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胸大肌撕裂

A chest-muscle tear, classically during a heavy bench press — how to recognise it and why complete tears are usually repaired early.

举重运动员进行卧推时,疼痛位于腋窝前部胸肌附着处。
胸大肌撕裂:胸部肌肉在附着于手臂的部位附近发生撕裂,典型情况发生在进行大重量卧推时。 Kieran Hirpara 4.0

本页面由机器翻译,尚未经临床医生审核。英文版本为权威版本。

您的感受

大多数人能准确回忆起那一瞬间。这种情况通常发生在进行大重量卧推时,当杠铃正下放至胸部时,肩部前方突然出现“啪”的一声或撕裂感,并伴有剧烈的疼痛。在一两天内,瘀青会蔓延至手臂前侧和胸部,该区域会出现肿胀。

随着肿胀消退,您可能会注意到胸部的形态发生了变化。腋窝前方正常的坚实褶皱可能变平或消失,肌肉本身可能向胸骨方向聚拢,看起来或感觉起来与另一侧不同。推的动作感觉无力:关上一扇沉重的门、从椅子上撑起身体,或将手臂横过身体进行拥抱,都不再具有往常的力量。早期的一些无力感可能仅仅是由于疼痛,但真正的推举力量丧失往往会持续存在。

实际发生了什么

胸大肌是胸部一块呈扇形的大型肌肉。它通过三种主要方式为手臂提供动力:推离身体的动作、将手臂环抱于胸前的动作,以及手臂内旋的动作。该肌肉逐渐变窄,形成一条强健的肌腱,锚定在上臂骨(肱骨)上,靠近肩部。

撕裂是指该肌-腱单位的断裂,最常发生在肌腱附着于骨骼处或其附近。常见原因是肌肉在强力收缩时突然受到剧烈拉伸(正如卧推底部放下重量时发生的情况)。这种情况在男性中更为常见,尤其是活跃的举重训练者,且合成类固醇的使用是一个公认的风险因素,因为它可能削弱肌腱。

撕裂程度各异。完全撕裂会使肌腱完全脱离骨骼,这会导致胸部形态的明显改变和最大的力量丧失。部分撕裂,或撕裂发生在肌腹内部而非肌腱处,会保留更多的附着结构。您所患的类型对于最佳治疗方案的选择至关重要。

我们能采取的措施

在我们的诊所,Kieran Hirpara 医生主导针对此损伤的评估,首先通过详细的病史采集和体格检查以确诊。对于活跃人群的完全撕裂,通常建议尽早进行修复,而不是先尝试非手术治疗;部分撕裂则通常无需手术即可处理。

第一步是准确确定撕裂的具体部位和位置。这通过检查肩部并借助 MRI 扫描 来确认,该扫描可显示撕裂是部分性还是完全性,并精确定位是肌腱从骨上撕脱还是肌肉内部撕裂。

对于活动量较大且存在肌腱完全撕裂的患者,通常建议进行手术将肌腱重新附着于骨骼。修复可恢复推举力量并重建胸部的正常轮廓,且证据一致表明,修复后的肌腱比自行愈合的撕裂能恢复更多的力量。此处最重要的单一因素是 时机:在早期进行修复效果最佳,理想情况下应在最初几周内进行,此时肌腱仍保持健康,尚未发生瘢痕化或回缩。这正是值得及时接受评估而非等待观察其自行稳定的主要原因。

部分撕裂、肌肉腹内撕裂以及年龄较大或体力需求较低的人群,通常无需手术即可获得良好的管理效果:先经历一段休息期,随后进行分级康复计划以重建活动度和力量。这种途径可恢复良好的日常功能,但与修复后的完全撕裂相比,通常仍会保留一定程度的峰值推举力量损失。如果完全撕裂未能早期发现,较晚的修复仍有可能进行,但手术要求更高且结果可靠性较低,这正是早期评估至关重要的原因。

