今日の臨床サポート

野球肩

著者: 米田稔1) 日本医科大学 整形外科学

著者: 山田真一2) JCHO星ヶ丘医療センター 整形外科

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:2017/03/31
患者向け説明資料

概要・推奨   

ポイント:
  1. 野球肩とは、投球時の肩の異常により自身本来のパフォーマンスが発揮できない肩関節状態の総称であり、その病態は多岐にわたる。1つの疾患名ではないことを、まず認識しておかなければならない。
  1. 野球肩の病態は疲労や機能異常から器質的損傷まで様々であり、それらの病態が複雑に絡み合っている。
  1. 野球肩の治療のためには病態把握と原因把握が重要である。
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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:
米田稔 : 特に申告事項無し[2021年]
山田真一 : 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]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 野球肩とは投球時の肩の異常により本来の自身最高のパフォーマンスが発揮できない肩関節状態の総称であり、その病態は多岐にわたる。1つの疾患名ではないことを、まず理解しなければならない。
  1. 野球肩のほとんどがオーバーユースによる疲労や微小外傷の繰り返しが基盤となって発症する。
  1. その病態は多彩で、全身運動としての運動連鎖・協調運動の乱れから、肩甲骨の運動機能不全や肩の後方タイトネスなどの機能異常、さらには腱板疎部損傷、関節唇損傷、腱板損傷などの器質的損傷まで、さまざまな病態が複雑に絡みあっている。
  1. 投球を障害している痛みなどの病変を把握・確定することは非常に重要であるが、その病変がなぜ発生したのか、そのメカニズムを熟考し、治療する必要がある。
  1. 投球を障害している病変が発生した原因をつきとめ、治療(改善)しなければ、再発は必至である。
問診・診察のポイント  
問診:
  1. 発症時期を確認する(いつから?)。

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文献 

著者: S J O'Brien, M J Pagnani, S Fealy, S R McGlynn, J B Wilson
雑誌名: Am J Sports Med. 1998 Sep-Oct;26(5):610-3.
Abstract/Text Labral tears and acromioclavicular joint abnormalities were differentiated on physical examination using a new diagnostic test. The standing patient forward flexed the arm to 90 degrees with the elbow in full extension and then adducted the arm 10 degrees to 15 degrees medial to the sagittal plane of the body and internally rotated it so that the thumb pointed downward. The examiner, standing behind the patient, applied a uniform downward force to the arm. With the arm in the same position, the palm was then fully supinated and the maneuver was repeated. The test was considered positive if pain was elicited during the first maneuver, and was reduced or eliminated with the second. Pain localized to the acromioclavicular joint or "on top" was diagnostic of acromioclavicular joint abnormality, whereas pain or painful clicking described as "inside" the shoulder was considered indicative of labral abnormality. A prospective study was performed on 318 patients to determine the sensitivity, specificity, and positive and negative predictive values of the test. Fifty-three of 56 patients whose preoperative examinations indicated a labral tear had confirmed labral tears that were repaired at surgery. Fifty-five of 62 patients who had pain in the acromioclavicular joint and whose preoperative examinations indicated abnormalities in the joint had positive clinical, operative, or radiographic evidence of acromioclavicular injury. There were no false-negative results in either group.

