肌腱病變
肌腱病變(英語:tendinopathy)又稱肌腱病[6](tendinosis)、肌腱变性,旧称肌腱炎[註 1](tendinitis),是一種肌腱的疾患,可造成疼痛、局部腫脹、與功能障礙[3][1]。典型的疼痛會隨著肢體動作而變得明顯[9]。好發於肩、肘、腕、髖、膝、踝等關節附近[3][10][2]。
肌腱病變 | |
---|---|
同义词 | 肌腱炎、肌腱退化[1][2] |
![]() | |
跟腱(肌腱病變好發部位之一) | |
症状 | 疼痛、腫脹[3] |
病因 | 損傷、重複性動作[3] |
診斷方法 | 症狀、理學檢查、醫學影像[4] |
治療 | 休息、非類固醇消炎止痛藥、副木、物理治療[5] |
预后 | 80%在六個月內改善[2] |
患病率 | 常見[3][2] |
分类和外部资源 | |
醫學專科 | 復健醫學 |
ICD-10 | M67.9 |
MedlinePlus | 001229 |
病因可為損傷或重複性動作[3]。高風險族群包含勞工、音樂家、運動員等[11]。較少見的原因包含有:感染、關節炎、痛風、甲狀腺疾病、糖尿病[12]。診斷通常依據症狀、理學檢查、偶爾加上醫學影像檢查[4]。受傷幾週後發炎會大幅減少,後續潛在問題則與肌腱細纖維虛弱或破裂有關[13]。
治療可包含休息、非類固醇消炎止痛藥、副木、和物理治療[5],偶爾採用類固醇注射、手術[5]等方式。80%的病人在六個月內改善[2]。肌腱病變是一個相對常見的疾病[3]。年長者更常受到影響[11]。肌腱病變可導致勞動力的大量損失[2]。
症狀
症狀包括觸診壓痛和疼痛,尤其是在運動或活動的時候[14]。
病因
病因可能包括損傷或重複性的動作,比如打網球[3] 。高危險群包括從事勞力工作的人、音樂家、運動員[11]。較少見的原因包括感染、關節炎、痛風、甲狀腺疾病、糖尿病[12]。肌腱受傷可能癒合不良[15]。
奎諾酮類抗生素可增加肌腱炎和肌腱破裂的風險[16]。2013年的一項研究發現,服用氟奎諾酮類藥物的人當中,肌腱損傷的發生率在0.08%至0.2%之間[17]。氟奎諾酮類藥物最常影響下肢的大型負重肌腱,尤其跟腱大約佔了肌腱破裂病例中的30%至40%[18]。
類型
病生理機轉
截至2016年,對肌腱病變的病生理機轉還是所知有限[19][20];雖然發炎反應看起來佔有一定角色,但是還不了解組織結構變化、肌腱功能、疼痛之間的關係,目前存在的幾種機轉理論模型都沒有被完全認可或否定。發炎的分子機制包括釋放發炎性細胞激素,例如IL-1β,會降低人類肌腱細胞第一型膠原蛋白信使核糖核酸的表現並導致肌腱細胞外基質降解[21]。
其多重因素理論可包括:超過負荷的拉扯、破壞肌腱細胞膠原蛋白的合成、過度負荷導致的局部缺血、神經芽體增生、熱損傷、適應性壓擠反應。肌腱束的腱內滑動和肌腱束界面處的剪力可能是發展肌腱病變和導致容易斷裂的重要力學因素[22]。肥胖症(更具體是指脂肪組織)也與肌腱病變的發病率增加有關[23]。
然而這種情況最普遍接受的原因是內外在因素都有關聯的過度使用症候群,可導致進行性的影響或原有修復反應失靈。肌腱病變涉及細胞凋亡、基質解體、血管新生[24]。
「肌腱退化」的典型特徵包括膠原基質的退化性變化、細胞過度增生、血管過度增生、發炎細胞缺乏,這些特徵挑戰「肌腱炎」這個原始誤稱[25][26]。
組織學發現包括肉芽組織、微破裂、退化性變化、沒有傳統的發炎現象,因此可用「外肘肌腱病變或肌腱退化」取代「肱骨外上髁炎」這個名稱[27]。
肱骨外上髁炎組織檢查顯示非發炎性組織,因此專業術語採用「血管纖維母細胞性肌腱退化」(英語:angiofibroblastic tendinosis)[28]。
有肌腱病變的肌腱培養發現第三型膠原蛋白產量增加[29][30]。
