대한정형외과학회지 : 제 40 권제 7 호 2005 J Korean Orthop Assoc 2005; 40: 839-44 근막동통증후군과동반된견관절충돌증후군 박진영 * ㆍ현정근ㆍ박홍근 건국대학교의과대학정형외과학교실 *, 단국대학교의과대학재활의학교실, 단국대학교의과대학정형외과학교실 목적 : 근막동통증후군이동반된견관절충돌증후군환자에서근막동통증후군의발생부위와그빈도를알아보고, 충돌증후군의치료가근막동통증후군의동통개선에효과가있는지를알아보고자하였다. 대상및방법 : 근막동통증후군으로진단된견관절충돌증후군환자중외래에서견갑골주위근육에통증을호소한환자 53 명을대상으로하였다. 치료방법에따라대상환자는세군으로나누었다. 견봉하주사를시행한군, 견갑골주위근육과회전근개의등장성근력강화운동만실시한군, 보존적치료에실패하여수술적가료를시행한군. 대상환자모두치료전에이학적검사를통해서근막동통증후군의위치를확인하였고관절주위동통및견관절의운동범위를측정하였으며기능적평가는 ASES 견관절점수를이용하였다. 결과 : 근막동통증후군의발생부위, 연령, 성별, 충돌징후, 관절주위압통은운동범위및기능적정도와연관성을보이지않았다. 동통의정도는 VAS 가치료전 6.2±2.3 에서치료후 1.2±1.5 로의미있게감소하였고 (p<0.01), ASES 견관절점수도치료전 32.1±15.3 에서치료후 87.5±17.7 로의미있게증가되었다 (p<0.05). 그러나동통및 ASES 견관절점수모두치료방법을달리한세군간에차이를보이지는않았다 (p>0.05). 결론 : 견관절충돌증후군의치료로근막동통증후군의증상이호전되는결과로볼때견관절충돌증후군이근막동통증후군의원인으로작용할가능성이있는것으로생각된다. 색인단어 : 견관절, 회전근개, 유발점, 근막동통증후군, 충돌증후군 Shoulder Impingement Syndrome Combined with Myofascial Pain Syndrome Jin-Young Park, M.D.*, Jung-Keun Hyun, M.D., and Hong-Keun Park, M.D. Department of Orthopaedic Surgery, Konkuk University School of Medicine*, Seoul; Departments of Rehabilitation Medicine, Orthopaedic Surgery, Dankook University College of Medicine, Cheonan, Korea Purpose: In order to study the frequency and the site of pain with shoulder impingement syndrome accompanied by myofascial pain syndrome (MPS), and to see how the treatment of impingement syndrome effects the improvement in myofascial pain. Materials and Methods: Among patients diagnosed with shoulder impingement syndrome with MPS and who complained around of shoulder muscle pain 53 subjects were selected as subjects for this study. Patients were divided into three groups according to method of treatment; the first group was the cases who received impingement injection test, the second group were only carried out isometric strengthening exercise of the periscapular muscles and the rotator cuff, and the third group was the cases who failed conservative treatment and had a surgical operation. All subjects had a physical examination before treatment to see if the MPS was present in the muscles around the shoulder, the range of motion of shoulder, and the American Shoulder and Elbow Society (ASES) shoulder score were measured. Results: There was no relation to between age, gender, impingement signs, tenderness around the joints, the range of motion and ASES shoulder score. The VAS was reduced from 6.2±2.3 to 1.2±1.5 (p<0.01), and ASES shoulder score increased from 32.1±15.3 to 87.5±17.7 (p<0.05). The differences among treatments