今天开贴,特别希望留学海外的同胞们一起来捧场! 呵呵,废话不讲. 这个主题是关于Rotator Cuff Tears. 搜索了一下只有关于这个话题的争论在治疗方面,没有更多的冬冬. 不喜欢不严谨的态度,不喜欢口水战. 只要有文献可以说服,任何事情都可以让我改变.呵呵.
这样吧列一个小LIST,本着学习的态度,本讨论欢迎中文讨论,更主张英文讨论,省去我要翻译两次.呵呵. 全部完成后,会逐步地翻译,到时候你只要看到目录,然后看到几楼就可以直接找到你要得信息了. 我呢,根据最新的文献,不定期更新,特别是大家有争议的地方都保留.
1. 如果要治疗得当,what should PTs know ?
2. 关于社会文化方面+历史: 美国的和中国的
3. 关于解剖
4. 关于Kinesiology
5. 体检 special tests
6. 治疗不同stage, irritability, postoperative......
7. 文献about including all above subjects. Evdience-based M....
8. 个人经验,教训, 喜好---不强求说服,要讲道理.
9. CASES
10 鉴别诊断 与别的骨科疾病鉴别,与非骨科疾病鉴别 how to rule out Red Flags!
欢迎增加你认为需要的题目.
目的:
如果你是老手给你个机会秀一下,注意查查EVIDENCE文献后再发彪--不要阴沟里翻船了哦.
如果你是生手,那么就一起学习拉,没有任何的问题是silly questions!
如果你是半生不熟手,那么就借机会从新整理一下你的临床思维吧.
拒绝口水战! 有书的给出哪一页? 有文献的上传,有图片的上传,有老师的讲义的也可以分享.
最好是上传来这里，太大的可以用 > 然后给出地址。
有更好的建议请提出。
希望大家集中精力一个一个疾病，一个一个关节搞定。
治疗的方面太多的具体的东西了，光是Theraputic exercises 就厚厚一本！所以呢大家最好精简整理，不要一来就从网络上搜索贴过来！ 那些东西要么太浅，教育普通大众的，要么不系统，太偏，要么太杂，合并了其他的特殊情况---比如不同的手术方法比较。
衍生的东西就太多了，从MMT，ROM, 到JT manipulation----从原则到具体手法，从基本原理到变通，从教科书到最新文献支持。。。。。
希望大家积极参与！因为是横向的视角,所以如果对特别某一个问题很希望给系统的信息的话呢,你就要等我完成了现在的project 后提供了. :>
我希望能在积累了50分后当上斑竹！ 呵呵。
打造精品文章! 认准Tbag商标!
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OK, 第一个话题,PT需要知道什么才可以给与病人最好的治疗呢?
1. anatomy of the shoulder
2. mechanisms of the tears
3. biomechanical reasoning(kinesiology)
4. relationship between shoulder function and scapular stabalization
5. innervation of all involved muscles, might be useful to differentiate other diseases....
6. ability to evaluate lab results and their the reliabilities (including diagnostic ultrasound,MRI, X-ray, Contrast arthrography ....)
7. others
未完...欢迎补充.
大家的看法可能多多阿。
接下来可以一点一点地掰开了揉碎了地谈谈解剖了,呵呵.
支线太多了,欢迎加入专题.
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4 muslces are involved here.
