ÕLAVALU FUNKTSONAALNE DIAGNOSTIKA

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1 ÕLAVALU FUNKTSONAALNE DIAGNOSTIKA Dr.TOOMAS TEIN SA TÜK Traumatoloogia-ortopeedia kliinik Erakliinik MEDEX 2012

2 Õlaliigese valu Õlavalu esineb 7 34 % rahvastikust (21 % > 70 a.) % läheb perearsti juurde 5 % perearsti poole pöördumistest (1a.) % paraneb konservatiivse raviga (1a.) Peters et all, 1994 Van der Windt et all, 1996 Smidt and Green, 2001

3 Õlaliigese valu Peamised põhjused Subakromiaalruumi kiildumise sündroom Rotaatormanseti rebend / lubikolle Liigese jäikus (kontraktuur) Ebastabiilsus Osteoartroos GH või AC liigeses

4 Õlavöötme lihased " Skapulohumeraalsed 5 " Skapulotorakaalsed 7 " Rotaatormansett 4 17

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6 Diagnoos Anamnees Objektiivne leid ~ 90% Rö UH MRI

7 Anamnees Valu liigutustel peale liigutusi rahuloleku (öine) Liikumispiiratus (kontraktuur)

8 Anamnees VALU õlaliigese peal õlaliigese küljel õlavarres,käes kael rotaatorite mansett A/C liidus

9 Objektiivne uurimine Anterior Lateral Posterior Palpatsioon rangluu-abaluu liidus suur köber processus coracoideus kakspealihase kõõlused subakromiaalne ruum

10 Objektiivne uurimine " Liikuvus Normaalne Abaluu liikuvus Passiivne Aktiivne

11 Normaalne liikuvus ekstensioon / flektsioon abduktsioon / adduktsioon välis- / siserotatsioon 40(60)

12 Abaluu normaalne liikumine

13 Õlaliigese valu dif. diagnostika Kaela spondüloartroos (C4, C5) Müofastsiaalsed valud Depressioon Subdiafragmaalne protsess N.suprascapularise pitsumine (ext.rotaatorite puudulikkus,atroofia) Kopsu/mediastiinumi kasvaja TOS - sündroom Lateraalne epikondüliit Karpaalkanali sündroom

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16 Õlaliigese radioloogiline diagnostika Rö norm distantsid 7-8mm

17 Õlaliigese radioloogiline diagnostika " Acromioni anatoomia

18 Õlaliigese radioloogiline diagnostika Kaltsifitseeruv tendiniit

19 Osteoartroos

20 Õlaliigese radioloogiline diagnostika " Õlga kiirguv valu 34 a. Meespatsient Dgn: Lümfogranulomatoos

21 Õlaliigese patoloogia ja ravi Kontraktuur ABD; ER; SR külmunud õlg (1934. Godman) võimlemine redressioon

22 Õlaliigese patoloogia ja ravi " Kontraktuur postraumaatiline " võimlemine " redressioon An abduction contracture of the left shoulder with winging of the scapula An extension contracture of the left shoulder, dimpling of the skin (arrowhead), and anterosuperior subluxation of the humeral head J Bone Joint Surg Am, Volume 80-A(2).February

23

24 Tendinitis calcarea Ravi põhimõtted koormuse piiramine valuvaigistid / süsteravi füsioteraapia / õlaliigese harjutused lubikolde transkutaanne purustamine lubikolde kirurgiline eemaldamine

25 Rotaatormanseti rebend Instrumentaalsed uuringud UH Kaltsifitseeruv tendiniit

26 Õlaliigese patoloogia ja ravi Tendiniidid kakspealihas m.supraspinatus m.deltoideus medikamentoosne ravi süsteravi operatiivne ravi

27 Õlaliigese patoloogia ja ravi Artroos rangluu-abaluu liidus süsteravi operatiivne ravi

28 Impingement sündroom

29 Õlavalu testid (Godman 1934)

30 Pitsumissündroomid Pitsumisest tingitud õlavalu Primaarne: subakromiaalruumi ahenemine (3 tüüpi akromion,akromioklavikalaar artroos,pehmete kudede turse ) Sekundaarne: pole struktruraalseid muutusi,pigem eri asenditest tingitud