PMID 9784804  Am J Sports Med. 1998 Sep-Oct;26(5):610-3.
著者: Shigeto Nakagawa, Minoru Yoneda, Kenji Hayashida, Masanori Obata, Sunao Fukushima, Yoshio Miyazaki
雑誌名: Arthroscopy. 2005 Nov;21(11):1290-5. doi: 10.1016/j.arthro.2005.08.025.
Abstract/Text PURPOSE: Although several clinical tests for detecting superior labral injury of the shoulder have been reported, some of the maneuvers involved are complicated and diagnosis is still inaccurate. The purpose of this report is to introduce our forced shoulder abduction and elbow flexion test (forced abduction test) along with an assessment of its efficacy in the throwing shoulder in comparison with other clinical tests.
TYPE OF STUDY: Prospective nonrandomized clinical trial.
METHODS: Fifty-four throwing athletes who underwent arthroscopic surgery were prospectively studied. Superior labral injury was present in 24 cases (Snyder's classification was type 2 in 22, and type 3 in 2). Several clinical tests were performed preoperatively and the results were recorded on our original chart. The condition of the superior labrum was then examined during arthroscopic surgery. The results of these tests were compared with the arthroscopic findings as a standard. The forced abduction test was defined as positive when pain at the posterosuperior aspect of the shoulder on forced maximal abduction was relieved or diminished by elbow flexion.
RESULTS: The sensitivity, specificity, and accuracy of the forced abduction test were 67%, 67%, and 67%, respectively. It was one of the most useful tests, along with the crank test and O'Brien's test (crank test, 58%, 72%, 66%; O'Brien's test, 54%, 60%, 57%; respectively). Furthermore, the results of the forced abduction test showed a significant correlation with the presence of superior labral injury (P = .0275, chi-square test).
CONCLUSIONS: The forced abduction test was technically simple and its usefulness was comparable to the O'Brien's and crank tests for diagnosing superior labral injury in throwing shoulders.
LEVEL OF EVIDENCE: Level II.

PMID 16325078  Arthroscopy. 2005 Nov;21(11):1290-5. doi: 10.1016/j.art・・・
著者: C S Neer, R P Welsh
雑誌名: Orthop Clin North Am. 1977 Jul;8(3):583-91.
Abstract/Text
PMID 329174  Orthop Clin North Am. 1977 Jul;8(3):583-91.
著者: H Ellman
雑誌名: Arthroscopy. 1987;3(3):173-81.
Abstract/Text Arthroscopic subacromial decompression (ASD) is a method of performing anterior acromioplasty utilizing basic arthroscopic techniques. The procedure is indicated in cases of chronic impingement syndrome that have failed to respond to prolonged conservative management. The purpose of this study is to present an analysis of the 1- to 3-year follow-up results of the initial 50 consecutive cases of ASD that I have performed. Forty (80%) of the cases had advanced stage II impingement without rotator cuff tear. Ten (20%) had full-thickness tears of the rotator cuff. Patients were evaluated pre and postoperatively on the UCLA Shoulder Rating Scale, which includes an assessment of pain, function, range of motion (ROM), strength, and patient satisfaction. Eighty-eight percent of the cases were rated "satisfactory" (excellent or good), and 12% were rated "unsatisfactory" (fair or poor). The procedure is technically demanding, and to achieve a satisfactory result the criteria of open anterior acromioplasty must be met. Arthroscopic subacromial decompression is presented as an alternative to open anterior acromioplasty in advanced stage II and selected cases of stage III impingement syndrome.

PMID 3675789  Arthroscopy. 1987;3(3):173-81.
著者: R J Hawkins, J C Kennedy
雑誌名: Am J Sports Med. 1980 May-Jun;8(3):151-8.
Abstract/Text Athletes, particularly those who are involved in sporting activities requiring repetitive overhead use of the arm (for example, tennis players, swimmers, baseball pitchers, and quarterbacks), may develop a painful shoulder. This is often due to impingement in the vulnerable avascular region of the supraspinatus and biceps tendons. With the passage of time, degeneration and tears of the rotator cuff may result. Pathologically the syndrome has been classified into Stage I (edema and hemorrhage), Stage II (fibrosis and tendonitis), and Stage III (tendon degeneration, bony changes, and tendon ruptures). The impingement syndrome may be a problem for the young, active, and competitive athlete as well as the casual weekend athlete. The "impingement sign" which reproduces pain and resulting facial expression when the arm is forceably forward flexed (jamming the greater tuberosity against the anteroinferior surface of the acromion) is the most reliable physical sign in establishing the diagnosis. Flexibility exercises, strengthening programs, and special training techniques are a preventive and treatment requirement. Rest and local modalities such as ice, ultrasound, and antiinflammatory agents are usually effective to lessen the inflammatory reaction. Surgical decompression by resecting the coracoacromial ligament or a more definitive anterior acromioplasty may rarely be indicated.

