302 pissn : , eissn : Review J Korean Orthop Assoc 2019; 54: 스포츠와연관

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1 302 pissn : , eissn : Review J Korean Orthop Assoc 2019; 54: 스포츠와연관된회전근개부분층파열 박태수 한양대학교구리병원정형외과 Partial Thickness Rotator Cuff Tears of the Shoulder Related to the Sports Tae-Soo Park, M.D., Ph.D. Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, Korea A painful shoulder is common among athletes, particularly those involved in overhead throwing. Professional and recreational athletes in throwing activities have an increased risk of partial thickness tears of the rotator cuff. The manuscript was to reviews the literature on the characteristics of injury, treatment strategies, and their results in throwing athletes. Key words: rotator cuff, partial thickness tear, sports injury, overhead throwing athlete, treatment 서론 최근인간의평균수명이연장되고소득이늘어남에따라삶의 질에대한관심이높아지고이와연관된문화, 예술분야와더불 어스포츠에대한관심또한증가하는추세다. 스포츠관람뿐만 아니라여가활동으로직접스포츠에참여하는인구가늘어나면 서전문적인스포츠선수와함께스포츠로인한손상또한증가 하고있다. 견관절통은운동선수, 특히던지기, 야구, 1) 테니스, 2) 골프, 3) 체조, 4) 배구, 5) 투창 5) 및수영 6) 같은종목에서과사용손상 (overuse injury) 등만성손상으로인하여생기는흔히접할수있 는임상증세이다. 이러한과사용손상은접촉성유무에따른운 동의종류, 선수의참여위치 (position), 나이와몸상태, 운동강도, 생역학적으로올바른연습이나훈련및운동수행을하는지의유 무, 참여시간등여러가지요인들이복합적으로작용하여발생 할수있다. 이중회전근개염증과부분층파열은극심한통증을 Received September 1, 2016 Revised October 10, 2017 Accepted July 23, 2018 Correspondence to: Tae-Soo Park, M.D., Ph.D. Department of Orthopedic Surgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 11923, Korea TEL: FAX: parkts@hanyang.ac.kr ORCID: 유발할수있으며, 부분층파열이오히려전층파열에비하여통증이훨씬더심하다는보고도있다. 7-9) 본론 야구투수의투구동작은준비동작 (windup phase), 초기거상기 (early cocking phase), 후기거상기, 가속기 (acceleration phase) 및감속기 (follow-through phase) 의 5단계로나누어진다. 10,11) 초기거상기에전거근 (serratus anterior) 과승모근 (trapezius) 이서로짝힘 (force couple) 으로작용하여견갑골을상방회전시키면서상완골두가외전및외회전할때관절와 (glenoid) 면을안정되게유지하여충돌을피할수있게해준다. 정상적으로견관절이 90도외전및최대외회전시회전근개가후상방관절와연 (glenoid rim) 으로압박을받으며 12) 이때대결절이회전근개를누르게되는 13,14) 내적충돌을일으키게되는데, 이는과외회전을억제하는정상적인현상이다. 그러나던지기중거상기와가속기때상완골두는관절와에위치하지만반복적인동작으로견관절근육이피로하게되면견갑골후방면으로상완골두의이전이심화되어내적충돌및전하방관절와상완인대손상등을초래하게된다. 특히야구투수의투구동작시거상기에서는견관절의외전상태에서외회전이정상인에비하여과도하게증가하게되 The Journal of the Korean Orthopaedic Association Volume 54 Number Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 303 Partial Thickness Rotator Cuff Tears Related to the Sports 고 15-17) 이로인하여전방관절낭이이완되며, 18-20) 또한이차적으로후하방관절낭에는구축이생겨내회전은감소하게된다. 