31 Pitsumissündroomi põhjused Väline (subakromiaalne) pitsumine: pehmete kudede (bursa,kõõlus) mehhaaniline pitsumine subakromiaalses ruumis õlaliigese abduktsioonil painful arc Sisemine pitsumine : rotaatormanseti pitsumine õlavarreluu ja glenoidi vahele anterosuperioorne (esineb väga harva) posterosuperioorne (rotaatormanseti kõõluste, SSP ja ISP,tub.majuse ja glenoidi post-sup.serva vastu

32 Pitsumisest tingitud õlavalu testid Jobe + Neer + ant Hawkins + apprehension + (pain) ant Väline (subakromiaalne pitsumine) Pitsumis sümptomid Jobe - Neer + post Hawkins - apprehension + (pain) post Seesmine( posteriosuperior glenoid pitsumine) Relocation - Relocation + release + (pain) Relocation + release + (pain) PRIMAARNE PITSUMINE Sekundaarne pitsumine Full can + SAT + SRT + Laxity tests + apprehension + (appr) relocation + (appr) O Brien + Speed s + biceps load II + IR ROM Rotaatorite patoloogia abaluu düskinees Ebastabiilsus Biceps-SLAP patoloogia GIRD

33 Pitsumistest (Jobe) empty can Mõlemad õlaliigesed 90*elevatsioonis ja maksimaalses siserotatsioonis ning vastupanu käe tõstmisele -- positiivne subakromiaal pitsumise korral negatiivne post.sup. pitsumise korral

34 Pitsumistest (Hawkins) Passiivne siserotatsioon õlaliigese 90* eesmises painutuses Positiivne valu subakromiaalse pitsumise korral, negatiivne näitab seesmist pitsumist

35 Pitsumistest (Neer) Fikseeritud abaluu korra õlaliigese maksimaalne flektsioon Subakromiaalse(mehhaaniline) pitsumise korral valu liigese eesosas

36 Apprehensiontest kartus (provokatsioon) ebastabiisus Horisontaalses abduktsioonis passiivne välisrotsioon(valu liigese ees viitab subakromiaalsele pitsumisele või valu liigese taga viitab posterosuperioorsele pitsumisele)

37 Relocation test (ebastabiilsus) Horisontaalses abduktsioonis passiivses välisrotsioonis suruda õlavarreluu dorsaasele Positiivne kui valu kaob st.et valu on teisene ja põhjustatud õlavarreluu pea eesmisest asendist. Negatiivse testi esinemine viitab primaarsele pitsumisele mitte aga liigese kinemaatikale

38 Rotaatorite vigastuse testid Full-can test( modified Jobe test) Mõlemad õlaliigesed 90*elevatsioonis ja maksimaalses VÄLISrotatsioonis ning vastupanu käe tõstmisele --kui mõlemad testid on positiivsed rotaatorite patoloogia Kui ainult empty-can ++ ja full-can --tõenäoliselt pitsumine,mitte kõõluse vigastus

39 Abaluu testid:srt (Scapula Retraction Test) empty can test+küünarvarre abil fikseeritud abaluu mediaalne serv Positiivne kui esialgne valu taandub (näitab abaluu stabiilsust)

40 Abaluu testid:sat (Scapular Assitance Test) Hinnatakse abaluu liikuvuse kvaliteeti valu vähenemine abaluu fikseerimisel Näitab abaluu kaasatust õlavalu korral

41 Ebastabiilsuse testid (lõtvus) load and shift test Õlavarreluu pea surutakse abaluu vastu ja ette: 1-3 lõtvusaste(3 astesublukstsioon ilma spontaanse reponeeumiseta)

42 Ebastabiilsuse testid (lõtvus) sulcus sign Käe tõmme allapoole

43 Ebastabiilsuse testid (lõtvus) posterior subluxation test Käsi abduktsioonis,siserotatsioonis ja 70-90* flektsioonis Positiivne kui tunda klõps -tagumine subluksatsioon

44 Biitsepsi patoloogia(slap) the Speeds test Õlaliiges 90* flektsioonis,küünarvars sirutuses ja supinatsioonis Positiivne kui valu bicepsi piikonnas

45 Vastupanutest kui käsi 90* flektsioonis ja10 *adduktsioonis+-pöial alla üles SLAP vigastuse kahtlus kui provokatsioonivalu väheneb teisel testil. Biitsepsi patoloogia (SLAP) O`Brien test

46 Biitsepsi patoloogia (SLAP) Biceps load test Positiivne kui valu küünarvarre tõstmisel (vastupanu)

47 GIRD-siserotatsiooni hindamine Abaluu fikseeritud vastu lauda ning käsi 90* abduktsioonis Positiivne kui erinevus üle 20*

