 肩袖损伤越来越常见，发病率最高占到肩关节疾患的 41%！只有充分了解肩袖损伤，才能针对性地进行治疗。  肩袖解剖 肩袖亦称旋转袖，是由附着于大结节上的冈上肌、冈下肌、小圆肌和附着于小结节上的肩胛下肌组成，起于肩胛骨、附着于肱骨头周围，在肱骨头解剖颈处形成袖套状结构，肩袖上方为喙肩弓，其间有肩峰下滑囊相隔。   肩袖的作用 1、组成肩袖的肌群，为肩关节的活动提供力矩： 冈上肌是肩关节外展的两个主要动力肌之一; 肩胛下肌同冈下肌是肩关节内、外旋的主要动力肌。  2、肩袖是肩关节重要的稳定结构： 肩袖功能是在上臂外展过程中，冈上肌、冈下肌与肩胛下肌协同收缩提供张力，将肱骨头压在肩胛盂上，肩袖断裂将减弱甚至丧失这一功能，而严重影响上肢外展功能。  肩袖的净下向和压缩力向量（双头箭头）与三角肌的净上向力向量（单头箭头）相平衡。 3、支持和稳定肩肱关节，维持肩关节腔的密闭功能、保持滑液营养关节骨，预防继发性骨关节炎。  肩袖肌肉（单头箭头）提供关节稳定性和关节盂中央肱骨头 病因 1、退行性变 随着年龄的增长肩袖供血不足，引起肩袖组织退行性变，提拉重物、过度活动、甚至轻微受力都可导致肩袖损伤。 2、间接暴力 创伤是青少年肩袖断裂的主要原因，当跌倒时手外展着地，或手持重物，肩关节突然外展上举或扭伤而引起。外力越大，肩袖断裂越严重。 3、肩部慢性撞击性损伤 当肩关节在做前屈及外展运动时，肩峰前缘及喙肩韧带与肱骨大结节发生撞击，引发肩峰下滑囊炎症，发生肩袖撕裂。  长期从事过顶运动如举重、投掷、划船、橄榄球、足球、游等人群更容易发生肩峰下撞击综合征，从而导致肩袖损伤。相关研究认为 95% 肩袖损伤是长期肩部撞击、磨损的结果。临床上约 50% 肩袖损伤病人无明显外伤史。 分类 1、根据损伤程度分型 1.1、肩袖部分损伤： 组成肩袖的肌腱出现损伤，但是为部分撕裂，未出现完全断裂的情况。  1.2、肩袖完全损伤：
 肩袖完全断裂的四种类型及形成机制：  A、横行断裂，反复损伤和肌肉痉挛可使一端发生纵裂；B、继而发生三角形断裂；C、以后形成半月形断裂；D、最后成为大块或完全断裂。 2、根据肩袖断裂大小分为四种类型： ③3 ~ 5 cm 为大撕裂； ④> 5 cm 为巨大撕裂。 3、根据病理类型分为 4 类： ③肩袖组织内部平裂成几层； ④肩袖组织内部的纵行破裂。 肩袖滑囊面断裂者可穿破肩峰下滑囊而产生肩峰下疼痛弧综合征。 临床表现 1、多见于 40 岁以上病人，特别是重体力劳动者。 2、肩关节疼痛： 是肩袖损伤的早期主要症状，尤其是肩外侧，初期呈间歇性，在劳作后及夜间卧向患侧症状加重，休息后减轻。 患者典型疼痛特点为夜间痛、背手痛及「痛弧」。
部分肩袖撕裂时，患臂外展上举 60° ～ 120° 范围疼痛加重。 3、肩关节功能障碍： 肩袖损伤患者最常见的活动障碍为肩关节外展受限，部分患者在日常生活中可感到不适，甚至无法进行梳头、手臂举过头顶等动作。 冈上肌、冈下肌和三角肌萎缩。肩峰前下方与大结节之间的间隙压痛。 4、活动性杂音： 活动时可听到或触及砾轧音，明显的砾轧音多见于撞击征三期，尤其是完全性肩袖撕裂伤者。 5、撞击试验： 肱骨大结节与肩峰撞击出现疼痛，但可使肩部痛症状得到暂时性完全消失。 辅助检查 1、X 线检查 慢性肩袖疾患的 X 线特征是肩关节间隙变窄，肱骨头及大结节、肩峰甚至肩锁关节发生退行性改变。 2、肩关节造影 肩关节造影是诊断肩袖撕裂的重要方法。双重对比造影对于全层肩袖破损准确率为 90%。 肩关节造影若见肩峰下滑囊与关节腔相通，则证实肩袖已完全断裂。此操作为有创操作不作为常规检查。 3、MRI 检查 能显示肩袖损伤的程度、大小和残余肩袖组织的情况（敏感性为 100%，特异性 95%）。 4、B 超检查 可显示肩袖断裂，是诊断肩袖损伤的检查方法之一。 5、关节镜检查 不仅可以作为肩袖治疗手段，也可以早期发现肩袖损伤。 6、早期肩袖损伤者，因肩部疼痛使病人不敢活动上肢，此时可行下述检查以资区别。 ①普鲁卡因封闭试验： 用 1% 普鲁卡因 10 mL 封闭压痛点，麻醉后若病人可以主动外展肩关节，表明肩袖未撕裂或仅为部分断裂。 若封闭后，肩关节仍不能主动外展，则表明肩袖严重撕裂或完全断裂。 ②上臂下垂试验： 将患侧上臂被动外展至 90°，如不加以支持，患肢仍能保持这一位置，表示肩袖无严重损伤；如不能维持被动外展位置，则表明肩袖严重撕裂或完全断裂。 作者：孙小六；排版：景胜杰 插图：文末文献 投稿：jingshengjie@dxy.cn 参考文献（特别特别多） 1.Deydre S. Teyhen, PT, PhD, Editor, and Jeanne Robertson, Illustrator.(2020). Painful Shoulder: Exercise Can Reduce Pain and Improve Mobility and Function. 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