PMID 7377445  Am J Sports Med. 1980 May-Jun;8(3):151-8.
著者: G Walch, P Boileau, E Noel, S T Donell
雑誌名: J Shoulder Elbow Surg. 1992 Sep;1(5):238-45. doi: 10.1016/S1058-2746(09)80065-7. Epub 2009 Feb 19.
Abstract/Text Seventeen athletes presenting with unexplained shoulder pain on throwing underwent arthroscopic examination. All but one practiced a throwing sport. The dominant arm was involved in all patients except one bodybuilder. Their mean age was 25 years (range 15 to 30 years), and they had symptoms present for a mean of 27 months. None had clinical, radiologic, or arthroscopic evidence of anterior instability. Preoperative clinical examination typically revealed localized pain on full external rotation and 90° abduction, signs of rupture of the rotator cuff, and positive impingement sign. In 10 cases computed tomographic arthrogram showed evidence of abnormality at the posterior edge of the glenoid. The mean humeral retrotorsion was 10° (range 5° to 30°). Under arthroscopy, with the arm placed in full external rotation and 90° abduction (the throwing position), impingement was found between the posterosuperior border of the glenoid and the undersurface of the tendinous insertions of supraspinatus and infraspinatus. A partial rupture of the cuff, which was demonstrated by arthrogram, was confirmed in eight patients, whereas a partial capsulotendinous rupture, which was not demonstrated by arthrogram, was seen in nine patients. Twelve patients had further lesions of the posterosuperior labrum. This study suggests that in addition to Neer's "impingement syndrome" and Jobe's "instability with secondary impingement," impingement of the undersurface of the cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease of the shoulder in the thrower.

Copyright © 1992 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
PMID 22959196  J Shoulder Elbow Surg. 1992 Sep;1(5):238-45. doi: 10.10・・・
著者: R J Hawkins, N G Mohtadi
雑誌名: Clin Orthop Relat Res. 1991 Nov;(272):152-61.
Abstract/Text The main areas of controversy in anterior shoulder instability are acute dislocation, recurrent instability, pain and instability in the "throwing athlete", and the role of arthroscopy. Treatment of the acute dislocation involves rest initially, followed by aggressive rehabilitation with protection of the shoulder until strength and motion have returned and pain and apprehension have resolved. Patients with recurrent instability may be seen with a variety of clinical scenarios. The surgical indications, pathology, and two methods of soft-tissue reconstruction are described along with an approach to postoperative rehabilitation. Return to sporting activity may be feasible by three months. The current thinking on the painful shoulder in the "throwing athlete" is outlined. Management must be based on an accurate diagnosis. Strengthening of the rotator cuff and scapular stabilizers is recommended with surgery to correct the pathology in those who fail this program. Arthroscopy is a valid tool in the diagnosis of anterior shoulder instability. The clinical significance of some intraarticular findings has not yet been clarified. Therapeutic use should be undertaken only in experienced hands, appreciating that failure of arthroscopic repair is higher than comparable open surgical techniques. The open approach to anterior stabilization is preferred.

PMID 1934726  Clin Orthop Relat Res. 1991 Nov;(272):152-61.
著者: S H Liu, M H Henry, S L Nuccion
雑誌名: Am J Sports Med. 1996 Nov-Dec;24(6):721-5.
Abstract/Text We studied 62 patients (40 men and 22 women) with an average age of 28 years over a 28-month period who presented with shoulder pain that was refractory to 3 months of conservative management. Patients with a prior glenohumeral dislocation or a rotator cuff tear were excluded. The "crank" test was performed with the arm elevated to 160 degrees in the scapular plane of the body, loaded axially along the humerus, and with maximal internal and external rotation. Although similar tests have been described, the crank test is a new examination previously unreported. Half of the patients (31) had a positive crank test. Arthroscopy performed on all 62 patients revealed glenoid labral tears in 32 patients. Two patients who had positive crank tests did not have labral tears but had partial-thickness, articular-side rotator cuff tears. The sensitivity of the crank test was 91%, the specificity was 93%, the positive predictive value was 94%, and the negative predictive value was 90%. With these data, the crank test fulfills the criteria as a single physical examination test that is highly accurate for the preoperative diagnosis of glenoid labral tears. Accordingly, expensive imaging modalities currently used in this patient population may be employed less in the future.

