoulder instability. Most rotator cuff tendonitis patients fall into the

impingement category. The most important aspect of the initial eval‎uation is to rule out red flags suggestive of tumor, infection or fracture. If present such patients always require additional testing and often referral. A patient will be classified into the impingement category if there is (a) pain with active shoulder motions (i.e., painful arc), (b) pain with overpressure of passive shoulder elevation (i.e., a positive Neer’s test) or horizontal shoulder adduction/internal rotation (Hawkins test), and (c) painfully weak resisted shoulder motions. Impingement syndrome patients should also be eval‎uated for partial or full-thickness rotator cuff tears, especially if the response to 4–6 weeks of rehabilitation is unsatisfactory. Patients with adhesive capsulitis have severe ROM loss. The most restricted ROMs are with shoulder abduction, external rotation, and flexion. In contrast, patients with shoulder instability are hypermobile. A history of recurrent dislocations is often present. An apprehension sign may be present. SLAP II-IV lesions are common in this

patient group and the labrum can be seen to be stretched anterior during many of the functional tests.