今日の臨床サポート

ジャンパー膝

著者: 高橋周 東あおば整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2016/05/13
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. ジャンパー膝はジャンプやランニング動作を繰り返す10歳代のスポーツ選手に好発する膝伸展機構の障害である。
 
診断:
  1. 診察では、膝蓋腱の膝蓋骨付着部中央から内側に圧痛と腫脹・局所熱感を認めることが多い。また、スクワットでは屈位60°~80°でpainful arcを認める。
  1. 上記の診察所見と、超音波画像診断により腱の肥大、fibrillar patternの開大・不整・消失、血流増加(ドプラ)を認めることで診断できる。
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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:
高橋周 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. ジャンプやランニング動作を繰り返すスポーツ選手に好発する膝伸展機構の障害である。
  1. 膝関節伸展機構は、大腿四頭筋、膝蓋骨、膝蓋腱、脛骨結節で構成される。<図表>
  1. オーバーユースに起因する膝のスポーツ障害である。
  1. 好発年齢:10歳代
  1. 原因:大腿四頭筋の柔軟性低下、膝伸展機構に繰り返しの過度の牽引力などがある。
  1. 膝蓋腱実質(膝蓋骨付着部)に出血、浮腫、ムコイド変性、フィブリノイド変性を生じる。
  1. 腱実質の微小断裂が生じる(最重症例では完全断裂)。
問診・診察のポイント  
問診
  1. 発症時期を確認する。

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文献 

著者: J Roels, M Martens, J C Mulier, A Burssens
雑誌名: Am J Sports Med. 1978 Nov-Dec;6(6):362-8.
Abstract/Text A jumper's knee is an overload lesion of patellar or quadriceps tendon near its insertion at the lower or upper pole of the patella. If conservative treatment fails, an operation can be performed in Phase 3 where disabling symptoms, are present. The necrotic tissue in the patellar tendon is excised. The early results of this surgery are encouraging.

PMID 736196  Am J Sports Med. 1978 Nov-Dec;6(6):362-8.
著者: D P Richards, S V Ajemian, J P Wiley, R F Zernicke
雑誌名: Am J Sports Med. 1996 Sep-Oct;24(5):676-83.
Abstract/Text We quantified the lower extremity dynamics developed during the volleyball spike and block jumps to find out if predictive relations exist between jump dynamics and patellar tendinitis. Lower extremity movement biomechanics were analyzed for 10 members of the 1994 Canadian Men's National Volleyball Team (all right-handed hitters). Based on physical examination, 3 of the 10 players had patellar tendon pain associated with patellar tendinitis at the time of testing. In masked biomechanical and logistic regression analyses, we discovered that the vertical ground-reaction force during the take-off phase of both spike and block jumps was a significant predictor of patellar tendinitis-correctly predicting the presence or absence of patellar tendinitis in 8 of 10 players. Deepest knee flexion angle (during landing from the spike jump) predicted 10 of 10 cases correctly for the left knee. The external tibial torsional moment (during the takeoff for the right knee with the spike jump and for the left knee with the block jump) was also a significant predictor of tendinitis. In these players, the likelihood of patellar tendon pain was significantly related to high forces and rates of loading in the knee extensor mechanism, combined with large external tibial torsional moments and deep knee flexion angles.

PMID 8883692  Am J Sports Med. 1996 Sep-Oct;24(5):676-83.
著者: Øystein Lian, Per-Egil Refsnes, Lars Engebretsen, Roald Bahr
雑誌名: Am J Sports Med. 2003 May-Jun;31(3):408-13.
Abstract/Text BACKGROUND: Patellar tendinopathy is assumed to result from chronic tendon overload. There may be a relationship between tendon pain and jumping ability.
HYPOTHESIS: There is no difference in performance characteristics between volleyball players with patellar tendinopathy and those without.
STUDY DESIGN: Prospective cohort study.
METHOD: We examined the performance of the leg extensor apparatus in high-level male volleyball players with patellar tendinopathy (N = 24) compared with a control group (N = 23) without knee symptoms. The testing program consisted of different jump tests with and without added load, and a composite jump score was calculated to reflect overall performance.
RESULTS: The groups were similar in age, height, and playing experience, but the patellar tendinopathy group did more specific strength training and had greater body weight. They scored significantly higher than the control group on the composite jump score (50.3 versus 39.2), and significant differences were also observed for work done in the drop-jump and average force and power in the standing jumps with half- and full-body weight loads.
CONCLUSIONS: Greater body weight, more weight training, and better jumping performance may increase susceptibility to patellar tendinopathy in volleyball players.