of the three groups were not significant in pain and treatment outcome (p>0.05). Conclusion: Treatment of shoulder impingement syndrome reduced the symptoms of MPS, thus shoulder 통신저자 : 박진영서울시광진구화양동 4-12 건국대학교의과대학정형외과학교실 TEL: 02-2030-7614 FAX: 02-2030-7369 E-mail: drpark@chol.com Address reprint requests to Jin-Young Park, M.D. Department of Orthopaedic Surgery, Konkuk University Hospital, 1 Hwangyang-dong, Kwangjin-gu, Seoul 143-914, Korea Tel: +82.2-2030-7614, Fax: +82.2-2030-7369 E-mail: drpark@chol.com 839
840 박진영ㆍ현정근ㆍ박홍근 impingement syndrome can be the one of the causes of MPS. Key Words: Shoulder, Rotator cuff, Trigger point, Myofascial pain syndrome, Impingement syndrome 근막동통증후군은지속적인근육의과운동으로흔히발생되며근골격계동통의주요원인이되고있다. 견관절충돌증후군환자는견관절의외전이나굴곡시극상근의충돌로인한동통으로관절와상완관절의움직임이제한될수있다 11,13). 이를보상하기위해견갑흉곽관절의거상이보상적으로증가되며, 이때견갑흉곽관절의거상을담당하는근육들이과운동을하게된다 9,10). 하지만견관절충돌증후군환자들에서견갑부및경부에근막동통증후군과동반된경우에대한보고는문헌에서찾기힘든실정이다. 저자들은견관절충돌증후군이있을때통증으로인한와상완관절의운동제한이견갑흉곽관절에서보상되면서견갑골주위근육의과운동이발생되고이로인해근막동통증후군이발생할수있다고가정하였다. 저자들은이학적검사및방사선검사를통해견관절의충돌증후군으로진단된환자중에서근막동통증후군이동반되었음을확인하고, 충돌증후군에대한치료를시행하여결과를문헌고찰과함께보고하고자하였다. 연구대상및방법정형외과견관절클리닉으로 1995 년 7월부터 2002년 12월까지근막동통증후군으로진단되어내원한견관절충돌증후군환자중외래에서견갑골주위근육에근막동통증후군으로진단된환자 53명을대상으로하였다. 대상환자중남자는 18 예, 여자는 35 예이었고, 평균연령은 47±12 세이었다. 평균추시기간은 3.1 년 ( 범위, 1-10 년 ) 이었다. 모든대상환자에서이학적검사상 Neer 의충돌징후와 Hawkins의충돌징후, 그리고오구돌기의충돌징후가있는지여부를조사하였고, 이중 Neer 와 Hawkins 의충돌징후에양성을보이고견봉하충돌검사상 50% 이상의통증이감소하여야충돌증후군으로진단하였다. 치료전에견관절주위에동통이있는근육을이학적검사하여근막동통증후군의발생여부를판단하였다. 근막동통증후군의진단은 Travel 등 20) 에의한진단기준에의해시행하였다. 섬유근육통과같은만성동통질환이나신경근질환, 말 초신경질환을동반한경우는대상에서제외하였으며, 관절와상완관절염, 석회화건염, 이두근장두건의파열, 경추부관절염, 경추부추간판탈출증, 두부손상의질환이있는환자는제외하였다. 치료방법에따라다음과같이세군으로나누었다. 증상이오래되거나심한경우는견봉하공간에스테로이드와국소마취제의혼합액을주사한후회전근개와견갑골주위근육에대한등장성근력강화운동을시행하였고 ( 제 1군 ), 증상이심하지않은환자는견봉하주사없이등장성근력강화운동만을시행하였다 ( 제 2군 ). 재활치료를 6개월이상시행하였으나증상의호전이없었던환자는수술적가료를시행하였다 ( 제 3군 ). 견봉하주사와등장성운동을시행한제 1군은 33예 (62.3%), 등장성운동만실시한제 2군은 9예 (17.0%), 보존적치료 ( 견봉하주사와등장성운동 ) 가실패하여수술적가료를시행한제 3군은 11예 (20.8%) 이었다. 견봉하주사는 1명의전문의에의해병원의외래에서주사되었다. 약제는 2% Lidocaine (Lidocaine HCl, 광명제약, 경기도, 한국 ) 5 cc 와 Triamcinolone acetate 40 mg (TAMCETONE, 한울제약, 서울, 한국 ) 을혼합하여 23 G 주사기를이용하여시행하였다. 주사방법은견봉의전외측을촉진한다음외측으로 1 cm 지점을확인하고주사바늘을피부에수직하여삽입한다음삼각근을지나견봉하공간밑에있는회전근개가부착하는대결절에닿는느낌이나면약간뒤로후퇴시킨뒤 2 cc를주사하여, 견봉하점액낭에잘주사되는지를확인하였다. 그후팔을하방으로견인하여견봉하공간을넓힌다음주사바늘의방향을수평으로바꾸어전진시킨다음후방에서전방으로천천히바늘을움직이면서주사하였다. 근력강화운동은 Theraband (Breg Inc., USA) 를이용하여폐쇄형사슬방식으로회전근개강화운동을하였고회전근개건염을방지하기위해하루에세번정도만시행하였다. 이운동은견관절근육의편심성과중심성을강화시키기위한운동으로여섯가지색상의 Theraband 를사용하여단계적으로시행하였다. 수술적가료가필요하였던환자는회전근개파열이없는충돌증후군 6명, 회전근개파열환자가 5명이었다.