外肘縱切超音波圖顯示伸肌肌腱增厚和異質性,與肌腱退化的表現一致,超音波顯示鈣化、質內撕裂、外上髁明顯的不規則。儘管常用「上髁炎」一詞來描述這個疾病,但大多數組織病理學研究均未發現急性或慢性的發炎證據。組織學研究表示這種情況起因於肌腱的退化,導致正常組織被失序排列的膠原蛋白所替代。因此該病比較適合稱作「肌腱退化」或「肌腱病變」,而不是「肌腱炎」[31]。
彩色都卜勒超音波可顯示肌腱的結構變化,其血流強度和低迴波區可對應到位於伸肌肌肉起點疼痛處[32]。
過度負荷所誘發的非破裂性肌腱病變與下列狀況相關:第三型膠原蛋白比例增加(相對於第一型膠原蛋白)、膠原纖維管徑變小、肌腱細胞外基質膠原束彎曲變形、肌腱細胞及其細胞核彎曲變形[33]。
診斷
不同病例的症狀差異可以很大,從痠痛或疼痛、局部關節僵硬、到發炎肌腱周圍整個關節的灼熱感。某些情況下,腫脹會伴隨局部發熱和發紅,關節周圍可能出現可見的硬塊,此時關節活動期間和活動後疼痛通常會加劇,次日肌腱拉緊肌肉時,肌腱和關節區域變得僵硬。許多病患表示生活壓力與初期的疼痛有關。
醫學影像
超音波檢查因其價格合理、安全性高、檢查速度快而變得越來越流行。超音波可以用於組織成像,音波也能提供組織機械狀態的相關資訊[35]。
治療
肌腱損傷大部分採用保守治療。
非類固醇消炎止痛藥
非類固醇消炎止痛藥可用於短期緩解疼痛,對長期結果沒有太大改變[2]。其他類型的止痛藥,如乙醯胺酚,可能有類似效用[2]。
類固醇
目前尚無證據顯示類固醇注射具有長期的益處,但短期內比非類固醇消炎止痛藥更有效[36]。類固醇注射似乎對旋轉袖肌腱炎沒有什麼幫助[37]。使用類固醇常被擔心可能產生負面影響[38]。
其他注射
沒有足夠證據建議常規例行使用各種注射療法(自體血、高濃度血小板血漿、去蛋白血液透析液、抑肽酶、多硫酸化醣胺聚醣、皮膚纖維母細胞等)治療跟腱肌腱病變[39]。截至2014年,尚無足夠的證據支持注射高濃度血小板血漿來治療肌肉骨骼軟組織損傷,例如韌帶、肌肉、肌腱的撕裂傷和肌腱病變[40]。
預後
病情初步改善通常在2到3個月內,完全康復通常在3到6個月內。大約80%的病患在12個月內完全康復[2]。
流行病學
肌腱損傷及其導致的肌腱病變佔運動相關醫師和肌肉骨骼醫事人員的諮詢病例可達30%[41]。肌腱病變最常見於運動員,無論是受傷前或受傷後,但是非運動員和久坐的民眾也越來越普遍,比如在一個以一般民眾為基礎的研究中,發現多數跟腱肌腱病變的病例並未與其體育活動有關[42]。在另一個研究中,從1979-1986年到1987-1994年跟腱肌腱病變發病率增加了六倍[43]。旋轉袖肌腱病變發生率從0.3%到5.5%不等,年盛行率介於0.5%到7.4%之間[44] 。
專業術語
「肌腱炎」是一個非常普遍使用但容易被誤解的專業術語。根據定義,後綴「炎」表示「發炎」。發炎[45]是人體對組織損傷的局部反應,其中涉及紅血球、白血球、使損傷部位血管擴張的血液蛋白。肌腱是相對缺乏血管的[46]。皮質類固醇是抑制發炎的藥物,可短期緩解慢性肌腱病變的疼痛並改善功能與減少腫脹,但是長期復發的風險會增加[47]。皮質類固醇通常與少量稱為利多卡因的麻醉藥一起注射。研究顯示注射皮質類固醇後的肌腱較為脆弱。肌腱炎仍然是非常普遍的診斷,儘管越來越多的研究認為這些肌腱炎常常其實是肌腱退化[48]。
解剖學上相近但不同的狀況有:
研究
其他動物
屈腱炎是馬術師用來表示肌腱炎和肌腱退化的術語,最常見於馬前腿的淺指屈肌肌腱。
备注
參考資料
- ^ 1.0 1.1 Tendinopathy MeSH Browser. US National Library of Medicine. [18 November 2018]. (原始内容存档于2018-11-18) (英语).
