Review Article pissn 1738-3757 eissn 2288-8551 J Korean Foot Ankle Soc 2015;19(3):81-85 http://dx.doi.org/10.14193/jkfas.2015.19.3.81 족관절급성염좌의진단과치료 변주환, 정진화 가톨릭대학교의과대학부천성모병원정형외과학교실 Diagnosis and Treatment of Acute Ankle Sprain Chu-Hwan Byun, Jin-Wha Chung Department of Orthopedic Surgery, Bucheon St. Mary s Hospital, School of Medicine, The Catholic University of Korea, Bucheon, Korea Acute sprain of the ankle requires comprehensive history taking and physical examination in diagnosing the type of severity and deciding on the plan of treatment. Literature supports functional treatment as the treatment of choice for grade I and II injuries. During the acute phase, the goal of treatment focuses on controlling pain and swelling. PRICE (protection, rest, ice, compression, and elevation) is a well-established protocol at this phase. There is some evidence that application of ice and use of nonsteroidal anti-inflammatory drugs improves healing and speeds recovery. Then the functional treatment (motion restoration and strengthening exercises) is administered to progress the rehabilitation appropriately in order to facilitate healing and restore the mechanical strength and proprioception. Early mobilization has been shown to result in more rapid return to work and daily activities than immobilization. Grade III injuries still generate controversy in terms of the best management available, and more studies on early mobilization, cast immobilization, or surgery are needed. Even the Cochrane reviews published to date are not conclusive. Key Words: Ankle, Sprain, Strain, Functional treatment, Proprioception 서 족관절에과도한내번력이가해져외측인대복합체의손상이유발되는급성염좌는근골격계손상에서다수의빈도를차지하고있는외상이다. 급성염좌를수상한환자들중 10% 에서 30% 는재손상을경험하며, 특히운동선수의경우재손상의비율이 80% 까지높게보고되는등만성적인족관절의불안정으로이행하기도한다. 1-3) 흔하게발생할뿐만아니라여러가지합병증을유발할수있는족관절의급성염좌는정형외과뿐만아니라다른임상과는물론, 한의학및침술치료등의대체의학분야에서도진단과치료를시행하고있고, 진단이론및치료방법또한혼재해있는것이 Received June 23, 2015 Revised July 12, 2015 Accepted July 24, 2015 Corresponding Author: Jin-Wha Chung Department of Orthopedic Surgery, Bucheon St. Mary s Hospital, 327 Sosa-ro, Wonmi-gu, Bucheon 14647, Korea Tel: 82-32-340-7035, Fax: 82-32-340-2341, E-mail: koreafoot@gmail.com Financial support: None. Conflict of interest: None. 론 사실이다. 하나의외상또는질환에대하여근거중심의진단과치료가정확하게이루어지지않다보니검사및치료에소요되는비용이중복되는부작용이증가하고있다. 이에문헌고찰을통해족관절의급성염좌에대하여근거에기반한올바른진단과적절한치료방침을알아보고자한다. 