근막동통증후군과동반된견관절충돌증후군 841 수술은관절경하견봉감압술, 활액막제거술, 회전근개봉합술등을시행하였다. 모든환자에서충돌징후와관절주위압통유무및위치와견관절의운동범위를측정하였다. 시술전에견관절의기능평가를위해서 1994년에미국견 주관절학회 (American shoulder and elbow society; ASES) 에서발표된견관절기능평가법 ( 이하, ASES 견관절점수 ) 15) 을사용하였다. 동통지수는동통이없는경우를 0으로동통이가장심한경우를 10으로하는시각상사척도 (Visual analog scale; VAS) 를이용하여산정하였다. 견관절운동범위는전방거상과외회전, 90 외전에서의외회전의능동적운동범위를각각측정하였다. 견관절의기능과동통, 운동범위의평가는치료전과치료후 2개월마다검사하였으며최종외래추시가되지않은경우는전화면접을시행하였다. 결과에서나타나는견관절의기능과동통, 운동범위의평가는각치료방법에따라구분하여치료전후와치료방법에따른차이를확인하고자하였다. 통계분석은 SPSS ver. 12프로그램을이용하였다. 근 막동통증후군의부위와빈도에따른임상양상의차이를 확인하기위해서 Student T-test 와 one-way ANOVA 를시행하였다. 치료방법에따라분류한세군간의임상 Table 1. Locations of trigger points of the cases Muscle No. of Cases (%) Upper trapezius 31 (38%) Rhomboideus 29 (35%) Levator Scapulae 14 (17%) Infraspinatus 8 (10%) Table 2. Correlation of ROM, VAS score and ASES score according to the number of involved muscles No. of involved muscles ROM FE* ER ER90 VAS score ASES score 3 (n=7) 122.9± 61.4± 61.4± 7.0± 25± 45.7 28.5 23.6 1.8 14.7 2 (n=15) 136.0± 55.3± 73.3± 5.7± 32± 28.2 27.2 14.9 2.0 13.5 1 (n=31) 136.5± 59.7± 68.4± 6.2± 33.7± 24.9 21.8 18.7 2.5 16.3 *FE, Forward elevation ( ); ER, External rotation ( ); ER90, External rotation at 90 abduction ( ). p>0.05 by one-way ANOVA among three groups divided by the number of involved muscles. 적인차이를확인하기위해서 one-way ANOVA 를시행하였고, 치료전과치료후의견관절기능평가및동통의정도차이를확인하기위해서 paired T-test를시행하였다. p value 는 0.05 미만을통계학적으로의미있는결과로간주하였다. 결과근막동통증후군은상부승모근, 능형근, 견갑거근, 극하근순으로나타났다 (Table 1). 근막동통중후군이나타난근육부위에따른견관절운동범위및동통의정도, ASES 견관절점수의차이는나타나지않았다. 근막동통증후군이발생한근육의갯수별로살펴보면 3부위에서발생한예가 7예, 2부위가 15예, 1부위가 31예였으며, 근육의발생빈도에따른견관절운동범위및동통의정도, ASES 견관절점수는마찬가지로연관성을나타내지않았다 (Table 2). 치료방법을달리한세군사이에서발생부위와연령, 성별, 충돌징후및관절주위압통은운동범위및기능적평가정도와연관성을보이지않았다. 전체대상군의동통정도 (VAS) 는치료전 6.2±2.3에 서치료후 1.2±1.5 로의미있는동통의감소를보였으나 (p<0.01), 치료방법을달리한세군사이에서동통의정도는치료전과치료후모두차이를보이지않았다 (p> 0.05) (Table 3). 치료후에견관절운동범위는치료전과비교하여관절운동범위는향상되었으나치료전후로통계학적으로유의성이없었으며, 세치료군에서도유의성을보이지않았다 (p>0.05) (Table 4). ASES 견관절점수는 Table 2의동통정도와마찬가지로치료전에비해치료후에향상되었으나 (p<0.05), Table 3. Comparisons of visual analog scale(vas) among three treatment groups before and after treatments Symptom duration (months) Pretreatment Posttreatment Group 1 9.2±11.1 5.4±1.7 1.2±1.5* Group 2 8.7±13.5 5.14±1.9 0.7±0.8* Group 3 9.0±16.6 5.9±2.4 1.3±1.7* Total 8.9±15.0 6.2±2.3 1.2±1.5* Group 1: Treated with injection and strengthening exercise, Group 2: Treated with strengthening exercise only, Group 3: Treated with operation. *p<0.01 compared to pre-treatment VAS by paired t-test.
