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1 Shoulder 스포츠 손상과 치료 강의를 초청하여 주셔서 감사합니다 감사합니다.. 박진영, PARK Jin-Young 건국대학교 의학전문대학원 Shoulder, Elbow & Sports Service Sports injury?? Sports injury?? Sports injury?? AC joint injury Most common injury in contact sports e.g. football 1

2 [OSEN= 대구, 손찬익기자 ] ' 난공불락 ' 오승환 (28, 삼성투수 ) 이오른쪽팔꿈치뼈조각관절경수술을성공적으로마쳤다. Let s think about Sports Injury 오승환은지난 8월 12일오른쪽팔꿈치에서웃자린뼈조각을제거하는수술을받았다. 구단관계자는 " 오승환이이틀간입원한뒤퇴원할 예정이며 Non-Athletes 향후재활일정을아직결정되지않았다 " 고밝혔다. 선동렬 삼성 Pain 감독은 itself " 오승환은 is important 포스트시즌에진출하면그때가서다시생각해봐야겠다 " 고밝힌바있다. 2006년부터 3년연속구원왕에 오른오승환은 Should 올시즌 not 16 disturb 경기에 daily 등판, 4 activity 세이브 ( 방어율 of living 4.50) 를기록했으며 지난달 To sports-loving 18 일 1 군엔트리에서 people: 말소된 important 바있다 t. issue to continue sports activity Athletes Injury? End of the season + loose everything Return to sports? as soon as possible Pain itself disturbs the sports activity Common injury in sports? 1. Baseball 2. Football (US) 3. Soccer 4. Swimming 5. Tennis 6. Golf 7. Ski 8. Snowboard Shoulder, Elbow Knee Knee Shoulder Elbow Shoulder & Knee Knee Wrist, Elbow Joint pain? 1 st thing to do If pathologic condition is not definite? 1. Immobilization and then observation a. Nonathletes? : Accepted b. Athletes? : Never accepted without complaint Rehabilitation is important in sports medicine. Warning signs in sports medicine Redness, heat, joint swelling, joint pain, stiffness, numbness, weakness and clicking sound Don t ignore them!! Prevent further damage! Immediately stop the activity R.I.C.E. (Rest, Ice, Compression, Elevation) Joint pain? 1 st thing to do If pathologic condition is not definite? 1. Observation 2. Icing 3. Immobilization 4. Pain medication Principle in Sports Medicine Warm-up & Stretch your body before any kinds of sports activity Pushing yourself too hard during sport or overdoing everyday activities may be enough to trigger muscle or joint pain. 2

3 Shoulder pain related with sports activity Snowboard Injury 상지의스노우보드손상 I Vail Colorado ski resorts, USA From 1988 to 1998 : 7430 cases 남자 : 여자 = 74% : 26% 초보자 : 39% 중급자 / 상급자 : 61% 상지손상 : 49% 골절 56% 염좌 27% 탈구 10% -Idzikowski 2000 Am J Sports Med- Snowboard Injury 상지의스노우보드손상 II From 1988 to 1998 : 7430 cases Vail Colorado ski resorts 손상부위 수근관절부 (wrist) : 22% 초보자, 여자 어린사람들에서호발 수부 (hand), 주관절 (elbow), 견관절 (shoulder) 중급자, 상급자에서호발 Snowboard Injury 상지의스노우보드손상 III 견관절부 (Shoulder) 945 cases 골절 (Fracture) 54 cases 탈구 (Dislocation) 227 cases 쇄골골절 (Clavicle fracture) 279 cases AC 관절탈구 385 cases 주관절부 (Elbow) 306 cases 골절 (Fracture) 79 cases 탈구 (Dislocation) 227 cases 전완부골절 (Forearm Fx) 92 ases 수근관절부 (Wrist) 1570 cases 골절 (Fracture) 1199 cases 탈구 (Dislocation) 20 cases 염좌 (Sprain) 304 cases 주상골골절 (Scaphoid Fx) 47 cases 수부 (Hand) 161cases Snowboard Injury 견관절 (Shoulder) 전체상지손상중 32% (945/2982 cases) 손상기전 Backward fall : more often Forward fall : clavicle l Fx, AC D/L 손상종류 Fracture (including greater tuberosity Fx) & dislocation clavicle Fx, D/L AC joint rotator cuff tear Snowboard Injury 견관절 (Shoulder) 3