본론 1. 진단 1) 분류및신체검사인대의손상은 O donoghue 4) 와 Balduini 등 5) 이기술한바와같이 3단계로분류하는것이일반적이다. 1단계손상은인대를구성하는섬유들의일부가파열되는경도 (mild) 의손상으로서인대가신장 (stretching) 되었음을의미하며관절의안정성에영향을주지않는다. 반면에, 인대전체중일부가부분적으로파열되는중등도 (moderate) 의 2단계손상과완전히파열되는심한 (severe) 3단계 Copyright c2015 Korean Foot and Ankle Society. All rights reserved. CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
82 Vol. 19 No. 3, September 2015 손상은관절의불안정성을유발할수있다. 한편, Dias 6) 는족관절의외측인대복합체를구성하는전방거비인대, 종비인대및후방거비인대등 3개의인대들을고려하여전방거비인대의부분또는완전파열을 1단계, 전방거비인대와종비인대의파열을 2단계, 그리고 3개의인대들모두가파열되는 3단계손상과함께, 이들 3개의인대들과함께내측삼각인대의부분파열이동반되는 4단계손상을추가하였다. 하지만, 환자가족관절급성염좌로내원하였을때신체검사를통하여외측인대들의손상정도가어떤단계인지, 또한전방거비인대의단독손상인지아니면종비인대의손상이동반되었는지를해부학적으로정확히판단하기는어렵다. 정적인신체검사에서족관절외측에종창이나반상출혈이존재한다면 2단계이상의손상으로추정할수는있겠지만, 동적인신체검사의실행은족관절급성손상을입은환자에서부종과통증으로인하여검사자체가어려울뿐만아니라추가적인연부조직손상을유발할수도있다. 그러므로의사는족관절급성염좌에대하여임상경험을통한주관적판단으로만진단하게되며, 염좌를설명하는방식도외측인대의 늘어남또는단순염좌 부터 파열또는끊어짐 까지다양하게이루어지므로환자들에게혼란을유발하는계기가되기도한다. 또한, 치료방침역시대부분의의료기관에서는족관절의안정을통한보존적치료를시행하지만, 근래에는슬관절의전방십자인대파열을예로들면서족관절의급성염좌를그대로방치하면지속적인통증과함께만성불안정으로진행하게되어퇴행성관절염이발생할수있음을환자에게설명한후, 손상된인대를보다정확하게진단하기위함이라는이유로자기공명영상검사를시행하고, 봉합술이나재건술등의수술적치료를권하는사례들이점차증가하고있다. 이렇게의사들마다급성족관절염좌에대한진단이나치료방침이다르므로환자들이침술치료나대체요법을수상초기에찾게되는원인을제공하기도한다. 이에저자는환자내원시정적인신체검사를통해원위경비인대결합이나내측삼각인대, 비골건또는거골하관절의동반손상여부를파악하고 Ottawa 법칙에의거하여단순방사선촬영을통해외과및중족골의골절유무를감별한후, Bachmann 등 7) 과 Jackson 등 8) 이기술한실제임상증상에따라족관절금성염좌를분류하기를권장한다 (Table 1). 즉, 신체검사상종창과반상출혈이 Table 1. Grades of Acute Ankle Sprain Sign and symptom Grade I Grade II Grade III Ligament tear Intrasubstance Partial Complete Pain Mild Moderate Severe Swelling Mild Moderate Severe Ecchymosis Usually not Common Yes Decreased ankle motion Minimal Some Great Difficulty bearing weight None Usual Always 족관절외측에서관찰된다면, 이를외측인대들의 2단계또는 3단계손상으로진단하고치료를시작하며, 약일주일에서열흘간의안정가료를시행한후동적인신체검사를포함한추가적검사들을시행하여손상의정도를보다자세히파악하는것이필요하겠다. 2) 영상검사스트레스부하방사선검사는 147 N의일정한힘을기계적으로양측족관절에가하여촬영하는정적인검사로서거골의내반각형성이나전방전위정도를정상측과비교하거나수치로표현한다. 다만, 이는족관절의만성불안정에서주로시행하는검사이며, 급성기에시행할경우환자의통증으로인해근육의강직이유발되어정확한측정이불가능할뿐아니라손상된인대의추가손상이우려되므로권장하지는않는다. 9) 초음파를이용한검사는비침습적이고비용면에서유리하며방사선노출도없는장점과함께, 족관절의동적인상태를파악할수있어만성불안정에최근많이이용되고있으며, 급성손상으로도적용범위를넓혀가고있다. 10,11) 한편, 자기공명영상검사는급성손상시최소 2주이상의시간이경과하였음에도불구하고환자가지속적으로통증을호소하며족관절운동범위의회복이이루어지지않을때, 외측부인대의손상이외에다른문제들즉, 거골의골연골병변이나원위경비인대결합의손상 (high ankle sprain), 거골하관절의인대또는비골건의손상과같은동반손상의유무를감별하기위해시행한다. 12,13) 비골건의손상은족관절염좌환자에게서종종동반되며, 이의기질내파열이나아탈구는기능적불안정성 (functional ankle instability) 의중요한이유가된다. 