Shoulder pain (어깨통증, 견갑통증)

The Root of Ambulatory Care (외래 진료 지침서) 전체 목록 보기
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The Root of Ambulatory Care

The Root of Ambulatory Care

  • 저 자 : 이진우
  • 출 판 : 군자출판사
  • 페이지수: 543면

이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.

KEYWORDS: ..어깨 주위의 복잡한 구조물에도 불구하고 가정의학 외래에서 보이는 어깨통 증의 원인은 몇 가지로 많지 않다. - Impingement syndrome - Adhesive capsulitis (frozen shoulder) - Glenohumeral instability - Acromioclavicular joint problem ..Apley scratch test가 정상이면 능동운동은 정상이며 수동적 운동평가를 할 필 요가 없다. ▶ Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation. → 능동운동 범위감소 + 수동운동 범위정상 : Rotator cuff tear → 능동운동 범위감소 + 수동운동 범위감소 : severe impingement syndrome, adhesive capsulitis ..Radiologic test는 일반적으로 손상 환자에서 시행되며 과사용에 의한 문제 초기 평가에서는 필요치 않다. 3주 이상의 보존적 치료에 효과가 없으면서 지속적 인 통증이 있거나 어깨 불안정성의 병력이 있는 환자에서는 시행되어야 한다. Shoulder pain 1. Prior trauma ? : Increases likelihood of fracture, acute rotator cuff tear, calvicle injury, or dislocation 2. Age : Adhesive capsulitis, bursitis, and tendonitis common in elderly 3. Work-related activities : Patients in occupations requiring repetitive movement of the arms are at high risk for bursitis and rotator cuff tendinitis (e.g., carpenters, painters, assembly-line workers) 4. Recreational activities : Overhand-throwing athletes and swimmers are at high risk for rotator cuff impingement and tears as well as glenohumeral instability and labrum tears (e.g., pitcher, quarterback, tennis and volleyball players) 5. Night pain : pain caused by bursitis and rotator cuff inflammation is often worse at night 6. Sensation of slipping or instability of the head of the humerus : suggestive of prior dislocation 7. Crepitations or popping with movement : common with calcific tendonitis 8. Weakness of distal extremity : Suggests cervical spine or axillary nerve injuries. 9. Constitutional symptoms : may suggest infectious or neoplastic process. Impingement syndrome ..Risk factors : repetitive overhead motion (e.g., throwing, racquet sports, swimming) : overuse (e.g., carpenters, painters, plumbers) ..Bursitis, Rotator cuff tendinitis, Rotator cuff tear 등이 원인이며 어깨 통증의 가 장 흔한 원인이다. : Bursitis → Rotator cuff tendinitis → Rotator cuff tear 1. Pain with overhead activities, worse at night ; anterolateral shoulder pain, possibly radiating to elbow ..Neer impingement sign (+)면 대개 확진할 수 있다. 251 The Root of ambulatory care Key questions Key Symptms Key tests Key treatment Shoulder pain 1. AP and transscapular lateral plain radiograph : for degenerative changes 2. Outlet or Alexander view : subacromial space to grade acromial impingement 3. MRI : 95% sensitive/specific detecting partial/complete tears, cuff degeneration, and chronic tendinitis 1. Ice , Rest , PT 2. NSAIDs 3. Injection of the subacromial bursa with corticosteroid + lidocaine : Triamcinolone 20~40mg + lidocaine 3~4cc ▶ (Left)The entry point for a subacromial space injection is inferior and medial to the corner of the acromion precess. The shoulder is grasped with thumb at the posterior border of the acromion and the forefinger on the coracoid process. (The acromion and coracoid process are outlined in black) (Right)A lateral view shows the needle position relative to the joint structures. The needle is parallel to the undersurface of the acromion, is directed upward toward the coracoid at an angle of about 15, and inserted about 11/8 to 13/8 in. The position of the needle is important because it can enter the glenoid space if it is angled medial to the coracoid process in the true horizontal plane. ▶ Neer’s test for impingement of the rotator cuff tendons under the coracoacromial arch. The arm is fully pronated and placed in forced flexion. Subacromial space Coracoid process Acromion Glenoid cavity of scapula 253 The Root of ambulatory care ..치료 3개월 후에도 효과가 없다면 Orthopedic consultation이 필요하다. Adhesive capsulitis (Frozen shoulder) ..Risk factors : highest incidence in 40 to 50 year olds; shoulder immobilization; involves nondominant arm more often and women > men (어깨손상 후 움직이지 못했던 나이 든 환자에서 주로 생긴다.) 1. Painful loss of motion progression to relatively pain-free restricted motion ..능동적, 수동적 ROM 모두 감소하며 특히 external rotation이 감소한다. 1. AP /lateral radiograph : fracture or calcification 2. MRI : diagnostic test of choice 1. Ice , Rest , PT 2. NSAIDs : Ibuprofen 600~800mg with food tid/Naproxen 500mg with food bid for 2weeks or longer depending on the condition. 3. Injection of the subacromial bursa with corticosteroid + lidocaine : Triamcinolone 20~40mg + lidocaine 3~4cc ..호전과 악화를 반복할 수 있지만 대부분 (80%) 단순한 치료로 회복이 가능하 다. 하지만 이러한 각각의 시기는 6~9개월 지속될 수 있다. Key Symptoms Key tests Key treatment Key Symptoms Shoulder pain Shoulder dislocation and instability ..Risk factors : history of previous dislocation; adolescent female athletes ; repetitive overhead activity (e.g., gymnasts, swimmers, tennis, baseball pitching) ..대부분의 어깨 탈골(90%)은 상완골두가 견갑와 전방과 하방쪽으로 움직일 때 일어난다. 1. Vague pain referred to deltoid; feeling of impending dislocation or worse pain with overhead/abducted/extended rotated shoulder: “dead arm”after repetitive motion (e.g., pitching) ..때때로 환자들은 그들 스스로 탈골을 정복시킬 수 있으나, 의사의 도움이 필요하기도 하다. ..Apprehension test시 탈골에 대한 불안을 느끼는 증상이 apprehension (+) sign 이다. ▶ Apprehension test for anterior instability. The patient's arm is abducted to 90 degrees while the examiner externally rotates the arm and applies anterior pressure to the humerus. ▶ Apprehension test는 견관절 탈골을 막기 위하여 조심스럽게 이루어져야 한다. 255 The Root of ambulatory care 1. AP / lateral radiograph : usually negative, but may show anteroinferior glenoid rim fracture ..반복적 불안정성은 나이와 밀접한 연관이 있으며, 25세 이전의 환자들은 60~90% 정도의 재발율을 보이는 반면, 45세 이상의 환자들은 15% 미만의 재 발률을 보인다. Key tests 참고 문헌 Jerry Ryan : Shoulder Pain, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 966-968 김광민 : 어깨 통증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1148-1154 Brian R. Coleman, M.D. : Arm & Shoulder Complaints, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed).United States of America, The McGrwa-Hill Companies, Inc., 2005, P 30-36 오창석(ed) : 골관절염, in Complete Guide To Practical Based Prescription Medicine. 서울, 한우리, 2005, P 173-178 Walter B. Greene, M.D.(ed) : Frozen Shoulder,Impingement Syndrome, Shoulder Instability, in Essentials of Musculoskeletal Care. Rosemont, American Academy of Orthopaedic Surgeons, 2001, P 124-126, P 136-138, P 147-150