이어관절와상완관절의접촉점이후상방으로이전하여거상위치에서상완이두근장두의부착부위에비틀림응력 (torsional stress) 이가중되어박피 (peel-back) 현상을초래함으로써상완이두근-관절와순복합체손상 (SLAP 병변 [superior labrum anterior and posterior lesions]) 21) 및내적충돌을발생시킬수있으며, 특히이들두병변들은투구운동선수에서볼수있는마비상완증후군 (dead arm syndrome) 의원인이될수있다. 거상기때의외회전된견관절이 초사이 80도의빠른내회전이일어나는가속기때에는상완골내부에서 14,000 inch pounds (in-lbs; 158 Nm) 의힘 (torque) 이생성되고초당 6,100-8,000 의각속도가발생한다. 22,23) 이때관절와에상완골두를위치시키기위해견갑골은앞으로내밀게되며 (protraction) 견관절을안정시키고자하는압축부하 (compressive load) 는 860 N에달한다. 22,24) 견관절근육만으로는빠른공을던지기에필요한에너지를얻을수없고하지로부터시작하여전신의조화된동작을통하여서만이가능하다. 투수들이고속의공을반복하여던질때관절와내로상완골두의중심을유지하고자하는해부학적동적안정화구조물인회전근개에는전단응력 (shear stress), 인장응력 (tensile stress) 및압축응력 (compressive stress) 등의강력한부하 (load) 가특히감속기에걸리게된다. 감속기는손에서공이던져진후발생하고견관절은내전및내회전된다. 감속기에는가속기에서생성된힘이흡수되어야하며, 견관절과주관절에 -500,000 /s와상완골에 15,000 in-lbs (1,695 Nm) 의외회전력이걸린다. 11,22) 따라서야구투구동작은견관절근육들에고강도의복잡하고반복적이며상호협조적인역할을하도록영향을미친다. 비정상적이거나잘못된생역학운동이나운동기법은투구동작중반복되고점차증가되는응력 (stress) 을유발하며, 또한견관절근육들이고유의능력을벗어난에너지를생성하거나소모할때과사용으로인한손상이초래될수있다. 운동선수에서발생하는견관절손상의양상은일반인에서발생하는것과다를수있다. 특히 overhead throwing에관여하는운동선수인경우호발부위는대부분극상근건이고, 20,25,26) 회전근개손상은일반인인경우전방극상근관절면에서호발하는경우 27,28) 와는달리좀더후방인극상근과극하근사이관절면의건에서주로일어나며 8,29-32) 이는점액낭면손상에비해적어도두배이상호발한다. 25,33-40) 이러한호발부위의차이는퇴행성변화가주된원인인일반인에비하여운동선수에서는반복된내적충돌현상의결과로발생할수있다 ) 이에반하여중년이상나이든운동선수에서는점액낭면손상이더빈발하다. 41) 견관절손상은모든운동선수손상중 8%-13%, 회전근개부분층파열은모든파열중 13%-37% 34,39,42-44) 를차지하는것으로알려 져있으나 overhead 운동선수에서의빈도는명확하지않으며, 이 는운동선수의스포츠수행을심각하게제한할수있는견관절 통의가장흔한원인중의하나가된다 ) 1. 진단 진단은특히던지기종목에참여하는운동선수인경우최근공의 속도, 제어능력 (control), 지구력의변화및후기거상기 / 초기가속 기때경미한불편감, 불안정감에서부터찌르는듯하게심한만 성통증까지다양한형태의동통과함께참여정도및위치등에 대한정보를바탕으로평가하고, 견관절에대해치료나수술받 은과거력이있는지확인하여야한다. 신체검사는견관절의능동 적및수동적관절운동범위와함께동통궁 (painful arc), 근력, 신 경혈관상태, 안정성, 특징적인움츠림 (shrugging) 등을평가하고, O Brien test, 48) Neer sign 49) 및 test, 50) Hawkins test, 51,52) fulcrum & relocationtest, 53) Jobe s test ( 캔비우기검사 [empty can test] 54) 와캔 채우기검사 [full can test] 55) ), lag sign, 56) horn blower s sign, 57) liftoff test, 58) belly-press test, 59) belly-off sign, 60) Napoleon sign 61) 등을 시행하여회전근개, 관절와순, 상완이두근장두등의상태를검 사한다. 충돌시리즈를포함한방사선검사, 자기공명영상 (magnetic resonance imaging [MRI]) 혹은자기공명관절조영술 (magnetic resonance arthrography [MRA]) (Fig. 1) 등을시행하여확진 하며, 이외초음파검사, 관절조영술, 컴퓨터단층촬영 (computed tomography), 컴퓨터단층관절조영술 (computed tomography arthrography) 등을시행하기도한다. 그러나회전근개부분층파열 은임상적으로나 MRI 혹은 MRA 를이용하더라도진단이어려울 수있다. Figure 1. Oblique coronal T2-weighted image of magnetic resonance arthrography showing a partial thickness tear of the right supraspinatus in the articular side (arrow).