PMID 8947391  Am J Sports Med. 1996 Nov-Dec;24(6):721-5.
著者: F W Jobe, J P Bradley
雑誌名: Clin Sports Med. 1989 Jul;8(3):419-38.
Abstract/Text The specific emphasis in this article has been directed toward the diagnosis of prevalent shoulder pathology in a young athletic population; however, as the interest in sports has blossomed in recent years now encompassing a larger age range, the physician must not neglect common pathologic conditions of the older athletes. Fastidious adherence to complete history, physical examination, and a high level of suspicion for uncommon disorders is paramount. Arthritides such as osteo, rheumatoid, septic, and lyme as well as the hematologic disorders of multiple myeloma, lymphomas, leukemia, hemophilia, and Gaucher's disease can all present with shoulder pain. Thoracic outlet syndrome, scalene syndrome, supra-scapular nerve syndrome, and quadrilateral space syndrome comprise a group of nerve compression syndromes that are becoming more apparent as our diagnostic skills improve. Yet, the most pervasive disorders in the young athlete are due to lack of shoulder stability. By understanding the delicate balance in normal shoulder between mobility and stability, the clinician is better able to conceptualize the etiology and progression of the problem, and design the optimal treatment program.

PMID 2670266  Clin Sports Med. 1989 Jul;8(3):419-38.
著者: Alessandro Castagna, Ulf Nordenson, Raffaele Garofalo, Jon Karlsson
雑誌名: Arthroscopy. 2007 Feb;23(2):211-5. doi: 10.1016/j.arthro.2006.11.025.
Abstract/Text The wide spectrum of shoulder instability is difficult to include in 1 classification. The distinction between traumatic, unidirectional, and atraumatic multidirectional instability is still widely used, even though this classification is not sufficiently precise to include all the different pathological findings of shoulder instability. We present "minor instability," which is a pathological condition causing a dysfunction of the glenohumeral articulation, especially in combination with microtrauma, repetitive or not, or after a period of immobilization or inactivity. When "minor shoulder instability" is suspected, the patient's history and detailed clinical examination represent the most important factors when establishing the diagnosis. In particular, the apprehension test stressing the middle glenohumeral ligament (MGHL)/labral complex in the position of midabduction and external rotation may be painful and may even reveal anterior instability or subluxation. Conventional radiographs are negative in most cases, as is magnetic resonance imaging arthrography. It is only after an accurate arthroscopic assessment that the pathological lesion can be found. The major pathological process can be identified at the level of the anterior superior labrum, in particular the MGHL complex, and appears as hyperemia, fraying, stretching, loosening, thinning, hypoplasia, or even absence. It may, however, be difficult to distinguish between a normal variant and a pathological lesion. Clinical symptoms and examination should always be correlated with arthroscopic findings. Recommended treatment is to restore shoulder stability and thereby prevent shoulder pain secondary to the increase in laxity. A reduction in range of motion should be expected during the postoperative phase, at least up to six to nine months. External rotation is usually permanently reduced by a few degrees.

PMID 17276230  Arthroscopy. 2007 Feb;23(2):211-5. doi: 10.1016/j.arthr・・・
著者: Seung-Ho Kim, Jun-Sic Park, Woong-Kyo Jeong, Seong-Kee Shin
雑誌名: Am J Sports Med. 2005 Aug;33(8):1188-92. doi: 10.1177/0363546504272687. Epub 2005 Jul 6.
Abstract/Text BACKGROUND: Detection of a posteroinferior labral lesion by physical examination is often difficult.
PURPOSE: To introduce a novel diagnostic test for detecting a posteroinferior labral lesion of the shoulder.
HYPOTHESIS: The Kim test can detect a posteroinferior labral lesion of the shoulder.
STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1.
METHODS: In 172 painful shoulders, the Kim test was compared with the jerk test and was verified by arthroscopic examination. A sudden onset of posterior shoulder pain and click with or without clunk indicated a positive test result.
RESULTS: Thirty-three shoulders had a positive Kim test result, in which 24 had a posteroinferior labral lesion and 9 had a normal posteroinferior labrum. Of 139 shoulders with a negative Kim test result, 6 had a posteroinferior labral tear and 133 had a normal posteroinferior labrum. The sensitivity of the Kim test was 80%, specificity was 94%, positive predictive value was 0.73, and negative predictive value was 0.96. The interexaminer reliability between 2 examiners was 0.91. The accuracy of the jerk test in detecting a posteroinferior labral lesion was the following: sensitivity, 73%; specificity, 98%; positive predictive value, 0.88; and negative predictive value, 0.95. The location of the posterior labral lesion was predominantly posterior in 19 shoulders and predominantly inferior in 11 shoulders. The Kim test was more sensitive in detecting a predominantly inferior labral lesion, whereas the jerk test was more sensitive in detecting a predominantly posterior labral lesion. The sensitivity in detecting a posteroinferior labral lesion increased to 97% when the 2 tests were combined.
CONCLUSION: The Kim test is a reliable diagnostic test for detection of a posteroinferior labral lesion.