- ^ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Wilson, JJ; Best TM. Common overuse tendon problems: A review and recommendations for treatment (PDF). American Family Physician. Sep 2005, 72 (5): 811–8 [2019-11-30]. PMID 16156339. (原始内容存档 (PDF)于2007-09-29).
- ^ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017 [18 November 2018]. (原始内容存档于2019-10-08) (英语).
- ^ 4.0 4.1 Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017 [18 November 2018]. (原始内容存档于2019-10-08) (英语).
- ^ 5.0 5.1 5.2 Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017 [18 November 2018]. (原始内容存档于2019-10-08) (英语).
- ^ 肌腱病. [2022-12-05]. (原始内容存档于2022-12-05).
- ^ Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process.. Sports Med Arthrosc Rehabil Ther Technol. 2010, 2: 30. PMC 3006368 . PMID 21144004. doi:10.1186/1758-2555-2-30.
- ^ Abate M, Silbernagel KG, Siljeholm C, Di Iorio A, De Amicis D, Salini V, Werner S, Paganelli R. Pathogenesis of tendinopathies: inflammation or degeneration?. Arthritis Research & Therapy. 2009, 11 (3): 235. PMC 2714139 . PMID 19591655. doi:10.1186/ar2723.
- ^ Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017 [18 November 2018]. (原始内容存档于2019-10-08) (英语).
- ^ Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017 [18 November 2018]. (原始内容存档于2019-10-08) (英语).
- ^ 11.0 11.1 11.2 Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017 [18 November 2018]. (原始内容存档于2019-10-08) (英语).
- ^ 12.0 12.1 Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017 [18 November 2018]. (原始内容存档于2019-10-08) (英语).
- ^ Khan, KM; Cook JL; Kannus P; Maffulli N; Bonar SF. Time to abandon the "tendinitis" myth : Painful, overuse tendon conditions have a non-inflammatory pathology. BMJ. 2002-03-16, 324 (7338): 626–7 [2019-11-30]. PMC 1122566 . PMID 11895810. doi:10.1136/bmj.324.7338.626. (原始内容存档于2008-07-04).
- ^ Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. Sep 2009, 37 (9): 1855–67. PMID 19188560. doi:10.1177/0363546508324283.
- ^ Nirschl RP, Ashman ES. Tennis elbow tendinosis (epicondylitis). Instr Course Lect. 2004, 53: 587–98. PMID 15116648.
- ^ FDA May 12, 2016 FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur (页面存档备份,存于互联网档案馆)
- ^ Stephenson, AL; Wu, W; Cortes, D; Rochon, PA. Tendon Injury and Fluoroquinolone Use: A Systematic Review.. Drug Safety. September 2013, 36 (9): 709–21. PMID 23888427. doi:10.1007/s40264-013-0089-8.
- ^ Bolon, Brad. Mini-Review: Toxic Tendinopathy. Toxicologic Pathology. 2017-01-01, 45 (7): 834–837. ISSN 1533-1601. PMID 28553748. doi:10.1177/0192623317711614.
- ^ Millar, NL; Murrell, GA; McInnes, IB. Inflammatory mechanisms in tendinopathy - towards translation.. Nature Reviews. Rheumatology. 25 January 2017, 13 (2): 110–122. PMID 28119539. doi:10.1038/nrrheum.2016.213.
- ^ Cook, JL; Rio, E; Purdam, CR; Docking, SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?. British Journal of Sports Medicine. October 2016, 50 (19): 1187–91. PMC 5118437 . PMID 27127294. doi:10.1136/bjsports-2015-095422.
- ^ Millar, Neal L.; Murrell, George A. C.; McInnes, Iain B. Inflammatory mechanisms in tendinopathy - towards translation. Nature Reviews. Rheumatology. 2017-01-25, 13 (2): 110–122. ISSN 1759-4804. PMID 28119539. doi:10.1038/nrrheum.2016.213.
