- 學位論文
髕股關節疼痛症候群患者與健康成人之股內側斜肌形態差異--超音波研究
Morphology of the Vastus Medialis Obliquus in Patients with Patellofemoral Pain Syndrome and Healthy Young Adults --A Sonographic Study
摘要
背景：髕股關節疼痛症候群（PFPS）為一常見膝關節疾病，主要成因為髕骨不正常的向外側偏移造成髕股關節的壓迫。過去的研究指出股內側斜肌（VMO）為髕股關節的一個重要動態穩定者，負責將髕骨向內側做穩定。然而1998年，由Hubbard JK.等人解剖374具大體，欲觀察髕股關節磨損程度與VMO形態之相關性，結果卻顯示無顯著相關。以上研究在大體內進行，與活體內之情形不盡相同，因此本研究選用超音波量測VMO之各項參數。 目的：以超音波影像測量患有PFPS之50歲以下患者與正常無膝痛病史者之各項VMO參數是否有差異。方法：以31位PFPS患者及與其配對之31位健康對照組為受試者，以HDI 5000超音波儀器量測VMO之各項參數，包括VMO終點連接到髕骨位置佔髕骨總長的百分比、肌纖維走向與股骨之夾角、連接到髕骨上之VMO體積以及連接到髕骨上之VMO形狀變化率。 結果：兩組各有可互相配對的51筆資料。在各項VMO形態參數中，只有VMO終點連接到髕骨位置佔髕骨總長的百分比一項顯示統計上的差異(p<0.05)。PFPS組平均值為40.61% (±11.99%)，健康組為46.46% (±7.6%)。兩組之VMO終點連接到髕骨位置的長度，在髕股關節疼痛症候群組平均值為2.07cm (±0.63cm)，健康組為2.43cm (±0.48cm)，兩組差了將近0.4cm。將兩組的VMO體積與具統計差異的VMO終點連接到髕骨位置佔髕骨總長的百分比做相關性的分析，結果顯示PFPS組之VMO體積與VMO終點連接到髕骨位置佔髕骨總長的百分比有顯著的中度相關，R=0.695（p<0.000），在健康組同樣呈現顯著的中度相關，R=0.517（p<0.000）。而14位單側為患側之PFPS病人，比較其患側與非患側之各項參數，在所有VMO形態參數皆無顯著差異。 討論：臨床上對於此類病人的訓練著重於股內側斜肌的肌力訓練，但本研究中唯一有差異的參數，肌肉終點的位置無法經由肌力訓練而改變。對於肌肉終點位置較靠近端（proximal）的病人，肌力訓練的成效可能較不如預期，以手術的方式將髕股關節做整形可能是較可行的方法。以我們目前的研究結果無法指出到底終點接在多少的患者是可以訓練，而少於多少得訓練效果不彰，未來研究可將患者依照終點連接位置作分組訓練，以驗證我們的假設。 結論：各項VMO形態參數中，只有VMO終點連接到髕骨位置佔髕骨總長的百分比一項在PFPS組與健康組比較中顯示統計上的差異(p<0.05)。VMO終點連接到髕骨位置佔髕骨總長的百分比和VMO連接到髕骨上之體積有中度相關，可作為VMO體積大小的參考指標。
並列摘要
Background：Patellofemoral pain syndrome（PFPS） is a common knee disorder characterized by anterior or retropatellar pain associated with activities that load the patellofemoral joint. Previous studies reveal that the vastus medialis obliquus（VMO） is an important dynamic medial stabilizer of the patellar. Insufficiency of the VMO leads to lateral shift of the patella and the increases the patellofemoral contact force. An in vitro study conducted by Hubbard JK. et al. claimed that there were no significant relationship between several morphologic characteristics of the VMO and the extent of patellofemoral joint deterioration. We consider that the condition might be different in vivo, so we chose ultrasonogrphy as the measurement tool to examine the morphology of the VMO in PFPS patients and healthy controls. Purpose：To determine if there are significant differences in several morphologic parameters of the VMO between patients with PFPS and healthy controls under 50. Method：31 PFPS patients and 31 matched healthy adults under 50 were recruited for the study. The HDI 5000 ultrasonography machine was used to evaluate morphologic parameters of the VMO, including the percent of patella attachment, fiber angle, the volume attached to the patella, and the change of shape of the VMO. Result：51 data were collected in each of the two groups and were perfectly matched by age, gender, and BMI. The only parameter that revealed significant difference was the percent of patella attachment (p<0.05). The mean percentage of the PFPS group was 40.61%, while that of the healthy group was 46.46% (±7.6%). The actual length of the VMO attachment on the patella was 2.07cm (±0.63cm) in the PFPS group and 2.43cm (±0.48cm) in the healthy group, revealing a 0.4 cm difference. Furthermore, we found that there is a moderate correlation between VMO volume attached to the patella and the percentage of VMO insertion in both groups, R=0.695（p<0.000）in the PFPS group and R=0.517（p<0.000） in the healthy group. On the other hand, comparing the affected and non-affected side of the 14 unilateral affected PFPS patients, all parameters failed to reveal significant difference. Discussion：Training programs for PFPS patients usually include strength training of the VMO muscle, but the only morphological parameter which revealed significant difference in our study, the percent of VMO attachment, was not capable of being trained. For those PFPS patients who have a proximally inserted VMO, strength training might not be effective and surgery might be a better choice for treatment. Conclusion：The only parameter which revealed significant difference between the two groups is the percent of VMO attachment (p<0.05). There is a moderate correlation between the percent of VMO attachment and VMO volume.