이와더불어거골하관절의인대손상역시급성족관절염좌의 10% 25%, 많게는 80% 까지동반된다고보고되고있다. 8,12,14,15) 단지, 외측부인대의손상만을진단하기위한자기공명영상검사는비용대비효과가적으며, 술전자기공명영상검사에서전방거비인대의결손이나완전파열로판독되어있더라도실제수술시야에는그렇지않은경우가종종있다. 즉, 자기공명영상검사에서 30% 는위양성을보인다. 9,12) 하지만실제임상에서, 특히환자가산업재해또는교통사고로수상하였을경우사고에의한기여도를파악하기위해자기공명영상검사에의한진단이요구되는관행이있어추후발생할수있는보상이나장해판정등의문제들에대비하여동반된손상이의심되지않는족관절의단순염좌라하더라도촬영을할수밖에없는현실적인부분도간과할수없다. 2. 치료 1) 수술급성염좌에있어서봉합술을시행하는것보다는보존적치료를시행하여양호한결과들을얻었다는보고들이대다수이다. 16-18) 이
Chu-Hwan Byun, et al. Diagnosis and Treatment of Acute Ankle Sprain 83 에 Pijnenburg 등 19,20) 은기존의급성염좌에대하여수술을시행한비교연구들을고찰하여비록통계적의미는없지만봉합술을시행한군에서좀더양호한결과를보이는경향이있다고하였으며, 특히치료후환자가주관적으로느끼는발목꺾임 (giving-way) 을포함한불안정성은봉합술을시행한군에서의미있게적었다고하였다. 하지만수술자체에의한합병증과비용을고려할때봉합술을일차적치료방법으로선택할수는없다고결론지었다. 또한, 젊은운동선수의 3단계손상은수술적가료를시행하는것이추후재손상및만성불안정을방지할수있는효과적인방법이라고주장하는연구결과들이있는반면에, 21-24) 이에반대되는연구결과들도있기때문에 17,22,25) 아직결정된치료방침은없는것이사실이다. 2007년 Kerkhoffs 등 26) 이발표한 Cochrane 보고서에서수술적가료는보존적치료에비하여우위에있다는증거가없다고하였다. 하지만지금까지대부분의저자들은급성염좌에있어일단보존적치료를시행한이후, 혹시치료에실패하여시간이흐른후에지연봉합을시행하더라도수상즉시봉합한결과와비교하여큰차이가없이양호한결과를보인다는데는동의하고있다. 3,16,17,27-29) 2) 기능적치료 (functional treatment) 기능적치료는 3단계로나뉘며, 최종적으로는손상된인대의자연적치유과정을이루어환자의재수상을방지하는것이목적이다. 우선 1단계 (phase one) 치료는족관절의부종과통증을경감시키기위하여 PRICE (protection, rest, ice, compression, and elevation) 로대표되는안정가료를시행하는것을말하며, 1단계치료는환자의압통과부종이감소하여체중부하보행을할수있을때까지의시간이다. 13,27,30) 이때족관절을고정하는방법이나이를유지하는기간에는저자들마다다소차이를보이고있지만, 대부분의문헌에서석고고정을통한안정을장시간유지하는것보다족관절의굴신운동을조기에허용하는것이기능적치료에서보다양호한결과를보인다고하였다. 29,31-33) 일반적으로젊은환자의 1단계또는 2단계염좌는하루나이틀정도의짧은고정의기간이소요되고, 3단계염좌일경우에는좀더긴시간이필요하다. 하지만 3단계염좌라하더라도체중부하보행을시작하는시기는보통 10일이후또는아무리길어도 3주이전에는실시하게되는데, 체중부하를함으로써하지의근력강화와함께족관절의신전이이루어지게되어손상된전방거비인대및종비인대가벌어지지않고가깝게유지될수있는장점이있다. 즉, 고정의장기화가족관절의안정성을보장하는것은아니다. 한편, 고령환자의경우인대손상의치유에젊은환자들보다좀더많은시간을요하는반면, 육체적활동도가낮으므로치료에있어고정의방법이나기간에젊은환자들과별차이를두지않으며, 보행시균형감각이저하되어있는경우가많으므로재활과정중균형능력향상에초점을맞추어야한다. 연부조직손상에있어단기적으로시행하는한랭요법 (cryother- apy) 은미세혈관의축소, 국소대사량의감소, 통증역치의증가등의기전을통하여환자의종창과통증을감소시켜일상생활로의복귀를빠르게한다는장점이있지만, 그기간과방법에대한증거를지닌연구는아직없다. 일반적으로족관절급성염좌에는최소 3일에서최대 7일사이의기간동안환자가깨어있을때두시간간격으로약 10분에서 20분동안얼음팩을환부에접촉시키는것이권장되며, 신경병증이있는환자나고령환자들에게는과도한적용으로인해동상이발생하는것에유의해야한다. 34-36) 또한, 족관절의통증과부종이심하여비스테로이드성항소염제 (nonsteroidal anti-inflammatory drugs) 를처방할수있다. Piroxicam이나 naproxen, diclofenac, ibuprofen, celecoxib 등의항소염제들은환자들에게복용시키거나연고나패치의형태로적용하면위약 (placebo) 과비교할때수상초기에통증을경감시키는역할을한다는보고들이있어경험적으로많이쓰이는반면에, 이러한약물들에의한염증조절효과자체는족관절염좌에서는증명되지않았다. 