今日の臨床サポート

肩腱板断裂

著者: 菅谷啓之 東京スポーツ&整形外科クリニック

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2020/06/05
患者向け説明資料

概要・推奨   

  1. 外傷歴のはっきりしない腱板断裂や無症候性腱板断裂存在する。
  1. このような腱板断裂は炎症性疼痛のコントロールと肩甲胸郭機能の修正を図る理学療法で多くは症状が軽減する
  1. 逆に比較的若年男子の外傷性腱板断裂で大きな断裂は可及的早期(受傷後2カ月以内)の手術が推奨される
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
菅谷啓之 : 特に申告事項無し[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、補足・修正を行った(大きな変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腱板断裂は腱板の退行変性を基盤として主に50歳以上の中高年に好発し、多くは外傷を契機として発症し、肩の痛みや脱力を主訴とすることが多い。
  1. 腱板小断裂のMRIと関節鏡視所見:図<図表>
  1. 腱板大断裂のMRIと関節鏡視所見:図<図表>
  1. ただし、高齢になるほど腱板自体の変性が進行するため軽微な外傷により断裂しやすくなり、高齢者では外傷の既往をまったく自覚していないことも少なくない。
  1. 中高年者が肩痛を主訴に外来を訪れた場合にまず想定すべき疾患がこの腱板断裂で、このような中高年者の3人に1人ぐらいの頻度である。
  1. 症状は、関節可動域制限がさほど強くなく、夜間痛や動作時痛を訴えるのが特徴で、単純X線写真上、石灰沈着がなければ腱板断裂である可能性が高い。
  1. 腱板断裂はほとんどが上方の棘上筋腱および棘下筋腱に起こり、3割程度に前方の肩甲下筋腱の損傷を合併する[1][2][3]
問診・診察のポイント  
問診:
  1. 外傷歴の有無と症状発現からの時間経過、安静時痛・夜間痛の有無、疼痛の出やすい肢位、脱力の有無、職業・スポーツなど患者のアクティビティー。

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文献 

著者: Ryuzo Arai, Hiroyuki Sugaya, Tomoyuki Mochizuki, Akimoto Nimura, Joji Moriishi, Keiichi Akita
雑誌名: Arthroscopy. 2008 Sep;24(9):997-1004. doi: 10.1016/j.arthro.2008.04.076. Epub 2008 Jun 16.
Abstract/Text PURPOSE: The purpose of this study was to clarify anatomically and clinically how the subscapularis tendon supports the superior portion of the biceps tendon to the intertubercular groove.
METHODS: Thirty-three embalmed shoulder girdles were examined to investigate the subscapularis tendon and the pathway of the biceps tendon. In addition, operation records of 435 consecutive arthroscopic rotator cuff repairs were retrospectively reviewed.
RESULTS: Anatomically, the superior-most insertion of the subscapularis tendon was located on the upper margin of the lesser tuberosity. In addition, a thin tendinous slip extended from the insertion and attached to the fovea capitis of the humerus. The insertion, the tendinous slip, and the lateral portion of the cranial part of intramuscular tendons were in direct contact with the inferior side of the biceps tendon at its corner portion. The clinical study showed that 27.4% of rotator cuff tears (119/435) had subscapularis tendon tears. In cases with an unstable biceps tendon there was no intact subscapularis tendon. The superior-most insertion of the subscapularis tendon was involved in all transverse tears. Of 29 full-thickness transverse tears, 13 (44.8%) showed intra-articular dislocation.
CONCLUSIONS: The trochlea-like structure was composed of the superior-most insertion, the tendinous slip, and the lateral portion of the cranial part of intramuscular tendons supporting the biceps tendon. The transverse tear of the subscapularis tendon, which included this trochlea-like structure, often leads to intra-articular dislocation of the biceps tendon.
CLINICAL RELEVANCE: Instability of the biceps tendon should be carefully assessed because it is associated with subscapularis tendon tears at a very high incidence. When we repair a transverse tear of the subscapularis tendon, we should widely fix sufficiently strong tissue to support the biceps tendon on the uppermost margin, not on the anteromedial portion, of the lesser tuberosity.