304 Tae-Soo Park 던지기선수에서회전근개부분층파열과감별해야할질환은관절와상완관절의아탈구, 다방향성불안정성, SLAP 병변, 견봉쇄골관절병변, 경추병변, 신경손상, 류마토이드병변, 드물지만흉곽출구증후군을포함한신경-혈관병변과종양등이다. 2.

비스테로이드계진통소염제, 스테로이드계약물등의국소주입, 물리치료, 던지기운동시해당운동의사용기술을포함한활동조절및위치변경등의방법을고려할수있다. 치료기간동안근력, 지구력, 투구동작이나기술들을생역학적인면에서재점검하고, 잘못되거나부족한점이있다면고치고보충하여과사용손상의악순환에빠지지않도록예방하는것이중요하다.

일반환자에서수술의적응증은회전근개건두께의 50% 이상침범한경우를기준으로삼는반면, 투수를포함한던지기종목의운동선수에서는건두께의 75% 이상침범할경우 24,41,64) 를기준으로하자는의견이있다.

2), 부분층파열을전층파열로전환후 foot print 부위에봉합나사를이용한봉합술등이소개되고있으며, 적절한방법에대해서는아직논란이있다. 던지기선수를대상으로관절경적변연절제술후치료결과를발표한 Payne 등 39) 은급성외상성손상인경우와만성인경우를비교하여만족한결과는 86% 와 66%, 손상전과동일한수준으로의운동복귀율은 64% 와 45% 로각각보고하였다.

그러나부분층파열에대한변연절제술을시행하여증상이호전되었다고하더라도이미파열된부위가치유된것이아니므로복귀한후다시과도한충격이가해지거나사소한충격이라도반복되어누적될경우증상이재발될가능성이높다. 건내부분층파열인경우봉합나사를이용한 foot print 부위로의봉합은피하고병소에대한제한된봉합만을시행하는것이추천된다.