4 각운동별견통의빈도 수영 (Swimmer) 과견통 수영선수 66% 야구선수 ( 투수 ) 57% 배구선수 44% 창던지기선수 29% 어깨통증초기 : 진단이쉽다 진행되면 : 염증으로인한전체적인통증 참으면서수영계속시 : 어깨의손상 어깨손상의 50% 이상이재발 통증은 몸의이상을알리는경계신호! 수영동작 ( 자유형 ) 자유형과어깨통증 통증이가장심한동작 Pull-through 의초기 : 70% Recovery 의초기 : 18% Free Style Stroke 수영선수 233 명 (17 대학팀 ) 다치는장소는? 스트로크와근육피로 사체연구 회전근개, CA arch 로의이두박근건 전상방관절와순 인체견관절의특징 근육피로 (fatigue) 불안정성 (instability) 전거근 (Serratus anterior) 견갑하근 (Subscapularis) 피로증가 피로증가 전방 & 중간삼각근 (ant & middle Deltoid), 승모근 (Trapezius), 능형근 (Rhomboid) 피로증가 Dropped elbow in Hand Exit 4

5 수영선수견관절의진단 출구면충돌증후군 : NO! 관절낭이완 : uncommon true instability! 관절낭이완에따른이차적인충돌현상 회전근개의스트레스증가 견갑골주위근육의기능약화 어깨손상의징후 (sign) 정상 / 비정상의조기발견 코치의역할가장중요 팔떨굼 (Dropped Elbow) 익상견 (Winging Scapula) 내회전 / 외회전 (Balance) 손상의미세징후 Throwing Mechanics 옆으로입수 (Wider entry) 견갑하근, 삼각근의수축감소 비대칭운동 (Asymmetric pull) 손상된팔에의한힘의불균형 레인중앙을벗어남 (Not staying in center) 반대쪽운동감소 - 발운동 ( 킥 ) 변화 빨리손빼기 (Early water exit) 과도한몸동작 (excessive body-roll) 투구동작의역학 투구에중요한동작 Wind-up : A,B,C,D Stride : D,E,F Arm cocking :FGH F,G,H Arm acceleration : H,I Arm deceleration : I,J Follow-through : J,K Stride Arm cocking Arm acceleration 5

6 투구동작의역학 견관절후방근육 : 약한작용 극상근 삼각근중간부분 극하근 견관절전방근육 : 강한작용 견갑하근 광배근 대흉근 투구동작시문제점 I 강력한구질의공 많은양의 arm acceleration + cocking Arm deceleration시엄청난가속도감소 Cocking과 arm deceleration 에서견관절손상이가능 투구동작시문제점 II 과사용에따른편심성과부하 점차적인견관절손상 근육, 인대, 관절낭, 견와순 견관절불안정성 조직의재파괴 정상적인생역학의변화 이차적충돌증후군 라켓을이용하는선수손상기전 견봉쇄골관절 오랫동안라켓사용한선수 스매싱, 하이클리어 내적충돌증후군 어깨를너무뒤에서앞으로움직이며서틀콕을칠때 경도의전방불안정증 회전근개건염및파열 어깨위로라켓을많이사용할때 상방관절와순 (SLAP) 병변및결절낭종 : 넘어질때 Pain anywhere in shoulder Shoulder Sports Injury and Treatment Mostly due to muscle weakness Important injuries are.. Glenohumeral instability SLAP and impingement Fracture Tendon rupture. 6

