肩关节疾病的诊断

肩关节疾病的诊断,山东省中医院运动损伤骨科王少山,肩关节的疾病你知道多少,普通人医务工作者骨科医生运动医学医师肩关节疾病的特征 疼痛 关节僵硬,Anatomy Review,Shoulder Girdle,Anatomy Review,Bony AnatomyScapulaClavicle,Anatomy Review,Bony AnatomyHumerusRibs,Anatomy Review,Anterior musculature of the shoulder girdle,Anatomy Review,Musculature of posterior shoulder girdle,Anatomy Review,Shoulder ligaments,Anatomy Review,Shoulder joint capsule and cartilage,Anatomy Review,Blood Supply and Intervention,Shoulder Evaluation (History),HistoryWhat is the cause of pain?Mechanism of injury? Previous history?Location, duration and intensity of pain?Creptitus, numbness, distortion in temperatureWeakness or fatigue?What provides relief?,?,Shoulder Evaluation (Observation),Elevation or depression of shoulder tipsPosition and shape of clavicleAcromion processBiceps and deltoid symmetryPostural assessment (kyphosis, lordosis, shoulders),Position of head and armsScapular elevation and symmetryScapular protraction or wingingMuscle symmetry Scapulohumeral rhythm,Shoulder Evaluation (Observation),Scapulohumeral RhythmMovement of scapula relative to the humerus Initial 30 degrees of glenohumeral abduction does not incorporate scapular motion (setting phase)30 to 90 degrees the scapula abducts and upwardly rotates 1 degree for every 2 degrees of humeral elevationAbove 90 degrees the scapula and humerus move in 1:1 ratio,Shoulder Evaluation (Palpation),Bony StructuresSternoclavicular jointClavicular shaftAcromioclavicular jointCoracoid processAcromion processHumeral headGreater and lesser tuberosityBicipital groove Spine of scapulaScapular vertebral border,Scapular lateral borderScapular superior angleScapular inferior angle,Shoulder Evaluation (Palpation),Soft Tissue PalpationSternoclavicular, acromioclavicular and coracoclavicular ligamentsRotator cuff muscles and tendonsSubacromial bursaSternocleidomastoidBiceps and tendonCoracoacromial ligament,Glenohumeral joint capsuleDeltoidRhomboidsLatissimus dorsiSerratus AnteriorLevator scapulaeTrapeziusSupraspinatusInfraspinatusTeres major and minor,Shoulder Evaluation (Special Tests),Active Range of Motion (ROM)Flexion 180oExtension 50oAbduction 180oAdduction 40oInternal Rotation 90oExternal Rotation 90o,Manual Muscle TestingFive Point grading system5 = Complete ROM against gravity, with full resistance4 = Complete ROM against gravity, with some resistance3 = Complete ROM against gravity, with no resistance2 = Complete ROM, with gravity omitted1 = Some muscle contractility with no joint motion0 = No muscle contractility,肩周炎的概念,历史 1896年Duplay提出 pereglanoiolitis 盂肱关节周围炎 首次医学描述肩僵硬演变Codman1934年命名为肩周炎 1945年J.S.Neviase第一次使用adhesive capsulitis粘连性肩关节囊炎现状 由于肩关节周围炎的描述模糊不清，病理至今没有病理生理学基础,肩周炎是垃圾箱-弃用,症状模糊不清多种疾病混淆没有清晰的病理生理机制和证据给临床带来混乱,有必要对肩疼痛疾病分类,冻结肩肩峰撞击证肩袖损伤钙化性肌腱炎盂唇损伤肩锁关节骨性关节炎盂肱关节骨性关节炎,冻结肩,有明确的时限性疼痛有固定的曲线有固定的症状和体现没有明确的发病原因最终结局是乐观、一般不留关节障碍,病程分期,冷冻期 初期 19个月=疼痛冻结期 中期3-12个月=关节僵硬解冻期 后期5个月-2年=疼痛减轻 功能恢复,冻结肩是一种自限性疾病不必忧虑,如何确诊冻结肩,病史 没有明确的原因疼痛的特点 疼痛逐渐加重，夜间疼痛关节僵硬 逐渐盂肱关节的活动度减少肌肉无损伤 肌力无明显改变,临床检查,肩关节功能 ROM 前屈外展上抬 0度180度 外旋 0度60度 内旋 体侧6、7胸椎棘突 全方位功能受限,辅助检查,影像学没有明确的阳性改变,MRI,肩峰撞击症,何为肩峰撞击症肩峰撞击症的概念 Neer提出肩关节在运动的过程中有一些结构性因素和动力性因素与肩峰发生摩擦产生病理性疼痛 包括内容 肩峰的形态 Bigliani分型 肌腱炎 滑囊炎,构性因素因素 肩峰的形态 肌腱的炎性退变增粗 滑囊炎容积增大 大结节骨折,撞击的病理,动力性因素 肩胛骨失效 肌腱过度负荷 盂肱关节不稳定 重复性微细创伤,撞击产生的机制岗上肌出口,模拟撞击原理,撞击症的症状,疼痛 发病 疼痛成隐匿性进展 部位 肩前外侧有时放射至肘 方式 肩关节运动到某一部位 夜间疼痛 只在患侧卧位时疼,特殊检查,Neer Hawkins,影像学检查,肩袖损伤,肩袖的构成肩袖的位置肩袖的肌腱走行和方向肩袖的作用,肩袖损伤的原因和机制,急性损伤 运动 （过顶运动）创伤慢性损伤 年龄 （退变） 过度使用 骨赘 机械撞击症,临床评估,病史 与冻结肩鉴别疼痛肩关节无力和功能障碍临床检查 影像学评估关节镜评估,临床评估方法,岗上肌 Jobe症岗下肌 Leg 症小圆肌肩胛下肌 Liftoff,影像学评估,超声波 敏感性较高 准确性差磁共振 敏感性 准确性