本日は、肩痛について。

2008 Feb 15;77(4):453-60.

Chronic shoulder pain: part I. Evaluation and diagnosis.

Burbank KM¹, Stevenson JH, Czarnecki GR, Dorfman J.

肩痛は筋骨格系疾患の約16％を占める。

6か月以上続く方の痛みは、慢性の肩痛

こうした状態を起こす疾患の一般的なものに、

回旋筋腱板障害、癒着性関節包炎、肩の不安定性、肩関節炎などがある。

慢性の肩痛の病歴や身体所見について。

これらの肩痛を起こす病歴；

Table 1

History Findings and Associated Shoulder Disorders

HISTORY

ASSOCIATED CONDITION

年齢5 、6 、7	40歳未満：不安定、回旋腱板腱障害
年齢5 、6 、7	40歳以上：回旋腱板裂傷、癒着性関節包炎、肩甲上腕骨変形性関節症
糖尿病や甲状腺疾患8 、9	接着性嚢炎
外傷の既往	40歳未満の場合：肩脱臼/亜脱臼
外傷の既往	40歳以上の場合：腱板断裂
可動域の低下	癒着性関節包炎、肩甲上腕骨変形性関節症
夜間痛	腱板障害、癒着性嚢炎
しびれ、うずき、肘を越えて広がる痛み	頸部の病因
痛みの場所	肩鎖関節病変に関連する前上肩痛
痛みの場所	腱板障害、癒着性関節包炎、または肩甲上腕骨変形性関節症に関連する三角筋領域のびまん性肩痛
頭上活動の痛み10	腱板障害
スポーツ参加11	オーバーヘッドスポーツ（野球、ソフトボール、テニスなど）、および衝突スポーツ（サッカー、ホッケーなど）に関連する肩の不安定性
スポーツ参加11	重量挙げに関連する肩鎖関節の病理
筋力低下	腱板障害、肩甲上腕骨変形性関節症

身体所見；

Table 2

Selected Tests of the Shoulder

EXAMINATION MANEUVER	ASSOCIATED CONDITION	SENSITIVITY (%)	SPECIFICITY (%)	LR+	LR−
Inspection
Supraspinatus or infraspinatus atrophy10	Chronic rotator cuff tear	56	73	2.07	0.60
Palpation
Acromioclavicular tenderness16	Acromioclavicular joint OA or chronic sprain	96	10	1.07	0.4
Range of motion
Restrictive active10	Rotator cuff disorder	30	78	1.36	0.90
Provocative tests
Hawkins' impingement15	Impingement/rotator cuff disorder	72	66	2.1	0.42
Drop-arm15	Large rotator cuff tear	27	88	2.25	0.83
Empty-can supraspinatus15	Rotator cuff disorder involving supraspinatus	44	90	4.4	0.62
Lift-off subscapularis17	Rotator cuff disorder involving subscapularis	62	100	> 25	0.38
External rotation/infraspinatus strength15	Rotator cuff disorder involving infraspinatus	42	90	4.2	0.64
Cross-body adduction18	Acromioclavicular joint OA or chronic sprain	77	79	3.50	0.29
Apprehension19	Glenohumeral instability	72	96	20.22	0.29
Relocation19	Glenohumeral instability	81	92	10.35	0.2

LR+ = positive likelihood ratio; LR- = negative likelihood ratio; OA = osteoarthritis.

note: The recommended progression of shoulder examination maneuvers is inspection, palpation, range of motion and strength tests, and provocative tests.

Information from references 10 and 15 through 19.

押さえておきたいテスト；

ホーキンステスト~Impingement/rotator cuff disorder、感度72％、特異度66％、LR＋2.1、LR-0.42

Figures 1a and 1b.

Hawkins' Impingement Test. Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. The arm is then internally rotated. A positive test, noted by pain on internal rotation, may signify subacromial impingement including rotator cuff tendinopathy or tear.

ドロップアーム回旋腱板テスト～Large rotator cuff tear、感度27％、特異度88％、LR＋2.25、LR－0.83

Figures 2a and 2b.

Drop-Arm Rotator Cuff Test. The arm is passively raised to 160 degrees. The patient is then asked to slowly lower the arm to the side. A positive test, noted by an inability to control the lowering phase and a dropping or giving way of the arm, may indicate a large rotator cuff tear.

エンプティーキャン　棘上筋テスト～Rotator cuff disorder involving supraspinatus、感度44％、特異度90％、LR＋4.4、LR-0.62

Figure 3.

Empty-Can Supraspinatus Test. The arms are abducted to 90 degrees and forward flexed 30 degrees. With the thumbs turned downward, the patient actively resists a downward force applied by the examiner. A positive test is indicated by weakness compared with the contralateral side and may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.

リフトオフ肩甲テスト～Rotator cuff disorder involving subscapularis、感度62％、特異度100％、LR＋> 25、LR-0.38

Figure 4.

Lift-Off Subscapularis Test. With the arm internally rotated behind the patient's lower back, the patient internally rotates against the examiner's hand. A positive test is indicated by the inability to lift the hand off of the back and may indicate subscapularis tendinopathy or tear.

外転テスト～Rotator cuff disorder involving infraspinatus、感度42％、特異度90％、LR＋4.2、LR-0.64

Figure 5.

External Rotation/Infraspinatus Strength Test. The patient's arms are held at their sides with the elbows flexed to 90 degrees. The patient actively externally rotates against resistance. A positive test is indicated by weakness compared with the contralateral side and may be associated with infraspinatus or teres minor tendinopathy or tear.

クロスボディ内転テスト～Acromioclavicular joint OA or chronic sprain、感度77％、特異度79％、LR＋3.50、LR-0.29

Figure 6.

Cross-Body Adduction Test. The arm is passively adducted across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology, including chronic sprain or osteoarthritis.

Apprehension and Relocation Tests～Glenohumeral instability、感度72％、特異度96％、LR＋20.22、LR-0.29

Figure 7.

Apprehension and Relocation Tests. With the patient supine, the patient's arm is abducted to 90 degrees and the elbow is flexed to 90 degrees. Pain and a sense of instability with further external rotation may indicate shoulder instability. Relief of these symptoms with a posteriorly directed force on the proximal humerus is a positive relocation test and further supports diagnosis of shoulder instability.

画像検査の精度；

特異度は身体所見とあまり変わりませんが、感度が画像検査の方が高い。

身体所見のみで否定することは難しいけど、画像検査は否定したいときに使うといいのだと思います。

Table 3

Imaging Tests for Rotator Cuff Tears

IMAGING TEST	FINDING	SENSITIVITY (%)	SPECIFICITY (%)	LR+	LR−
MRI	Any rotator cuff tear	83	86	4.85	0.22
	Partial thickness rotator cuff tear	44	90	3.99	0.66
	Full thickness rotator cuff tear	89	93	10.63	0.16
Ultrasonography	Any rotator cuff tear	80	85	5.09	0.27
	Partial thickness rotator cuff tear	67	94	8.90	0.36
	Full thickness rotator cuff tear	97	96	13.16	0.16