37-39) 우리나라와중국에는인대의염좌또는근육의긴장에대한치료로침술 (acupuncture) 을이용하는전통의학이존재하며, 단순한침 (needle-acupuncture) 뿐만아니라전기침 (electro-acupuncture), 레이저침 (laser-acupuncture), 약침 (pharmaco-acupuncture), 국소자극침 (non-penetrating acupuncture point stimulation) 및뜸 (moxibustion) 등이있다. 이론적근거로는침술로인해국소또는중앙통증기전을조절함으로써진통효과를얻으며, 항소염작용과함께결합조직의섬유세포들을재형성하여손상된인대를치유한다고알려져있다. 족관절급성염좌의치료에있어보존적치료를시행한대조군과비교하여침술로치료한군의경과가양호했다는보고들도있지만, 수상후 1개월이내의단기간추시결과이며통계적증거또한부족하다. 또한침술에대한전향적인무작위대조실험은이루어지지않았을뿐아니라침술의안정성과효용성또한증명되지않았다. 40) 또한, 초음파치료를통해조직내온도를높여세포대사율과콜라겐의점탄성을증가시킴으로써연부조직을치유하며통증과부종을경감시키는효과가있는것으로알려져있지만, 위약대조군 (sham ultrasound) 과의비교실험에서효과가입증되지는못하였다. 또한, 2011년발표된 Cochrane 보고서에서도초음파치료가급성족관절염좌의치료에인정될만한근거는없다고하였다. 41) 1단계치료에이어서족배굴곡위주의족관절운동범위회복이우선적으로고려되는 2단계치료가시행되는데, 비골근과족관절전방의근육들에대한근력강화운동을같이시행하며아킬레스건신장운동또한도움이된다. 이후족관절의족배굴곡이정상으로회복되고근력강화운동전후에도통증과부종이소실되면, 3단계치료가시작된다. 족관절의균형을유지하고고유감각을회복시키며지구력을향상시키는운동에주안점을두며수상후최소 4 주에서 8주까지시행된다. 특히, 환자가운동선수라면수상후 4주
84 Vol. 19 No. 3, September 2015 이전에는운동으로복귀하지못하게교육하여야한다. 3단계치료시기에도 2단계에서시행하였던족관절의운동범위회복을위한운동은중단없이지속되어야한다. 5,27) 수상초기에단기간의석고고정을통한안정가료후잔여치료기간동안족관절의운동을허용하는동시에안정성을부여하며추가적손상을방지하기위하여발목보호대 (ankle support) 를처방하게된다. 2002년 Kerkhoffs 등 33) 은 Cochrane 보고서를통해끈으로묶는 ( 레이스업, lace-up) 보호대나등자형 (stirrup) 보호대와같은반경성 (semi-rigid) 보호대가단순히압박붕대를이용해족관절을감싸서압박하는것보다통증의경감이나수상전활동으로의복귀에있어효과적이며, 특히레이스업보호대가등자형보호대보다부종을줄이는데우위에있다고보고하였다. 하지만등자형보호대를압박붕대와같이사용하여양호한결과들을얻었다는보고와같이, 다양한보호대들에의한양호한결과들이발표됨으로인해 2013년저자들은여러형식의발목보호대들간의효과적우위를보여주는증거가아직부족함을이유로이를철회하였다. 하지만일반적으로압박붕대의단독사용보다는레이스업이나등자형보호대를같이사용하는것이권장되고있다. 이상과같은보존적치료에대한결과로 van Rijn 등 3) 은기존에발표된 24개의연구결과들을고찰하여, 족관절급성염좌에서발생한통증은수상후 2주내에급격히감소하지만그이후에는매우느리게호전되어약 5% 33% 까지의환자들이수상후 1년까지도통증을호소하였고, 약 85% 의환자들은수상후 3년내에통증이완전소실되었다고하였다. 반면에, 재수상은처음수상후 3 년내에약 3% 34% 까지의환자들에게발생하였으며, 주관적불안정성역시수상후 3년이지나도최대 33% 의환자들에게잔존한다고하였다. 특이한점으로는초기수상당시의인대파열정도를포함한모든인자들은예후와는연관성이떨어진다는점이다. 즉, 인대손상단계에따른예후의차이를보이지않았다고하였다. 결론 족관절급성염좌의치료방침에대한문헌고찰상아직논란이있고정립된바는없다. 그이유로는환자의재수상이나족관절만성불안정의원인이급성염좌로발생한족관절외측부인대복합체의해부학적이상뿐만아니라환자의기능적인요인과같이공존하고, 족관절의재수상과만성불안정성과의상관관계도모호하며, 장기적추시결과에서서로다른치료방법에도불구하고어느정도양호한결과들이도출되고있기때문으로판단된다. 하지만 1단계및 2단계손상은물론 3단계손상까지의족관절급성염좌에서도봉합술을바로시행하기보다는일단보존적치료를시행하는방침이보다많은문헌적지지를받고있는것이사실이다. REFERENCES 111 Denegar CR, Miller SJ 3rd. Can chronic ankle instability be prevented? Rethinking management of lateral ankle sprains. J Athl Train. 2002;37:430-5. 222 Kobayashi T, Gamada K. Lateral ankle sprain and chronic ankle instability: a critical review. Foot Ankle Spec. 2014;7:298-326. 