1. Supraspinatus
起点 Origin: Medial 2/3 of the supraspinstus fossa
止点 Insertion: Superior Facet of the greater tubercle & shoulder joint capsule
作用 Action: Abduction & stabilizes the glenohumeral joint
神经支配 Innervation: Subscapular, Nerve Roots: C4, 5, & 6
2. Infraspinatus
O: Medial 2/3 of the infraspinatus fossa
I: Middle facet of the greater tubercle & joint capsule
A: External rotation & stabilization of the glenohumeral joint
N: Subscapular: C4, 5, & 6
3.Teres Minor
O: Upper 2/3, dorsal surface of the lateral border of the scapula
I: Middle facet of the greater tubercle & joint capusle
A: External rotation & stabilization of the glenohumeral joint
N: Axillary: C5 & 6
4. Subscapularis
O: Subscapular fossa
I: Lesser tubercle and joint capsule
A: Internal rotation & stabilization of the glenohumeral joint
N: Upper & Lower subscapular: C5, 6, & 7
Most commonly supraspinatus and infraspinatus
下图是左肩前外侧观。
注意：CHL: coracohumeral ligament
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韧带：
这是side view. 关节的稳定和joint manipulation的技巧原理，在后面会涉及到。
注意IGHL有前后两个band.
bicep tendon连接处，以后的bankart lesion 跟这个有关系。
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如何触诊：
Supraspinatus Tendon
The shoulder position that produces the maximum exposure of the supraspinatus
tendon with the least amount of overlying tissue was maximal shoulder
adduction, maximal medial rotation and maximal hyperextension (arm behind the
back).
In this position the distal portion of the supraspinatus tendon is
repositioned from under the acromion to a point anterior to the acromioclavicular
joint.
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如何触诊：
Infraspinatus and Teres Minor Tendons
The position that produces maximum exposure of the Infraspinatus and teres
minor tendons with the least amount of overlying tissue was shoulder flexion to
90 degrees, 10 degrees_of shoulder adduction and 20 degrees of shoulder lateral
rotation.
In this position, the infraspinatus tendon is deep to the posterior deltoid
muscle and inferior to the acromial angle. Cyriax advocated using this position
with the patient lying prone.
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如何触诊：
Subscapularis Tendon
The position that allows maximum exposure of the subscapularis tendon with the least amount of overlying tissue was with the shoulder adducted to the side of the thorax and neutral in terms of flexion/extension and medial/lateral rotation .
In this position, the tendon can be located deep in the deltopectoral triangle between the long and short heads of the biceps brachii muscle.
横断面
（缩略图，点击图片链接看原图）
很好，继续
学习中，多谢！
Primary Compressive:
Direct result of compression of the roator cuff tendons
between the humeral head and the overlying acromion, coracoacromial ligament,
coracoid and AC joint.
手术减压！动画哦！
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Acromion shape (I-III) may play a role.
See here:
{ side view}
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一些数据：
tpye 3 need surgery to relieve the pressure and increase the suprahumeral space.
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The Coracoacromial arch
consists of the acromion (A) ,
the coracoid process (C),
the coracoacromiial ligament (CAL) and
the acromioclavicular joint (AC) .
Beneath these structures passes the humeral head covered by the rotator cuff.
SS, supraspinatus;
IS, infraspinatus;
TM teres minor; SbS,
subscapularis
发病的机理跟这个有关系。这是右前外侧观
参考文献：
Panni AS, Milano G, Lucania L, et al: Histological analysis of the coracoacromial arch:
correlation between age-related changes and rotator cuff tears. Arthroscopy
1996; 12(5):531 -540[color=RoyalBlue][/color]
（缩略图，点击图片链接看原图）
Secondary Compressive:
compression is a secondary result of underlying instability of glenohumeral joint.
Static stability may be compromised leading to excessive translation or Poor dynamic control, overuse or fatigue of dynamic stabilizers may lead to excessive translation.
下图提示，过度的superior，导致引起的RC 被卡到。
可以是coracoacromial arch 也可以是superior labrum.
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Tensile overload:
Repetitive intrinsic tension overload (usually eccentric forces).