PMID 18760206  Arthroscopy. 2008 Sep;24(9):997-1004. doi: 10.1016/j.ar・・・
著者: Christopher R Adams, John D Schoolfield, Stephen S Burkhart
雑誌名: Arthroscopy. 2010 Nov;26(11):1427-33. doi: 10.1016/j.arthro.2010.02.028. Epub 2010 Sep 27.
Abstract/Text PURPOSE: The purpose of this study was to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) scan assessments of subscapularis tendon tears by comparing the preoperative MRI interpretations of radiologists with the actual results determined by arthroscopic evaluations of the same shoulders.
METHODS: This retrospective review comprised all 120 patients who underwent primary arthroscopic rotator cuff repairs performed by the senior author during 2006. Of the 120 patients, 90 had high-field strength, conventional MRI scans performed within 190 days before their arthroscopic procedures.
RESULTS: All 16 patients with preoperative MRI scans that were interpreted by the radiologists as positive for subscapularis tendon tears were confirmed to be positive by arthroscopy, resulting in perfect specificity. However, the radiologists diagnosed only 16 of 44 subscapularis tears (36%) identified by arthroscopy. This resulted in an overall sensitivity of 36%, specificity of 100%, positive predictive value of 100%, negative predictive value of 62%, and accuracy of 69%.
CONCLUSIONS: Preoperative MRI scans of the shoulder do not reliably predict which rotator cuff injury patients have subscapularis tendon tears. Subscapularis tendon tears that extend at least half the cephalad-to-caudal distance are more easily detected by MRI scans, whereas smaller tears are usually missed on MRI scans.
LEVEL OF EVIDENCE: Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).

Copyright © 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
PMID 20875724  Arthroscopy. 2010 Nov;26(11):1427-33. doi: 10.1016/j.ar・・・
著者: Guido Garavaglia, Henri Ufenast, Ettore Taverna
雑誌名: Int J Shoulder Surg. 2011 Oct;5(4):90-4. doi: 10.4103/0973-6042.91000.
Abstract/Text PURPOSE: With the advent of arthroscopic shoulder surgery the comprehension and description of rotator cuff tears have strongly evolved. Subscapularis tears are difficult to recognize and are underestimated. Our purpose is to report our observations concerning the relative frequency of subscapularis tears in patients undergoing arthroscopic rotator cuff repair and to compare the arthroscopic observations with the magnetic resonance imaging (MRI) findings.
MATERIALS AND METHODS: Retrospective cohort study including all patients undergoing arthroscopic rotator cuff repair was performed between March 2006 and March 2009 at our institution. Preoperative MRI findings, intraoperative arthroscopic findings, and details of surgical intervention were collected using medical charts.
RESULTS: We reviewed the medical charts of a total of 348 consecutive arthroscopic rotator cuff repairs. There were 311 supraspinatus tears (89%), 48 infraspinatus tears (14%), and 129 subscapularis tears (37%). MRI sensitivity and specificity were respectively 0.25 and 0.98 for subscapularis tendon tears, 0.67 and 1.0 for supraspinatus tears and 0.5 and 0.99 for infraspinatus tears.
CONCLUSION: Subscapularis tears are frequent lesions and usually appear concomitantly with supra or infraspinatus lesions. We propose a classification of subscapularis tendon tears, based on our observations of the pathoanatomy of the tears. While concordance with MRI results are good for the supraspinatus, MRI often fails to diagnose the presence of subscapularis tears and infraspinatus tears.

