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1 대한내과학회지 : 제 91 권제 2 호 Interpretation of diagnostic test 초음파를이용한어깨통증의진단 건국대학교의학전문대학원내과학교실류마티스내과 김해림 Ultrasonographic ssessment for Shoulder Pain Hae-Rim Kim Division of Rheumatology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea 서론어깨통증의발생률은일반인구의 15-20% 에이를정도로비교적흔하다 [1]. 지속적인어깨통증의원인으로는회전근개질환이 10%, 유착관절낭염 (adhesive capsulitis) 이 6%, 오목위팔관절 (glenohumeral joint) 의골관절염이 2-5% 등이다 [2]. 어깨통증의진단에있어초음파는방사선노출이미미하고, 가격이저렴하며, 진료실에위치하여진료의사가직접수행하여치료를바로결정할수있고, 움직임을관찰할수있다는장점이있다. 대개 60 mm의일자형탐촉자를이용하기때문에내과진료시갑상선또는경동맥을관찰하는초음파를이용하여쉽게관찰이가능하다. 다음은초음파로확인이가능한질환들에대한대표적소견이다. 힘줄윤활막염 (tenosynovitis) 힘줄집내액체를동반하거나동반하지않은저에코성또는무에코성의두꺼워진조직이탐촉자의두직각면에서관찰되고, 도플러신호가보일수있는병변으로정의된다 [3]. 위팔두갈래근 (biceps muscle) 의긴머리힘줄 (long head) 에서주로발생하며, 힘줄은비교적정상적인두께와에코를보이지만그주변으로무에코성의액체저류와증가된파워도플러신호가관찰된다 (Fig. 1). 위팔두갈래근의힘줄집은오목위팔관절과통해있으므로이관절의삼출이이동한것인지힘줄윤활막염단독병변인지를잘구별해야한다. 힘줄염 (tedinitis) 와힘줄병증 (tendinosis) 힘줄염이주로염증 (inflammation) 에의한힘줄병변이라면힘줄병증은퇴행 (degeneration) 에의한병변으로초음파로두질환의감별은쉽지않다. 가시위오목근은균질한실타래모양의에코를보이며어깨세모근과비슷한두께를보이는것이정상이나, 힘줄염이나힘줄병증이있는경우불균질하게증가또는감소하는에코를보이고부종에의해힘줄의두께가증가하며 ( 무증상의반대측에비해 mm 이상증가될때고려 ) 미세석회화가보이거나도플러신호가증가하기도한다 (Fig. 2). Correspondence to Hae-Rim Kim, M.D. Division of Rheumatology, Department of Internal Medicine, Konkuk University School of Medicine, Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea Tel: , Fax: , kimhaerim@kuh.ac.kr Copyright c 2016 The Korean ssociation of Internal Medicine This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Tenosynovitis of the long head of biceps

The hyperechogenic thickened tendon sheath

2 The Korean Journal of Medicine: Vol. 91, No. 2, 2016 C D Figure 1. Tenosynovitis of the long head of biceps tendon. () Transverse and () longitudinal ultrasonographic (US) images demonstrate anechoic fluid (*) within the tendon sheath. The hyperechogenic thickened tendon sheath exhibits increased power Doppler signal in (C) transverse and () longitudinal US images. C D Figure 2. Tendinosis of supraspinatus tendon. In contrast of normal supraspinatus tendon (T) seen in () transverse and () longitudinal US images, there are heterogeneous echogenicity without definite defect and increased thickness of the tendon seen in (C) transverse and () longitudinal US images

- Hae-Rim Kim. Ultrasonographic assessment for shoulder pain - 석회성건염 (calcific tendinitis) 가시위오목근에서흔하게발생하며골부착 1 cm 이내의위험대에잘발생한다 [4].

윤활막염 (synovitis) 윤활막염의대표적초음파소견으로는삼출 (effusion) 과윤활막증식 (synovial proliferation) 이있다. 삼출은피하지방과비교하여비정상적인저에코성또는무에코성 ( 때로는동일에코이거나고에코일수도있는 ) 의관절내물질로, 이동과압박이가능하나도플러신호를보이지않는다 [3].

회전근개파열파열된두께에따라부분층 (partial-thickness) 파열과전층 (full-thichness) 파열로나뉘고, 부분파열은파열된부위에따라힘줄내 (intrasubstance), 윤활낭면 (bursal surface) 과연골면 (articular surface) 파열로나뉘며, 힘줄이큰거친면 (greater

() Longitudinal and () transverse ultrasonographic images show hyperechogenic linear lesion (arrows) with faint posterior acoustic shadowing in the tendon. Figure 4.