842 박진영ㆍ현정근ㆍ박홍근 Table 4. Comparisons of range of motion among three groups before and after treatments Pre-treatment Group 1 Group 2 Group 3 Total Post-treatment Group 1 Group 2 Group 3 Total FE* 142±22 147±19 112±26 134±29 167±15 172±10 171±11 171±14 ER 63±24 59±2 46±18 59±24 74±15 77±6 135±29 76±13 ER90 71±15 71±16 57±25 69±18 78±7 78±5 135±29 77±14 *FE, Forward elevation ( ); ER, External rotation ( ); ER90, External rotation at 90 abduction ( ). Table 5. Comparisons of American shoulder and elbow society (ASES) scores among three groups before and after treatments Pre-treatment 치료방법을달리한세군간에는치료전과치료후모두통계학적으로유의성이없었다 (p>0.05) (Table 5). 고 근막동통증후군은흔히만성동통을유발하는근골격계질환중의하나로써알려져왔다. 국소적인압통, 띠모양구조 (taut band), 경련반응과압박시방사통유발등을특징으로하며동통유발점에의해생기는국소적인동통증후군으로정의한다. 1942년 Travel 등 20) 이근막동통증후군환자에있어근막통점에관해처음기술한이래로이의병태생리학적기전에관한연구가있었으나아직객관적이고정확한기전은알려지지않고있다. 근막동통증후군은동통을호소하여재활의학과외래로방문하는환자중많은비율을차지하며, 근막동통증후군의진단은 Travel 과 Simon 21) 의진단기준이널리사용되는데동통및압통의특징적인소견과함께유발점, 띄모양구조, 연관통 (referred pain) 및국소연축반응 (local twitch response) 등주로이학적검사에의존하고있어 1,8) 검사자간에차이를보이고있는실정이며, 최근에는진단이나그심각도판정및치료효과판정, 추후관찰등에사용되기위한여러가지방법들이시도되어왔다. 가장널리보편화된도구는피부온도측정계 2,15) 와압력계 (pressure algometer) 2) 이며, 이는동통유발점에서의압력에대한민감도를측정하는도구로근막동통 찰 Post-treatment Group 1 35.8±17.0 85.8±19.4* Group 2 31.7±8.3 85.6±20.1* Group 3 21.4±8.7 95±4.5* Total 32.1±15.3 87.5±17.7* * p<0.05 compared to pre-treatment ASES score by paired t-test. 유발점을보다객관적으로정량적으로규명하고자한것이다. 또근막동통증후군환자에서동반되는자율신경계, 특히교감신경계이상에의한체온의변화를측정하여진단에이용하기위하여적외선체열촬영장비 6) 를이용하기도하는데, Fischer 2) 는동통유발점에서압통역치가감소되고열점 (hot spot) 이적외선전신촬영상에서형성되었다고보고한바있다. 그러나이런기구들을이용한방법들은개인에대한오차가있어근막동통증후군의진단이나심각도정도를나타내기에는어려움이있으며, 적외선체열촬영장비를통한진단도정확하지않다는주장도있어 14) 기구나검사장비를이용한방법들이임상적인진단기준보다더객관적인방법이라고단정할수없는실정이다. 본연구에서도임상적인진단기준으로근막동통증후군을진단하였다. 견관절충돌증후군은건자체의내적요인과오구견봉궁에의한외적요인등 12) 여러요인들이그원인으로작용하고있다. 견관절충돌증후군의치료는보존적요법과수술적요법으로대별할수있다. 수술적요법중전방견봉성형술은대표적인치료방법으로추천되어왔으며 12), 이술식에는오구견봉인대절제, 견봉하공간내에서의염증, 반흔조직과견봉하점액낭의제거및전하방견봉의골절제술이포함된다. Ingber 5) 은견관절충돌증후군및근막동통증후군이있는 3명의환자를동통유발점에약물없는주사법 (dry needling) 과등장성운동을한결과 1명에서만족할만한결과를얻었으나 2명은결국관절경수술이필요했다고보고하여근막동통증후군의치료만으로는견관절충돌증후군이호전되지않는다는사실을알수있다. Mannerkorpi 등 3,7) 은동통유발점이있는근육의수와견관절기능검사간에어떤상관관계가있는지조사한결과동통유발점의수가많은환자일수록견관절기능이현저하게저하되었다고보고하였다. 한등 4) 은정상