7 1. 충돌 Impingement 2. 회전근개손상 Rotator Cuff Injury 3. 관절와순손상 Glenoid Labrum Injury 4. 관절와상완관절탈구 Dislocation of Glenohumeral Joint 5. 어깨불안정성 Shoulder Instability 6. 어깨강직 ( 동결견 ) Shoulder Stiffness( Frozen Shoulder ) 7. 쇄골골절 Fracture of the Clavicle 8. 견봉쇄골관절손상 Acromioclavicular Joint Injury 9. 연관통 Referred Pain 10. 그밖의원인 1. 충돌 Impingement 2. 회전근개손상 Rotator Cuff Injury 3. 관절와순손상 Glenoid Labrum Injury 4. 관절와상완관절탈구 Dislocation of Glenohumeral Joint 5. 어깨불안정성 Shoulder Instability 6. 어깨강직 ( 동결견 ) Shoulder Stiffness( Frozen Shoulder ) 7. 쇄골골절 Fracture of the Clavicle 8. 견봉쇄골관절손상 Acromioclavicular Joint Injury 9. 연관통 Referred Pain 10. 그밖의원인 충돌 Impingement 1. 외적충돌 (External impingement) 일차적 (primary) 충돌 Impingement 이차적 (secondary) 2. 내적충돌 (Internal impingement) 일차적외적충돌 Primary External Impingement between humeral head and acromion 일차적외적충돌 Primary External Impingement 원인 Osteophyte( 골극 ) or Beak 견봉하방면의모양 Curved type Hooked type Os acromiale 7

8 이차적외적충돌 Secondary External Impingement 원인 Periscapular muslces : Imbalance Antero-Inferior translation of Acromion Deltoid vs Rotator cuff : Imbalance Superior translation of Humerus 내적충돌 Internal impingement 구기운동선수 mostly in Late cocking Extension Abduction (>90º) External rotation 충돌부위관절와후 - 상방면 vs 회전근개하방면 내적충돌 Internal impingement Repeated hyperexternal rotation at cocking cause pathologic internal impingement repetitive hypertwisting of RC fiber fatigue & torsional overload failure of RC cause of dead arm syndrome in throwing athletes with other pathology 충돌의치료 Treatment Rest, NSAIDs Subacromial injection Strengthening exercise Periscapular muscle Rotator cuff ASD : arthroscopic subacromial decompression 1. 충돌 Impingement 2. 회전근개손상 Rotator Cuff Injury 3. 관절와순손상 Glenoid Labrum Injury 4. 관절와상완관절탈구 Dislocation of Glenohumeral Joint 5. 어깨불안정성 Shoulder Instability 6. 어깨강직 ( 동결견 ) Shoulder Stiffness( Frozen Shoulder ) 7. 쇄골골절 Fracture of the Clavicle 회전근개손상 Rotator Cuff Injury 8. 견봉쇄골관절손상 Acromioclavicular Joint Injury 9. 연관통 Referred Pain 10. 그밖의원인 8

9 회전근개손상 Rotator Cuff Injury 회전근개건병증 Rotator Cuff Tendinopathy 회전근개건병증 Rotator cuff tendinopathy 회전근개염좌 / 파열 Rotator cuff strain/tear Overuse Apoptosis Tendinosis 단백질키나아제활성화콜라겐합성저하, 기질재형성저하시간의경과 석회화건염 Calcific tendinitis Tendon rupture 회전근개건병증 Rotator Cuff Tendinopathy Clinical manifestation & Diagnosis Pain in overhead activity Tenderness on Greater tuberosity Painful arc : 70~120º Impingement sign & test + MRI : useful 회전근개건병증 Rotator Cuff Tendinopathy Treatment Rest, Ice bag Subacromial steroid injection i Treatment of Comorbidity Glenohumeral instability Muscle weakness Capsular tightness Scapular dyskinesis 회전근개파열 Rotator Cuff Tear Complete tear Repair Mini-open repair Arthroscopic repair 1열봉합술 2열봉합술 골터널봉합술 교량형봉합술 통증호전 + 기능향상 1. 충돌 Impingement 2. 회전근개손상 Rotator Cuff Injury 3. 관절와순손상 Glenoid Labrum Injury 4. 관절와상완관절탈구 Dislocation of Glenohumeral Joint 5. 어깨불안정성 Shoulder Instability 6. 어깨강직 ( 동결견 ) Shoulder Stiffness( Frozen Shoulder ) 7. 쇄골골절 Fracture of the Clavicle 8. 견봉쇄골관절손상 Acromioclavicular Joint Injury 9. 연관통 Referred Pain 10. 그밖의원인 9