3 304 Tae-Soo Park 던지기선수에서회전근개부분층파열과감별해야할질환은관절와상완관절의아탈구, 다방향성불안정성, SLAP 병변, 견봉쇄골관절병변, 경추병변, 신경손상, 류마토이드병변, 드물지만흉곽출구증후군을포함한신경-혈관병변과종양등이다. 2. 치료치료시보존적치료기간, 수술적치료가필요하다면그시기와수술후재활을거쳐다시운동에복귀가능한시점등을결정하는것이중요하다. 보존적치료는통증을해소하고, 정상적인관절운동을회복하며, 회전근개및견갑골주변근육의근력과기능을강화시키도록하여야한다. 비스테로이드계진통소염제, 스테로이드계약물등의국소주입, 물리치료, 던지기운동시해당운동의사용기술을포함한활동조절및위치변경등의방법을고려할수있다. 치료기간동안근력, 지구력, 투구동작이나기술들을생역학적인면에서재점검하고, 잘못되거나부족한점이있다면고치고보충하여과사용손상의악순환에빠지지않도록예방하는것이중요하다. 그러나회전근개부분층파열에대한비수술적치료후에도문헌에서보고된일반인의 5%-10% 62) 에비하여, 훨씬높은빈도인 40% 의환자에서지속적인증세를보이므로 63) 이에대한추가적인연구가필요한실정이다. 비수술적치료에도반응하지않고심한증상이지속되면수술적치료가필요하다. 일반환자에서수술의적응증은회전근개건두께의 50% 이상침범한경우를기준으로삼는반면, 투수를포함한던지기종목의운동선수에서는건두께의 75% 이상침범할경우 24,41,64) 를기준으로하자는의견이있다. 이는회전근개봉합술후발생하는재파열은외상같이심한부하로생기는경우보다는봉합된건이치유되기전에반복부하가발생하여파열될 가능성이높다 65) 는던지기종목의운동선수를고려한것으로보이지만던지기선수에서수술의이점은아직명료하지않은실정이다. 수술방법은변연절제술, 손상된건부위의봉합술 (Fig. 2), 부분층파열을전층파열로전환후 foot print 부위에봉합나사를이용한봉합술등이소개되고있으며, 적절한방법에대해서는아직논란이있다. 던지기선수를대상으로관절경적변연절제술후치료결과를발표한 Payne 등 39) 은급성외상성손상인경우와만성인경우를비교하여만족한결과는 86% 와 66%, 손상전과동일한수준으로의운동복귀율은 64% 와 45% 로각각보고하였다. Andrews 등 33) 은 85% 에서양호이상의좋은결과를보고하였으나, 일부대상에서는관절와순및상완이두근병변이회전근개손상과동반된경우였다. Reynolds 등 66) 은소형크기에대하여변연절제술을시행한결과프로투수수준으로의복귀율이 76%, 손상전과동일한수준으로의복귀율은 55% 로보고하였다. 그러나부분층파열에대한변연절제술을시행하여증상이호전되었다고하더라도이미파열된부위가치유된것이아니므로복귀한후다시과도한충격이가해지거나사소한충격이라도반복되어누적될경우증상이재발될가능성이높다. 건내부분층파열인경우봉합나사를이용한 foot print 부위로의봉합은피하고병소에대한제한된봉합만을시행하는것이추천된다. 64) 특히회전근개전층파열의경우비수술적치료와수술적치료의선택에논란이있지만파열의크기가클수록증상회복의기대가어렵고파열부위가자연치유되기보다는더욱커지고비가역적인근위축으로발전할수있는등병변이악화될수있으 Figure 2. Arthroscopic picture shows that on an articular partial thickness tear of the supraspinatus (A), a percutaneous needle is placed to shuttle a No. 2 Ethibond in place of the shuttle wire (B). (C) Multiple No. 2 Ethibond sutures across the delaminated fragment are closing down the defect. (D) Repositioning the arthroscope in the subacromial space, the paired sutures are tied securely. (E) The articular flap tear is then reduced and repaired. After then the articular flap tear is reduced and repaired.