근막동통증후군과동반된견관절충돌증후군 843 관절범위를가지는근막동통증후군환자에서시행한견관절기능검사상동통유발점을가지는환자에서견관절기능이현저하게저하되었다고하며, 근막동통증후군환자에서견관절기능검사를시행하면병의중등도에대해간접적인평가를한다거나견관절의기능을평가할수있고, 치료후경과추적검사시치료효과를좀더객관적으로판단할수있다고하였다. 서론에서언급했던것처럼견관절충돌증후군환자에서제한된관절와상완관절의움직임의보상으로견갑흉곽관절의거상이증가하면서이를담당하는근육들이과운동을하고이로인해근막동통증후군이발생할수있다고가정한다면견관절운동범위가제한될수록상기연구와같이동통이유발되는근육의수와동통정도가더증가할것으로생각되었지만본연구에서는근막동통증후군이발견된근육의수와관절운동범위, 동통정도, 기능적지수와의상관관계는발견되지않았다. 외래환자중근막동통증후군환자가차지하는비율에관한국내의보고는별로없으나, 외국의예를보면 283 명의동통센터에내원한환자중 85% 가근막동통증후군환자였다는보고도있고 17-19), 내과에서동통으로의뢰된환자중 31% 가근막동통증후군이었다는보고도있었다 16). 하지만근막동통증후군이동반된견관절충돌증후군환자는어느정도인지는보고된바가없으며, 따라서이때에어떤치료가가장효과적인방법인지도정확히알려져있지않은실정이다. 본연구에서는근막동통증후군이동반된견관절충돌증후군환자를대상으로하였는데 VAS 도구로는동통의호전정도를근육별로나누어기술하기가불가능하기때문에호전된이유가견관절충돌증후군의호전에의한것인지근막동통증후군의호전에의한것인지그인과관계를뚜렷하게분간할수없는한계점이있다. 근막동통증후군의치료만생각할때에는온열요법, 마사지, 경피전기신경자극요법과동통유발점에주사를놓는등의치료방법들이있지만본연구의대상환자들은이러한방법들을시도하지않았거나시도했더라도호전을보이지않았고연구방법에서제시한견관절충돌증후군의세가지치료방법으로호전되는결과를보였다. 이로볼때견관절주위의근막동통증후군이있는환자는동통이발생한근육에대한치료뿐만아니라견관절충돌증후군이동반되었을가능성을염두에두고견관절 의기능평가나방사선학적검사등이를진단하기위한노력이필요할것으로생각된다. 또한견관절충돌증후군의치료로근막동통증후군도호전되는결과로볼때견관절충돌증후군이근막동통증후군의원인중하나일것으로생각된다. 그러나견관절충돌증후군에서근막동통증후군이발생하게된정확한기전을밝히기위해서는다양한동통측정도구와좀더객관적인평가방법을이용한추가적인연구가필요할것으로생각된다. 결론근막동통증후군이동반된견관절충돌증후군환자에서견관절충돌증후군을치료하기위한보존적인주사요법과운동요법및수술적치료의세가지방법모두견관절주위의동통이나기능적지수들이호전되는결과를보였다. 따라서견관절충돌증후군이근막동통증후군의원인으로작용할가능성이있으나명확하지는않으며그기전에대해서는추가적인연구가필요할것으로생각된다. 참고문헌 1. Fischer AA: Documentation of myofascial trigger points. Arch Phys Med Rehabil, 69: 286-291, 1988. 2. Fischer AA: The present status of neuromuscular thermography. Postgrad Med, 79: 26-33, 1986. 3. Hagberg M and Kvarnstrom S: Muscular endurance and electromyographic fatigue in myofascial shoulder pain. Arch Phys Med Rehabil, 65: 522-525, 1984. 4. Han TR, Choi KH, Huh BY and Yoo TW: Shoulder function test in myofascial pain syndrome. Korean Acad Rehab Med, 19: 368-374, 1995. 5. Ingber RS: Shoulder impingement in tennis/racquetball players treated with subscapularis myofascial treatments. Arch Phys Med Rehabil, 81: 679-682, 2000. 6. Kruse RA Jr and Christiansen JA: Thermographic imaging of myofascial trigger points: a follow-up study. Arch Phys Med Rehabil, 73: 819-823, 1992. 7. Mannerkorpi K, Svantesson U, Carlsson J and Ekdahl C: Tests of functional limitations in fibromyalgia syndrome: a reliability study. Arthritis Care Res, 12: 193-199, 1999. 8. McClaflin RR: Myofascial pain syndrome. Primary care strate-
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