3 - Hae-Rim Kim. Ultrasonographic assessment for shoulder pain - 석회성건염 (calcific tendinitis) 가시위오목근에서흔하게발생하며골부착 1 cm 이내의위험대에잘발생한다 [4]. 석회화의단계에따라다양한초음파소견을보이는데, 약 79% 에서뚜렷한후음향음영 (postacoustic shadow) 을동반한고에코성병변, 14% 에서후음향음영이희미한고에코성병변, 7% 에서후음향음영이없는고에코성병변으로관찰된다 (Fig. 3). 윤활막염 (synovitis) 윤활막염의대표적초음파소견으로는삼출 (effusion) 과윤활막증식 (synovial proliferation) 이있다. 삼출은피하지방과비교하여비정상적인저에코성또는무에코성 ( 때로는동일에코이거나고에코일수도있는 ) 의관절내물질로, 이동과압박이가능하나도플러신호를보이지않는다 [3]. 어깨에서삼출은오목위팔관절의후면또는액와부에서가장잘 관찰된다 (Fig. 4). 윤활막증식은피하지방과비교하여비정상적인저에코성 ( 때로는동일에코이거나고에코일수도있는 ) 의관절내조직으로, 삼출과는달리이동하지않고도플러신호를보일수있는병변이다 [3]. 회전근개파열파열된두께에따라부분층 (partial-thickness) 파열과전층 (full-thichness) 파열로나뉘고, 부분파열은파열된부위에따라힘줄내 (intrasubstance), 윤활낭면 (bursal surface) 과연골면 (articular surface) 파열로나뉘며, 힘줄이큰거친면 (greater tuberosity) 에부착하는부위에서잘발생한다. 초음파소견으로는고에코성의균질한실타래에코가갑자기중단되어국소적인저에코성또는무에코성병변이존재하는것이탐촉 Figure 3. Calcific tendinitis of supraspinatus tendon. () Longitudinal and () transverse ultrasonographic images show hyperechogenic linear lesion (arrows) with faint posterior acoustic shadowing in the tendon. Figure 4. Synovitis of glenohumeral joint. Transverse ultrasonographic images at posterior glenohumeral joint shows () anechoic effusion (*) accentuates the appearance of the cartilage (double cortex sign; arrow) and () combined hyperechogenic synovial proliferation and relatively hypoechogenic effusion (**) enlarges the joint space between labrum (L), humerus and intraspinatus tendon (IS)

- 대한내과학회지 : 제 91 권제 2 호통권제 672 호 2016 - Figure 5. Rotator cuff tear.

T, supraspinatus tendon. 자의두직각면에서모두관찰되고탐촉자에의해힘줄사이가압박이될수도있다 (Fig. 5) [5]. 그러나출혈에의해파열부위가오히려고에코성으로관찰되거나, 뚜렷한결함없이힘줄이점진적으로얇아지거나, 오래된광범위파열인경우힘줄이끌어당겨져관찰되지않을수도있다.

정상적으로는 2 mm 이하의두께의, 두층의고에코성윤활낭주변지방층과저에코성의윤활낭액선이나란히관찰되며내부의액체저류는보이지않으나, 윤활낭염이발생한경우이부위의액체저류와윤활낭벽의두께증가가보이며이는어깨를관찰하는여러각도의스캔에서쉽게관찰이가능하다 (Fig. 6) [5]. Figure 6. Subacromial-subdeltoid bursitis.

결 이상에서어깨통증의원인질환중초음파로쉽게확인이가능한병변을소개하였다. 각질환의특성을이해하고해부학적인지식과진찰이선행된다면어깨통증에대한평가및치료가가능할것이다. 중심단어 : 어깨 ; 초음파 ; 회전근 ; 힘줄윤활막염 ; 윤활막염개 론 REFERENCES 1. Greving K, Dorrestijn O, Winters JC, et al.

4 - 대한내과학회지 : 제 91 권제 2 호통권제 672 호 Figure 5. Rotator cuff tear. Transverse ultrasonographic images shows () bursal surface partial-thickness tear and () full-thickness tear of supraspinatus tendon making cartilage interface sign. T, supraspinatus tendon. 자의두직각면에서모두관찰되고탐촉자에의해힘줄사이가압박이될수도있다 (Fig. 5) [5]. 그러나출혈에의해파열부위가오히려고에코성으로관찰되거나, 뚜렷한결함없이힘줄이점진적으로얇아지거나, 오래된광범위파열인경우힘줄이끌어당겨져관찰되지않을수도있다. 윤활낭염 (subacromial subdeltoid bursitis) 세모근밑주머니 (subdeltoid bursa) 와봉우리밑주머니 (sabacromial bursa) 는어깨의넓은부위를덮고있는인체에서가장큰윤활낭들로대부분두윤활낭이통해져있다. 정상적으로는 2 mm 이하의두께의, 두층의고에코성윤활낭주변지방층과저에코성의윤활낭액선이나란히관찰되며내부의액체저류는보이지않으나, 윤활낭염이발생한경우이부위의액체저류와윤활낭벽의두께증가가보이며이는어깨를관찰하는여러각도의스캔에서쉽게관찰이가능하다 (Fig. 6) [5]. Figure 6. Subacromial-subdeltoid bursitis. Transverse ultrasonographic image demonstrates well-defined, anechoic fluid (*) accumulates in the bursal space which is located between long head of biceps tendon and deltoid muscle. 결 이상에서어깨통증의원인질환중초음파로쉽게확인이가능한병변을소개하였다. 각질환의특성을이해하고해부학적인지식과진찰이선행된다면어깨통증에대한평가및치료가가능할것이다. 중심단어 : 어깨 ; 초음파 ; 회전근 ; 힘줄윤활막염 ; 윤활막염개 론 REFERENCES 1. Greving K, Dorrestijn O, Winters JC, et al. Incidence, prevalence, and consultation rates of shoulder complaints in general practice. Scand J Rheumatol 2012;41: Meislin RJ, Sperling JW, Stitik TP. Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. m J Orthop (elle Mead NJ) 2005;34(12 Suppl): Wakefield RJ, alint PV, Szkudlarek M, et al. Musculoskeletal ultrasound including definitions for ultrasonographic

5 - 김해림. 초음파를이용한어깨통증의진단 - pathology. J Rheumatol 2005;32: ureau NJ. Calcific tendinopathy of the shoulder. Semin Musculoskelet Radiol 2013;17: Moosikasuwan J, Miller TT, urke J. Rotator cuff tears: clinical, radiographic, and US findings. Radiographics 2005; 25:

( ) Jkra076.hwp

( ) Jkra076.hwp Vol. 11, No. 4, December, 2004 Objective: Ultrasonography (USG) of joints has a unique position for the diagnosis of joint diseases. Bone surface, cartilage, periarticular soft tissue and their pathologic