- ^ Sun, Y-L; et al. Lubricin in Human Achilles Tendon: The Evidence of Intratendinous Sliding Motion and Shear Force in Achilles Tendon. J Orthop Res. 2015, 33 (6): 932–7. PMID 25864860. doi:10.1002/jor.22897.
- ^ Gaida JE, Ashe MC, Bass SL, Cook JL. Is adiposity an under-recognized risk factor for tendinopathy? A systematic review. Arthritis Rheum. 2009, 61 (6): 840–9. PMID 19479698. doi:10.1002/art.24518.
- ^ Charnoff, Jesse; Naqvi, Usker. Tendinosis (Tendinitis). StatPearls. Treasure Island (FL): StatPearls Publishing. 2017 [2019-12-20]. PMID 28846334. (原始内容存档于2021-03-09).
- ^ Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process.. Sports Med Arthrosc Rehabil Ther Technol. 2010, 2 ( ): 30. PMC 3006368 . PMID 21144004. doi:10.1186/1758-2555-2-30.
- ^ Abate M, Silbernagel KG, Siljeholm C, Di Iorio A, De Amicis D, Salini V, Werner S, Paganelli R. Pathogenesis of tendinopathies: inflammation or degeneration?. Arthritis Research & Therapy. 2009, 11 (3): 235. PMC 2714139 . PMID 19591655. doi:10.1186/ar2723.
- ^ du Toit, C; Stieler, M; Saunders, R; Bisset, L; Vicenzino, B. Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. British Journal of Sports Medicine. 2008, 42 (11): 572–576. ISSN 0306-3674. PMID 18308874. doi:10.1136/bjsm.2007.043901.
- ^ Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med. October 1992, 11 (4): 851–70. PMID 1423702.
- ^ Maffulli N, Ewen SW, Waterston SW, Reaper J, Barrass V. Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendons. An in vitro model of human tendon healing.. Am J Sports Med. 2000, 28 (4): 499–505. PMID 10921640. doi:10.1177/03635465000280040901.
- ^ Ho JO, Sawadkar P, Mudera V. A review on the use of cell therapy in the treatment of tendon disease and injuries.. J Tissue Eng. 2014, 5 ( ): 2041731414549678. PMC 4221986 . PMID 25383170. doi:10.1177/2041731414549678.
- ^ McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. J Ultrasound Med. October 2006, 25 (10): 1281–9. PMID 16998100. doi:10.7863/jum.2006.25.10.1281.
- ^ Zeisig, Eva; Öhberg, Lars; Alfredson, Håkan. Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study. Knee Surgery, Sports Traumatology, Arthroscopy. 2006, 14 (11): 1218–1224. ISSN 0942-2056. PMID 16960741. doi:10.1007/s00167-006-0156-0.
- ^ Pingel J, Lu Y, Starborg T, Fredberg U, Langberg H, Nedergaard A, et al. 3-D ultrastructure and collagen composition of healthy and overloaded human tendon: evidence of tenocyte and matrix buckling.. J Anat. 2014, 224 (5): 548–55. PMC 3981497 . PMID 24571576. doi:10.1111/joa.12164.
- ^ Duenwald S, Kobayashi H, Frisch K, Lakes R, Vanderby R. Ultrasound echo is related to stress and strain in tendon. J Biomech. February 2011, 44 (3): 424–9. PMC 3022962 . PMID 21030024. doi:10.1016/j.jbiomech.2010.09.033.
- ^ Duenwald-Kuehl S, Lakes R, Vanderby R. Strain-induced damage reduces echo intensity changes in tendon during loading. J Biomech. June 2012 , 45 (9): 1607–11. PMC 3358489 . PMID 22542220. doi:10.1016/j.jbiomech.2012.04.004.
- ^ Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann. Rheum. Dis. December 2009, 68 (12): 1843–9. PMC 2770107 . PMID 19054817. doi:10.1136/ard.2008.099572.
- ^ Mohamadi, A; Chan, JJ; Claessen, FM; Ring, D; Chen, NC. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis.. Clinical Orthopaedics and Related Research. January 2017, 475 (1): 232–243. PMC 5174041 . PMID 27469590. doi:10.1007/s11999-016-5002-1.
- ^ Dean, BJ; Lostis, E; Oakley, T; Rombach, I; Morrey, ME; Carr, AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon.. Seminars in Arthritis and Rheumatism. February 2014, 43 (4): 570–6. PMID 24074644. doi:10.1016/j.semarthrit.2013.08.006.