PMID 22223958  Int J Shoulder Surg. 2011 Oct;5(4):90-4. doi: 10.4103/0・・・
著者: Hiroyuki Sugaya, Kazuhiko Maeda, Keisuke Matsuki, Joji Moriishi
雑誌名: Arthroscopy. 2005 Nov;21(11):1307-16. doi: 10.1016/j.arthro.2005.08.011.
Abstract/Text PURPOSE: The purpose of this study was to compare the functional as well as the structural outcomes of single-row and dual-row fixation after arthroscopic full-thickness rotator cuff repair.
TYPE OF STUDY: Retrospective cohort study.
METHODS: A consecutive series of 80 shoulders in 78 patients with full-thickness rotator cuff tears was evaluated using the rating scale of the University of California Los Angeles (UCLA) and the shoulder index of the American Shoulder and Elbow Surgeons (ASES) at an average of 35 months (range, 24 to 60 months) after arthroscopic rotator cuff repair. Thirty-nine shoulders were repaired using the single-row technique and 41 shoulders using the dual-row technique. Postoperative cuff integrity was determined through magnetic resonance imaging and was classified into 5 categories: type I, sufficient thickness with homogenously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, presence of a minor discontinuity; type V, presence of a major discontinuity.
RESULTS: The average UCLA score improved significantly to 32.4 in the single-row and to 33.1 in the dual-row group. The ASES shoulder index improved significantly to 93.0 in the single-row group and to 94.6 in the dual-row group. However, there was no statistical difference between the groups in the postoperative scores. Postoperative MRI revealed 11 type I, 6 type II, 12 type III, 4 type IV, and 6 type V in the single-row group, and 22 type I, 8 type II, 7 type III, 4 type IV, and no type V in the dual-row group. A statistical difference was observed between the groups (P < .01).
CONCLUSIONS: Arthroscopic rotator cuff repair yielded successful functional outcomes without significant difference between single and dual-row fixation techniques. However, dual-row repairs excelled in structural outcome over the single-row technique.
LEVEL OF EVIDENCE: Level III.

PMID 16325080  Arthroscopy. 2005 Nov;21(11):1307-16. doi: 10.1016/j.ar・・・
著者: Hiroyuki Sugaya, Kazuhiko Maeda, Keisuke Matsuki, Joji Moriishi
雑誌名: J Bone Joint Surg Am. 2007 May;89(5):953-60. doi: 10.2106/JBJS.F.00512.
Abstract/Text BACKGROUND: The retear rate following rotator cuff repair is variable. Recent biomechanical studies have demonstrated that double-row tendon-to-bone fixation excels in initial fixation strength and footprint coverage compared with the single-row or transosseous fixation methods. This study was designed to report the repair integrity and clinical outcome following arthroscopic double-row rotator cuff repair.
METHODS: A consecutive series of 106 patients with full-thickness rotator cuff tears underwent arthroscopic double-row rotator cuff repair with use of suture anchors and were followed prospectively. Twenty patients lacked complete follow-up data or were lost to follow-up. The eighty-six study subjects included fifty-two men and thirty-four women, with an average age of 60.5 years. There were twenty-six small, thirty medium, twenty-two large, and eight massive tears. Clinical outcomes were evaluated at an average of thirty-one months. Repair integrity was estimated with use of magnetic resonance imaging, which was performed, on the average, fourteen months postoperatively, and was classified into five categories, with type I indicating sufficient thickness with homogeneously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, the presence of a minor discontinuity; and type V, the presence of a major discontinuity.
RESULTS: The average clinical outcome scores all improved significantly at the time of the final follow-up (p < 0.01). At a mean of fourteen months postoperatively, magnetic resonance imaging revealed that thirty-seven shoulders had a type-I repair; twenty-one, a type-II repair; thirteen, a type-III repair; eight, a type-IV repair; and seven, a type-V repair. The overall rate of retears (types IV and V) was 17%. The retear rate was 5% for small-to-medium tears, while it was 40% for large and massive tears. The shoulders with a type-V repair demonstrated significantly inferior functional outcome in terms of overall scores and strength compared with the other types of repairs (p < 0.01).
CONCLUSIONS: Arthroscopic double-row repair can result in improved repair integrity compared with open or miniopen repair methods. However, the retear rate for shoulders with large and massive tears remains higher than that for smaller tears, and shoulders with large repair defects (type V) demonstrate significantly inferior functional outcomes.

PMID 17473131  J Bone Joint Surg Am. 2007 May;89(5):953-60. doi: 10.21・・・

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