PMID 12750135  Am J Sports Med. 2003 May-Jun;31(3):408-13.
著者: E Witvrouw, R Lysens, J Bellemans, D Cambier, G Vanderstraeten
雑誌名: Am J Sports Med. 2000 Jul-Aug;28(4):480-9.
Abstract/Text Many variables have retrospectively been associated with the presence of anterior knee pain. Very few prospective data exist, however, to determine which of these variables will lead to the development of anterior knee pain. It was our purpose in this study to determine the intrinsic risk factors for the development of anterior knee pain in an athletic population over a 2-year period. Before the start of training, 282 male and female students enrolled in physical education classes were evaluated for anthropometric variables, motor performance, general joint laxity, lower leg alignment characteristics, muscle length and strength, static and dynamic patellofemoral characteristics, and psychological parameters. During this 2-year follow-up study, 24 of the 282 students developed patellofemoral pain. Statistical analyses revealed a significant difference between those subjects who developed patellofemoral pain and those who did not concerning quadriceps and gastrocnemius muscle flexibility, explosive strength, thumb-forearm mobility, reflex response time of the vastus medialis obliquus and vastus lateralis muscles, and the psychological parameter of seeking social support. However, only a shortened quadriceps muscle, an altered vastus medialis obliquus muscle reflex response time, a decreased explosive strength, and a hypermobile patella had a significant correlation with the incidence of patellofemoral pain. We concluded that the latter four parameters play a dominant role in the genesis of anterior knee pain and we therefore deem them to be risk factors for this syndrome.

PMID 10921638  Am J Sports Med. 2000 Jul-Aug;28(4):480-9.
著者: P Jonsson, H Alfredson
雑誌名: Br J Sports Med. 2005 Nov;39(11):847-50. doi: 10.1136/bjsm.2005.018630.
Abstract/Text BACKGROUND: A recent study reported promising clinical results using eccentric quadriceps training on a decline board to treat jumper's knee (patellar tendinosis).
METHODS: In this prospective study, athletes (mean age 25 years) with jumper's knee were randomised to treatment with either painful eccentric or painful concentric quadriceps training on a decline board. Fifteen exercises were repeated three times, twice daily, 7 days/week, for 12 weeks. All patients ceased sporting activities for the first 6 weeks. Age, height, weight, and duration of symptoms were similar between groups. Visual analogue scales (VAS; patient estimation of pain during exercise) and Victorian Institute of Sport Assessment (VISA) scores, before and after treatment, and patient satisfaction, were used for evaluation.
RESULTS: In the eccentric group, for 9/10 tendons patients were satisfied with treatment, VAS decreased from 73 to 23 (p<0.005), and VISA score increased from 41 to 83 (p<0.005). In the concentric group, for 9/9 tendons patients were not satisfied, and there were no significant differences in VAS (from 74 to 68, p<0.34) and VISA score (from 41 to 37, p<0.34). At follow up (mean 32.6 months), patients in the eccentric group were still satisfied and sports active, but all patients in the concentric group had been treated surgically or by sclerosing injections.
CONCLUSIONS: In conclusion, eccentric, but not concentric, quadriceps training on a decline board, seems to reduce pain in jumper's knee. The study aimed to include 20 patients in each group, but was stopped at the half time control because of poor results achieved in the concentric group.

PMID 16244196  Br J Sports Med. 2005 Nov;39(11):847-50. doi: 10.1136/b・・・
著者: M A Young, J L Cook, C R Purdam, Z S Kiss, H Alfredson
雑誌名: Br J Sports Med. 2005 Feb;39(2):102-5. doi: 10.1136/bjsm.2003.010587.
Abstract/Text BACKGROUND: Conservative treatment of patellar tendinopathy has been minimally investigated. Effective validated treatment protocols are required.
OBJECTIVES: To investigate the immediate (12 weeks) and long term (12 months) efficacy of two eccentric exercise programmes for the treatment of patellar tendinopathy.
METHODS: This was a prospective randomised controlled trial of 17 elite volleyball players with clinically diagnosed and imaging confirmed patellar tendinopathy. Participants were randomly assigned to one of two treatment groups: a decline group and a step group. The decline group were required to perform single leg squats on a 25 degrees decline board, exercising into tendon pain and progressing their exercises with load. The step group performed single leg squats on a 10 cm step, exercising without tendon pain and progressing their exercises with speed then load. All participants completed a 12 week intervention programme during their preseason. Outcome measures used were the Victorian Institute of Sport Assessment (VISA) score for knee function and 100 mm visual analogue scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period and at 12 months.
RESULTS: Both groups had improved significantly from baseline at 12 weeks and 12 months. Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group. VAS scores at 12 months did not differ between the groups.
CONCLUSIONS: Both exercise protocols improved pain and sporting function in volleyball players over 12 months. This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain.

PMID 15665207  Br J Sports Med. 2005 Feb;39(2):102-5. doi: 10.1136/bjs・・・

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