预期情况

如果您接受手术,恢复期以月而非周计算。修复部位最初受到保护,通常需佩戴吊带约六周,并仅进行温和的引导性活动,以使肌腱牢固地重新附着于骨骼。此后逐步引入强化训练,并刻意推迟较大负荷的训练;推举练习和卧推通常在六至九个月内被禁止。大多数人约六周即可恢复日常活动,四至六个月可恢复更全面的运动或训练,力量在术后一年内仍会持续改善。

这种耐心的回报是显著的:大多数接受早期修复手术的患者恢复了强大的推举力量、胸廓形态以及他们重视的活动能力。未接受手术而接受保守治疗的患者通常也能恢复稳固的日常功能,但需接受峰值力量略有下降。无论采取哪种方式,坚持康复计划且不急于进行大重量推举,都是保护治疗效果的关键。

何时就医

  • 在提举重物或用力时,胸部或肩部前侧突然出现“啪”的一声或撕裂感:应尽快进行评估,因为早期修复可获得最佳手术效果。
  • 瘀斑沿手臂或胸部蔓延、明显肿胀,或胸部外形可见改变或腋窝前皱襞形态改变。
  • 初始疼痛消退后,在推压动作或将手臂横过身体时仍出现持续无力。
  • 任何不确定严重程度的撕裂伤:早期影像学检查可区分部分撕裂与完全撕裂,该决策具有时间敏感性。

深入探讨

Advanced reading: the deeper science (optional)

本节内容超出了您自身治疗决策所需的范围。胸大肌撕裂值得额外阅读,因为它是本网站上少数几个手术疗效明确优于非手术治疗的案例之一,且其并发症率之高,足以与手术获益并列提及,而非仅作为后续补充。

修复术优于非手术治疗

在 664 例患者中,胸大肌腱修复术的结果显著优于非手术治疗,在功能结局、等速肌力和等长肌力方面均有统计学意义的改善,且相关并发症发生率为 14.21% [1]。

这两部分属于同一句话。这是一种能够恢复可测量肌力的修复术,而非手术治疗无法做到这一点,且大约每七名患者中就有一人出现并发症。对于该部位的大多数肌腱损伤而言,手术优势较小且并发症发生率较低;而在此处,两者均较大。

肌力缺损之所以重要,是因为该肌肉的功能。胸大肌驱动水平内收和内旋,执行推压动作,将手臂横过身体。未修复的撕裂通常会导致可见畸形和推压力量的特定丧失,这就是为什么该损伤集中发生于举重者,且对他们最为重要。

撕裂部位决定可采取的治疗措施

并非所有胸大肌撕裂都属于同一种损伤。一种当代分类体系纳入了损伤时机、损伤部位以及用于描述撕裂范围的标准术语,该体系专门旨在反映肌腱解剖结构,从而更好地指导外科治疗 [2]。

实际区分在于:位于肱骨附着点的肌腱撕裂,可通过重新固定于骨骼获得良好修复;而位于肌腹内部的撕裂,由于缺乏可供锚定的肌腱,通常采用非手术治疗。介于两者之间的是肌腱连接部,这是处理难度较大的一组。

时机的重要性与其他部位相同:撕裂的肌腱会发生回缩和瘢痕化,因此慢性撕裂可能需要移植而非直接修复。

为何早期诊断常被遗漏

受伤后即刻,胸部及上臂广泛的瘀斑和肿胀主导了外观,掩盖了轮廓的改变。随着肿胀消退,特征性体征——前腋窝皱襞消失、抗阻按压时肌肉不对称以及可触及的缺损——变得更为清晰,但此时损伤可能已被标记为拉伤。

鉴于急性期修复更为直接,重压时出现明显的“啪”声并随后出现瘀斑,值得进行影像学检查,而非仅观察。

参考文献

[1] Bodendorfer BM, McCormick BP, Wang DX, Looney AM, Conroy CM, Fryar CM, et al. 胸大肌腱撕裂的治疗:关于修复时机和固定方法的系统综述与荟萃分析。Orthop J Sports Med. 2020;8(2). https://doi.org/10.1177/2325967119900813

[2] ElMaraghy AW, Devereaux MW. 胸大肌撕裂的系统综述与综合分类。J Shoulder Elbow Surg. 2012;21(3):412-22. https://doi.org/10.1016/j.jse.2011.04.035


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