333 van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008; 121:324-31. 444 O'donoghue DH. Treatment of ankle injuries. Northwest Med. 1958;57:1277-86. 555 Balduini FC, Vegso JJ, Torg JS, Torg E. Management and rehabilitation of ligamentous injuries to the ankle. Sports Med. 1987;4:364-80. 666 Dias LS. The lateral ankle sprain: an experimental study. J Trauma. 1979;19:266-9. 777 Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot: systematic review. BMJ. 2003;326:417. 888 Jackson DW, Ashley RL, Powell JW. Ankle sprains in young athletes. Relation of severity and disability. Clin Orthop Relat Res. 1974;(101):201-15. 999 Griffith JF, Brockwell J. Diagnosis and imaging of ankle instability. Foot Ankle Clin. 2006;11:475-96. 1111 Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS. New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound. Knee Surg Sports Traumatol Arthrosc. 2014;22:1701-7. 1111 Hua Y, Yang Y, Chen S, Cai Y. Ultrasound examination for the diagnosis of chronic anterior talofibular ligament injury. Acta Radiol. 2012;53:1142-5. 1111 Kwon DG, Sung KH, Chung CY, Park MS, Kim TW, Lee SH, et al. Associations between MRI findings and symptoms in patients with chronic ankle sprain. J Foot Ankle Surg. 2014;53:411-4. 1111 Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35. 1111 Strauss JE, Forsberg JA, Lippert FG 3rd. Chronic lateral ankle instability and associated conditions: a rationale for treatment. Foot Ankle Int. 2007;28:1041-4. 1111 Franson J, Baravarian B. Lateral ankle triad: the triple injury of ankle synovitis, lateral ankle instability, and peroneal tendon tear. Clin Podiatr Med Surg. 2011;28:105-15. 1111 Kaikkonen A, Kannus P, Järvinen M. Surgery versus functional treatment in ankle ligament tears. A prospective study. Clin Orthop Relat Res. 1996;(326):194-202. 1111 Povacz P, Unger SF, Miller WK, Tockner R, Resch H. A randomized, prospective study of operative and non-operative treatment of injuries of the fibular collateral ligaments of the ankle. J Bone Joint Surg Am. 1998;80:345-51. 1111 Shrier I. Treatment of lateral collateral ligament sprains of the ankle: a critical appraisal of the literature. Clin J Sport Med. 1995;5:187-95. 1111 Pijnenburg AC, Bogaard K, Krips R, Marti RK, Bossuyt PM, van
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