10 관절와순손상 Glenoid Labrum Injury SLAP 병변 ( 상부관절와순전후병변 ) Superior Labrum from Anterior to Posterior lesion 관절와순손상 Glenoid Labrum Injury Bankart 병변 ( 전방관절와순파열 ) shoulder instability Other labral injuries 상부관절와순전후병변 SLAP lesion Injury mechanism Throwing overuse Rupture of the biceps! 상부관절와순전후병변 SLAP lesion Injury mechanism HyperER +Abduction Repeat overhead-throwing : Peel-back l b k mechanism Scapular protraction GIRD (glenohumeral internal rotation deficiency) Exessive inferior traction ( 무거운물건들어옮기기 ) 상부관절와순전후병변 SLAP lesion Andrews: 1 st described in athletes Snyder: characterized & classified 상부관절와순전후병변 SLAP lesion SLAP repair Konkuk Univeristy Hospital Shoulder, Elbow & Sports Service 10

11 상부관절와순전후병변 SLAP lesion Type III Konkuk Univeristy Hospital Shoulder, Elbow & Sports Service 관절와순주위낭종 Paralabral Cyst Communication with G-H joint No evidence for proposed origin Sx Weakened rotator cuff posterior-superior shoulder pain Similar with labral injury locking, catching, popping Nerve compression weakness, burning sensation Difficult to detect d/t compensatory hypertrophy of teres minor 관절와순주위낭종 Paralabral Cyst Diagnosis 임상증상, 진찰 근전도, 신경전도검사 MRI Conservative Tx 휴식, 활동변형, 소염진통제 후방관절낭 stretching 근력강화재활 : 견관절안정화근육강화 관절와순주위낭종 Paralabral Cyst Surgical Tx. Depend on cyst location & on associated Sx. Spinoglenoid notch cyst Arthroscopic labrum repair Suprascapular notch cyst Arthroscopic glenohumeral joint evacuation Labral repair ± open decompression of nerve & cyst excision 1. 충돌 Impingement 2. 회전근개손상 Rotator Cuff Injury 3. 관절와순손상 Glenoid Labrum Injury 4. 관절와상완관절탈구 Dislocation of Glenohumeral Joint 5. 어깨불안정성 Shoulder Instability 6. 어깨강직 ( 동결견 ) Shoulder Stiffness( Frozen Shoulder ) 7. 쇄골골절 Fracture of the Clavicle 관절와상완관절탈구 Dislocation of Glenohumeral Joint 8. 견봉쇄골관절손상 Acromioclavicular Joint Injury 9. 연관통 Referred Pain 10. 그밖의원인 11

12 관절와상완관절탈구 Dislocation of Glenohumeral Joint Acute Glenohumeral Dislocations Cannot continue the activity Extreme pain on the first event 관절와상완관절탈구 Dislocation of Glenohumeral Joint Anterior Dislocation 90% of the acute dislocations Holds the extremity in abduction & ER position Posterior Dislocation Rare (1~4.3%) Extremity is internally rotated and adducted 전방탈구 Anterior Dislocation Injury mechanism Hyper-Abd. + Hyper-ER 에의해발생 전방관절와순의손상 Bankart lesion 전방탈구 Anterior Dislocation X-ray finding 원칙적으로정복전에시행 Reduction 전방관절와골절 bony Bankart lesion 상완골두의후방압박골절 Hill-Sachs lesion Axillary nerve injury( 외측감각이상 ) 골절발생가능 These are not absolute treatment methods Need immobilization or surgery 전방탈구 Anterior Dislocation Recurrence after the 1st event < 22 years old High recurrence! Recurrence in 60~70% May consider primary surgery in athletes Still mostly accepted treatment for the 1 st D/L : Immobilization for 3~4 weeks 전방탈구 Anterior Dislocation Arthroscopic treatment 최초탈구자는비수술적요법이추천되지만, 최근 20대이전의급성전방탈구에서는 처음치료로수술적치료도추천되고있다. 12

13 전방탈구 Anterior Dislocation Open treatment Severe glenoid bone loss Latarjet procedure 13