Progression of tendon pathology due to overload
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Macrotrauma:
Previous or single traumatic event in the clinical history (may be
accompanied by subluxation or dislocation).
o May recover from initial injury without suspicion of RC tear, but followingcontinued loading/stressing of tissue tear may become symptomatic,
o Healthy tendons require up to30% damage to result in substantial strength loss
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Mechanisms of Tears
• Repetitive microtrauma (greater with eccentric loading)
o Tensile overloading
o Posterior or internal impingement (undersurface)
• FOOSH (partial thickness tears in elderly)
• Impingement of the cuff against the acromion in a sudden abduction
movement without proper ER of the humeral head
• Unexpected force during pushing/pulling movements
• During a dislocation of the shoulder
FOOSH: Fall on outstretched arm (FOOSH), fall on tip of shoulder or direct impact
呵呵，英文不好，看起来太累。
推荐大家去看一本北医三院曲爷和田老爷子共同编的一本书吧《运动创伤检查法》，北医大出版社出的，绝对的经典！个人认为那本书上的所有检查都应该熟练掌握！
哦，对了，还有一点，查了字典才知道楼主说的是“肩袖撕裂”。呵呵，可否至少在标题里给一个中文名让俺们这些不懂洋文的人知道在说的啥？
在运动损伤、软组织损伤的诊断方面、基础研究方面，我们国家比美国等落后起码10年以上，因此，看英文资料是很重要的。
10 年的差距，在一线工作人员的眼中一定不比奖金重要啊，我的贴将来会翻译的。
目的是给有志于扎实提高理论到实践，把握国外的最新治疗，最新文献动态的人看的。
如果要讲哪一种检查手法好，如何检查的话，那么买几本书自己回家看就可以了。
呵呵。
支持Tbag , 希望还有更多有关肩部损伤或引起疼痛机制的资料, 可否作一些更具体的临床阐述与治疗呢? 谢谢!
Signs of Symptoms
• Severe acute pain at time of injury
• Night pain
• Pain/difficulty with overhead activities
• Local tenderness
• Painful arc 60-120 degrees
• Weakness of shoulder abduction and external rotation (supraspinatus)
• Abduction still possible with partial or full tears, but may be painful
呵呵，开个玩笑。虽然不是很懂E文，自己看看资料和书还是够用的。可是要为更多的人着想啊。
确实，对于各个关节的详尽检查是非常重要的。记得曾经看到过一本翻译过来的《贝氏身体检查指南》，虽然很简单，却是非常有用。建议初级的朋友好好看看那本书。呵呵，不过很贵的，大几百的说。
Diagnosis
• Complete tear = loss of abduction (and/or ER) despite strong deltoid
• Contrast arthrography demonstrates communication of sub-deltoid bursa with
the joint cavity, and has a sensitivity of 93 percent, positive predictive value of
96 percent, and a negative predictive value of 91 percent.
• Diagnostic ultrasound: Reported sensitivities and specificities for ultrasound
range from 57% to 95% and 76% to 94%, respectively.
• MRI: Sensitivity of 84-100% and a specificity of 77-97% for full-thickness tears
m Presentation is variable and doesn 't always correlate to tear size "Not all tears need
surgery and not all non-tears don't"
• Differential diagnosis: axillary nerve lesion (C5, C6) with deltoid paralysis,
instability with secondary impingement, calcific tendinitis, tendinopathy, rotator
cuff strain, and Posterolateral impingement syndrome
肩袖损伤分三度，每一期的病理变化不一样，临床症状也有所不同。伤病还是要早发现，早治疗。
Tbag:
Secondary Compressive:
compression is a secondary result of underlying instability of glenohumeral joint.
补充一点：
unbalanced force couples also is a very, very important issue.
p.s. good topic, but maybe it is better to discuss biomechanics earlier than diagnosis?
你自己敲上来的呀？佩服佩服
写得很好,正在学习中,继续!!!!!
逼着我要跟上你的英语水平程度! 我对患者肩部晚上疼痛的机制和治疗很感兴趣, 可否能具体阐述哪! 学习了!
是"晚上疼痛"，还是"卧位疼痛"，这可是重要的区别。要先把这两点分清。
占位， 忙搬家，过后来补课。
占位,正考虑从神经康复专业转投骨科康复,一定仔细研究楼主的帖子,加油!
写得很好,正在学习中！！！
好东西，顶