4 305 Partial Thickness Rotator Cuff Tears Related to the Sports 므로적절한수술시기를놓치지않도록치료방침을결정할시기에주의를기울여야한다. 회전근개봉합후스포츠복귀에대한 meta-analysis 결과 84.7% 의복귀율을, 65.9% 에서손상전과같은수준으로의스포츠복귀율을보였지만프로선수이거나 competitive athletes인경우후자의복귀율은 49.9% 에그쳤다고하였다. 67) 부분층파열시 59.7% 및전층파열시 71.4% 의스포츠복귀율을보이지만이는통계적으로유의한차이를보이지않았다고하였다. 67) 손상전보다낮은수준으로의스포츠복귀에대한위험요소로는프로운동선수 68,69) 와늦은복귀 70) 라는보고도있다. 젊은운동선수인경우외상과반복적인던지기로인한이차적인과사용이발생하여회전근개파열이발생하며이들에수술을시행한경우두경우모두만족한임상결과를보이지만과사용이많은엘리트투수에서는외상에의한경우보다손상전수준으로경기에복귀하는결과가불량하다고알려져있다. 71,72) 따라서엘리트던지기선수인경우비수술적치료의비중을높이고이를광범위하고충실한시행에무게를두는것이추천된다. 결론 결론적으로운동선수의기량을극대화하고손상을예방하며손상시만족한치료결과및손상전운동종목으로의성공적인복귀를얻기위해서는투구및던지기에대한생역학적지식뿐만아니라회전근개병변에대한이해와정확한진단은물론환자의활동도및치료결과에대한기대감등을반영한적절한치료방법을선택하여치료하고, 수술시행시수술후의지속적인재활치료등이필요하며, 재파열혹은재손상에대한염려나이로인하여소속팀과운동에서방출내지퇴출될수있다는공포심을치유하여줄심리적인치료또한필수적이라고생각된다. 스포츠손상을입은운동선수의가장주된바람은어떤종류의치료를받든지치료후스포츠에복귀하는것은물론가능하면손상전과같은기량을갖출수있는것이다. 만성적인과사용손상으로인한회전근개부분층파열이발생한젊은엘리트투수인경우많은문헌에서수술적치료후에좋은임상결과들을보고하고있지만손상이전의기량으로운동에복귀함에있어서는불량한결과를보이므로 40세이하젊은운동선수가회전근개파열된경우보존적치료에더무게를두는등그치료에있어서좀더면밀한연구및조사와알고리즘이필요할것으로생각된다. CONFLICTS OF INTEREST The author has nothing to disclose. REFERENCES 1. Barnes DA, Tullos HS. An analysis of 100 symptomatic baseball players. Am J Sports Med. 1978;6: Hill JA. Epidemiologic perspective on shoulder injuries. Clin Sports Med. 1983;2: McCarroll JR, Gioe TJ. Professional golfers and the price they pay. Phys Sportsmed. 1982;10: Weiker GG. Club gymnastics. Clin Sports Med. 1985;4: Yokoe K, Nanajima H, Yamazaki Y. Injuries of the shoulder in volleyball players and javelin throwers. Orthop Trauma Surg. 1959;22: Kennedy JC, Hawkins R. Swimmer s shoulder. Phys Sportsmed. 1974;2: Strauss EJ, Salata MJ, Kercher J, et al. The arthroscopic management of partial-thickness rotator cuff tears: a systematic review of the literature. Arthroscopy. 2011;27: Fukuda H. Partial-thickness rotator cuff tears: a modern view on Codman's classic. J Shoulder Elbow Surg. 2000;9: Gschwend N, Ivosević-Radovanović D, Patte D. Rotator cuff tear--relationship between clinical and anatomopathological findings. Arch Orthop Trauma Surg. 1988;107: King JW, Brelsford HJ, Tullos HS. Analysis of the pitching arm of the professional baseball pitcher. Clin Orthop Relat Res. 1969;67: Pappas AM, Zawacki RM, Sullivan TJ. Biomechanics of baseball pitching. A preliminary report. Am J Sports Med. 1985;13: Paley KJ, Jobe FW, Pink MM, Kvitne RS, ElAttrache NS. Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff. Arthroscopy. 2000;16: Jobe CM, Sidles J. Evidence for a superior glenoid impingement upon the rotator cuff. Paper presented at: Fifth International Conference on Surgery of the Shoulder; 1992 Jul 12-15; Paris, France. p.s Walch G, Boileau P, Noel E, Donell ST. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg. 1992;1: Crockett HC, Gross LB, Wilk KE, et al. Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med. 2002;30: Osbahr DC, Cannon DL, Speer KP. Retroversion of the hu-

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7 308 pissn : , eissn : Review J Korean Orthop Assoc 2019; 54: 스포츠와연관된회전근개부분층파열 박태수 한양대학교구리병원정형외과 견관절통은특히던지기운동선수에서흔히생기는임상증세다. 전문적인선수뿐만아니라여가활동으로참여하는대중의던지기선 수에서회전근개부분층파열이발생할위험은상존한다. 본논문에서는던지기선수에서회전근개부분층파열이있는경우부상 의특징, 치료전략및그결과에대하여문헌고찰을통하여알아보고자한다. 색인단어 : 회전근개, 부분층파열, 스포츠손상, 던지기선수, 치료 접수일 2016 년 9 월 1 일수정일 2017 년 10 월 10 일게재확정일 2018 년 7 월 23 일책임저자박태수 11923, 구리시경춘로 153, 한양대학교구리병원정형외과 TEL , FAX , parkts@hanyang.ac.kr, ORCID 대한정형외과학회지 : 제 54 권제 4 호 2019 Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

P.P.Templat Korea

P.P.Templat Korea Physical examination of the shoulder Range of motion Range of motion 1. active ROM test - Apley scratch test Range of motion 2. passive ROM test - limitation in ROM 신경학적검사 (neurologic examination) 2. Muscle