肩胛下肌損傷於肩夾擠症候群患者之影響:超音波影像與肩胛骨運動學研究

The Influences of Subscapularis Lesion on Ultrasonography and Scapular Kinematics in Patients with Shoulder Impingement Syndrome

陳登翔(Deng Siang Ting)

指導教授 ： 林居正

國立臺灣大學/醫學院/物理治療學研究所/碩士(2022年)

https://doi.org/10.6342/NTU202200004

摘要

研究背景：喙突下夾擠相較於肩峰下夾擠而言，在臨床上較不普遍。根據文獻回顧，喙突下夾擠被認為是造成肩膀前側疼痛的可能原因之一。在進行肩夾擠症候群臨床測試時，肩胛下肌可能於喙突下被夾擠。因此，針對喙突下夾擠與肩峰下夾擠之鑑別診斷，有助於制定治療策略。此外，喙肱韌帶在解剖構造上附著於喙突外側，被認為於喙突下夾擠可能扮演者重要的角色。喙肱韌帶的形態學特性可能是造成肩峰下夾擠之因子，而其可能會影響喙肱距離以及肩胛骨運動學。
研究目的：此研究的目的包括（1）使用超音波影像，探討肩夾擠症候群病患喙肱韌帶厚度與喙肱距離之相關性，（2）探討有無合併肩胛下肌損傷之肩夾擠症候群病患，於喙肱韌帶厚度與喙肱距離之差異，（3）探討有無合併肩胛下肌損傷之肩夾擠症候群病患，於肩胛骨運動學與肌肉活化之差異。
研究設計：本研究為橫斷式研究。
研究對象：本研究招募40位肩夾擠症候群病患。依照臨床肩胛下肌測試的結果，進一步將病患分為合併肩胛下肌損傷（SSCL）與無肩胛下肌損傷（SIS）兩組。
研究方法：受試者進行肩胛下肌、二頭肌隧道特殊測試以及超音波影像收集，並於手臂上抬時，使用運動追蹤與肌電圖，測量肩胛骨運動學與相關肌肉活化情形。測量參數包含：喙肱韌帶厚度，在不同肩膀旋轉姿勢下的喙肱距離，以及於手臂上抬時之肩胛骨運動學與相關肌肉活化程度。
統計分析：使用SPSS 25.0進行統計分析，顯著水準設為p值小於0.05。分析喙肱韌帶厚度與喙肱距離之相關性。使用獨立樣本t檢定分析超音波影像測量參數之組間差異。使用變異數分析比較兩組在手臂上抬時之肩胛骨運動學與相關肌肉活化之差異。
結果：在SSCL組之患側中，呈現內轉肌力比少於80%，內轉姿勢下的喙肱距離（CHDIR：9.4mm，CHRIRFA：8.8mm）呈顯著減少，其喙肱韌帶厚度、肩胛下肌肌腱厚度與肩胛下肌於喙肱距離佔比皆呈顯著增加。在SIS組之患側中，喙肱韌帶與喙肱距離（CHDNR：r=0.455，CHDIR：r=0.483）呈中度正相關。兩組於肩胛骨運動學與相關肌肉活化皆無顯著差異。
結論：喙肱韌帶增厚與喙肱距離增加之不一致變化機制可能為造成肩夾擠症候群病患肩胛下肌損傷的因素。臨床上評估肩夾擠症候群病患之喙肱韌帶，喙肱距離與內轉肌力比可能為預防肩胛下肌後續損傷的方法。可能之治療策略建議包括減少肩胛下肌肌腱厚度與肌力訓練。兩組受試者於手臂上抬時之肩胛骨運動學與相關肌肉活化皆呈現相似結果。

關鍵字

肩夾擠症候群 ； 喙突下夾擠 ； 喙肱韌帶 ； 喙肱距離 ； 肩胛下肌

並列摘要

Background: Subcoracoid impingement is relatively uncommon compared to subacromial impingement. It has been proposed as one of the causes in patient with anterior shoulder pain. The subscapularis (SSC) muscle can be impinged under the subcoracoid space during the clinical test of subacromial impingement. Differential clinical tests for subacromial impingement versus subcoracoid impingement are important for the treatment target. Additionally, the coracohumeral ligament (CHL) attaching on the lateral aspect of the base of the coracoid process is believed to play an important role relating to the subcoracoid impingement. The characteristics of CHL may affect coracohumeral distance (CHD) and associated scapular kinematics, which have been suggested as a possible factor of developing subacromial impingement.
Purpose: The purposes of the study were (1) to evaluate the correlation between the CHL thickness and CHD by using USG in patients with SIS, (2) to examine the difference in CHL thickness and CHD in SIS patients with and without SSC lesion, and (3) to determine the difference in scapular kinematics and muscle activation in SIS patients with and without SSC lesion.
Design: This study was a cross-sectional study.
Participants: The study recruited 40 patients with shoulder impingement syndrome. According to the result of the clinical SSC tests, these patients were assigned into 2 groups, shoulder impingement syndrome (SIS) and subscapularis lesion (SSCL).
Methods: The participants were assessed for SSC, bicipital tunnel special tests, ultrasonography, as well as scapular kinematics and associated muscular activation during arm elevation by motion tracking and electromyography. The outcomes were CHL thickness and CHD in different positions as well as scapular kinematics and muscle activation during arm elevation.
Statistical analysis: Correlation between CHL thickness and CHD was calculated. Independent t-test on the difference in USG measurements. ANOVA on scapular kinematics and associated muscular activation during arm elevation between 2 groups were calculated by using SPSS 25.0 with significant level set as 0.05.
Results: In SSCL group showed IR strength ratio deficiency over 20%, decreased CHDIR (9.4mm), CHDIRFA (8.8mm) and increased CHL thickness (2.5mm), SSC tendon (5.6mm) thickness, occupation ratio over CHD (54%) on affected side. In SIS group, we found moderate correlation between CHL thickness with CHDNR (r=0.455) and CHDIR (r=0.483) on affected side. No significant differences in scapular kinematic and associated muscular activation.
Conclusion: The inconsistent alteration of increasing CHL and CHD might be a factor causing SSC lesion in SIS patients. The evaluation of CHL thickness, CHD and IR strength might feasible when assessing SIS patients to prevent further SSC lesion. Treatment strategies for reducing SSC tendon thickness and muscle training was suggested. The 2 groups showed similar scapular kinematics and associated muscular activities during arm elevation.

並列關鍵字

Shoulder impingement syndrome ； Subcoracoid impingement ； Coracohumeral ligament ； Coracohumeral distance ； Subscapularis

參考文獻

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