- ^ Kearney, RS; Parsons, N; Metcalfe, D; Costa, ML. Injection therapies for Achilles tendinopathy. (PDF). The Cochrane Database of Systematic Reviews. 26 May 2015, (5): CD010960 [2019-12-13]. PMID 26009861. doi:10.1002/14651858.CD010960.pub2. (原始内容存档 (PDF)于2018-07-22).
- ^ Moraes, Vinícius Y; Lenza, Mário; Tamaoki, Marcel Jun; Faloppa, Flávio; Belloti, João Carlos. Cochrane Database of Systematic Reviews. Cochrane Database Syst Rev. 2014-04-29, (4): CD010071. PMC 6464921 . PMID 24782334. doi:10.1002/14651858.cd010071.pub3.
- ^ McCormick A, Charlton J, Fleming D. Assessing health needs in primary care. Morbidity study from general practice provides another source of information. BMJ. Jun 1995, 310 (6993): 1534. PMC 2549904 . PMID 7787617. doi:10.1136/bmj.310.6993.1534d.
- ^ de Jonge S; et al. Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med. 2011, 45 (13): 1026–8 [2019-12-18]. PMID 21926076. doi:10.1136/bjsports-2011-090342. (原始内容存档于2019-06-24).
- ^ Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67:277-9
- ^ Littlewood, Chris; May, Stephen; Walters, Stephen. Epidemiology of rotator cuff tendinopathy: a systematic review. Shoulder & Elbow. 2013-10-01, 5 (4): 256–265. ISSN 1758-5740. doi:10.1111/sae.12028 (英语).
- ^ Inflammation. The Free Dictionary. [2019-12-19]. (原始内容存档于2019-11-01).
- ^ avascular. The Free Dictionary. [2019-12-19]. (原始内容存档于2019-12-19).
- ^ Rees, J. D.; Stride, M.; Scott, A. Tendons - time to revisit inflammation. British Journal of Sports Medicine. 2013, 48 (21): 1553–1557. ISSN 0306-3674. PMC 4215290 . PMID 23476034. doi:10.1136/bjsports-2012-091957.
- ^ Bass, Lmt. Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. International Journal of Therapeutic Massage & Bodywork: Research, Education, & Practice. 2012, 5. doi:10.3822/ijtmb.v5i1.153.
- ^ Maria Antonietta D'Agostino, MD; Ignazio Olivieri, MD. Enthesitis. Best Practice & Research Clinical Rheumatology (Clinical Rheumatology). June 2006, 20 (3): 473–86. doi:10.1016/j.berh.2006.03.007.
- ^ The Free Dictionary. Enthesitis. 2009 [2010-11-27]. (原始内容存档于2019-07-28).
- ^ Schett, G; Lories, RJ; D'Agostino, MA; Elewaut, D; Kirkham, B; Soriano, ER; McGonagle, D. Enthesitis: from pathophysiology to treatment. Nature Reviews Rheumatology (Review). November 2017, 13 (12): 731–41. PMID 29158573. doi:10.1038/nrrheum.2017.188.
- ^ Schmitt, SK. Reactive Arthritis. Infectious Disease Clinics of North America (Review). June 2017, 31 (2): 265–77. PMID 28292540. doi:10.1016/j.idc.2017.01.002.
- ^ OrthoKids - Osgood-Schlatter's Disease. [2019-12-19]. (原始内容存档于2019-03-07).
- ^ Sever's Disease. Kidshealth.org. [2014-04-29]. (原始内容存档于2016-01-31).
- ^ Hendrix CL. Calcaneal apophysitis (Sever disease). Clinics in Podiatric Medicine and Surgery. 2005, 22 (1): 55–62, vi. PMID 15555843. doi:10.1016/j.cpm.2004.08.011.
- ^ Murrell GA. Using nitric oxide to treat tendinopathy. Br J Sports Med. 2007, 41 (4): 227–31. PMC 2658939 . PMID 17289859. doi:10.1136/bjsm.2006.034447.
- ^ Rowe V, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Med. November 2012, 42 (11): 941–67. PMID 23006143. doi:10.2165/11635410-000000000-00000.
- ^ Koch TG, Berg LC, Betts DH. Current and future regenerative medicine - principles, concepts, and therapeutic use of stem cell therapy and tissue engineering in equine medicine.. Can Vet J. 2009, 50 (2): 155–65. PMC 2629419 . PMID 19412395.