PMID 16000664  Am J Sports Med. 2005 Aug;33(8):1188-92. doi: 10.1177/0・・・
著者: Minoru Yoneda, Shigeto Nakagawa, Kenji Hayashida, Sunao Fukushima, Shigeyuki Wakitani
雑誌名: Am J Sports Med. 2002 Sep-Oct;30(5):728-36.
Abstract/Text BACKGROUND: Bennett lesions are often observed in throwing athletes, and, although usually asymptomatic, they can sometimes become painful and disturb an athlete's throwing ability. Because it is clinically difficult to determine whether a Bennett lesion is symptomatic or whether pain is from another lesion, the outcome of surgical treatment is variable.
HYPOTHESIS: Arthroscopic resection of Bennett lesions diagnosed according to our criteria and arthroscopic treatment of associated lesions performed simultaneously were effective for treatment of baseball players with symptomatic Bennett lesions.
STUDY DESIGN: Prospective cohort study.
METHODS: The following criteria for diagnosis of a symptomatic Bennett lesion were used to identify 16 baseball players who later underwent arthroscopic removal of the symptomatic Bennett lesion (arthroscopic Bennett-plasty): 1) detection of a bony spur at the posterior glenoid rim on radiographs; 2) posterior shoulder pain during throwing, especially in the follow-through phase; 3) tenderness at the posteroinferior aspect of the glenohumeral joint; and 4) relief of pain by injection of local anesthesia.
RESULTS: After a minimum follow-up of 1 year, there was no tenderness at the posteroinferior aspect of the glenohumeral joint in any of the patients. Throwing pain disappeared in 10 shoulders and was mitigated in 6 shoulders. Eleven patients returned to baseball at their previous level of competition.
CONCLUSIONS: Accurate diagnosis and minimally invasive arthroscopic surgery are important for appropriate treatment of baseball players with symptomatic Bennett lesions.

Copyright 2002 American Orthopaedic Society for Sports Medicine
PMID 12239010  Am J Sports Med. 2002 Sep-Oct;30(5):728-36.
著者: Minoru Yoneda, Shigeto Nakagawa, Naoko Mizuno, Sunao Fukushima, Kenji Hayashida, Tatsuo Mae, Kazutaka Izawa
雑誌名: Arthroscopy. 2006 Jul;22(7):801.e1-5.
Abstract/Text Posterior capsular tightness with glenohumeral internal rotation deficit is usually considered to be an acquired condition of the throwing shoulder and is usually treated conservatively. However, because posterior capsular tightness is sometimes irreversible, we have performed arthroscopic capsular release for painful throwing shoulder with posterior capsular tightness. The true loss of internal rotation and posterior stiffness was confirmed by examination with the patient under anesthesia, and contracture of the posterior capsule and the posterior band of the inferior glenohumeral ligamant was observed arthroscopically. Because an extensive adhesion between the capsule and the fascia of the external rotators was noted, a capsular release was performed from 6 o'clock to 11 o'clock (in the right shoulder) to completely expose the muscle belly of the external rotators. Of the first 16 consecutive patients, 4 had no concomitant lesions and underwent posterior capsular release alone. With a minimum of 2 years' follow-up, it was ascertained that the throwing pain completely disappeared in 14 patients and improved in 2. In all, 11 patients returned to their preinjury performance level, and 5 returned to a lower level of function. In the 4 patients who had no concomitant lesions, throwing pain completely disappeared, and all were able to return to their preinjury performance level.

PMID 16848064  Arthroscopy. 2006 Jul;22(7):801.e1-5.

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