48 Pitsumisest tingitud õlavalu testid Jobe + Neer + ant Hawkins + apprehension + (pain) ant Väline (subakromiaalne pitsumine) Pitsumis sümptomid Jobe - Neer + post Hawkins - apprehension + (pain) post Seesmine( posteriosuperior glenoid pitsumine) Relocation - Relocation + release + (pain) Relocation + release + (pain) PRIMAARNE PITSUMINE Sekundaarne pitsumine Full can + SAT + SRT + Laxity tests + apprehension + (appr) relocation + (appr) O Brien + Speed s + biceps load II + IR ROM Rotaatorite patoloogia abaluu düskinees Ebastabiilsus Biceps-SLAP patoloogia GIRD

49 Impingement sündroom Ravi põhimõtted valu provotseerivate koormuste vältimine valuvaigistid / süsteravi õlaliigese harjutused kirurgiline subakromiaalruumi ja rotaatormanseti taastamine

50 Taastusravi põhimõtted 1. Passiivse liikuvuse saavutamine ( FIKSEERIDA ABALUU!!!!) 2. Aktiivse liikuvuse taastamine 3. Lihaste tugevdamine ja funktsiooni tasakaalustamine

51 AITÄH TÄNAN KUULAMAST

52 Objektiivne uurimine - testid Inferior hyperlaxity (the sulcus sign) Walch: J Bone Joint Surg Br, Volume 78-B(4).July

53 Objektiivne uurimine - testid The drawer test (Rockwood 1984) Walch: J Bone Joint Surg Br, Volume 78-B(4).July

54 Objektiivne uurimine - testid The drawer test (Rodineau et al 1980) Walch: J Bone Joint Surg Br, Volume 78-B(4).July

55 Objektiivne uurimine - testid The relocation test (Jobe et al 1990) Walch: J Bone Joint Surg Br, Volume 78-B(4).July

56 M. biceps brachii tendiniit Rotaatormanseti rebend

57 M. supraspinatuse rebend

58

59 Õlaliigese kontraktuur redressioon / süsteravi õlaliigese liikuvuse säilitamine valuvaigistid

60 Pitsumisest tingitud õlavalu testid

61 Pitsumisest tingitud õlavalu testid Jobe + Neer + ant Hawkins + apprehension + (pain) ant External subacromial impingement Impingement symptoms Jobe - Neer + post Hawkins - apprehension + (pain) post Internal posteriosuperior glenoid impingement Relocation - Relocation + release + (pain) Relocation + release + (pain) Primary impingement Secondary impingement Full can + SAT + SRT + Laxity tests + apprehension + (appr) relocation + (appr) O Brien + Speed s + biceps load II + IR ROM Rotator cuff pathology Scapular dyskinesis Instability Biceps-SLAP pathology GIRD

62 Pitsumisest tingitud õlavalu testid Jobe + Neer + ant Hawkins + apprehension + (pain) ant External subacromial impingement Impingement symptoms Relocation - Primary impingement Full can + Rotator cuff pathology

63 Pitsumisest tingitud õlavalu testid Impingement symptoms External subacromial impingement Secondary impingement SAT + SRT + Scapular dyskinesis

64 Pitsumisest tingitud õlavalu testid Jobe + Neer + ant Hawkins + apprehension + (pain) ant External subacromial impingement Impingement symptoms Relocation + release + (pain) Secondary impingement Instability Laxity tests + apprehension + (appr) relocation + (appr)

65 Pitsumisest tingitud õlavalu testid Jobe + Neer + ant Hawkins + apprehension + (pain) ant External subacromial impingement Impingement symptoms Relocation + release + (pain) Secondary impingement Biceps-SLAP pathology O Brien + Speed s + biceps load II +

66 Pitsumisest tingitud õlavalu testid Jobe + Neer + ant Hawkins + apprehension + (pain) ant External subacromial impingement Impingement symptoms Jobe - Neer + post Hawkins - apprehension + (pain) post Internal posteriosuperior glenoid impingement Relocation - Relocation + release + (pain) Relocation + release + (pain) Primary impingement Secondary impingement Full can + SAT + SRT + Laxity tests + apprehension + (appr) relocation + (appr) O Brien + Speed s + biceps load II + IR ROM Rotator cuff pathology Scapular dyskinesis Instability Biceps-SLAP pathology GIRD

67 Pitsumisest tingitud õlavalu testid

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