臺灣博碩士論文加值系統

　　研究背景與目的•膝痛挾其高盛行率與低治癒率，始終是個擾人的話題。其中常見的前側膝痛更高居特發性不明原因膝痛之冠，至今有關其成因之探討不勝枚舉，然而卻眾說紛紜。許多研究認為股四頭肌角度異常為前側膝痛之主要成因，然而前側膝痛很可能是多因子疾患，其成因不應僅侷限於額狀面異常。近年來膝旋轉結構異常逐漸被認為是造成久治不癒的前側膝痛之主因，然而有關膝旋轉角度異常的界定與成因至今仍不甚明朗，相關研究尚在起步階段。另一方面，膕肌因其特殊之解剖位置除了是主要之膝內旋肌外，對於膝關節穩定度之貢獻亦不容小覷，例如在日常活動中常見的步行與或剪步急停動作中，即扮演不可或缺的角色。而籃球選手等經常從事剪步急停動作的人正是特發性前側膝痛的高危險群，不免令人懷疑是否膕肌過度使用正是致痛主因。倘若如此，這些膝痛高危險群必然已有些人呈現膝旋轉異常的相關特徵。因此，本研究目的將針對膝關節局部壓痛閾值、下肢結構、膝旋轉活動度、膝部肌力以及步行與剪步急停動作過程中，膝部肌肉活動情形以了解無膝痛籃球選手相對於非籃球選手或有膝痛籃球選手是否有差異。研究方法•本研究共延攬14位籃球校隊(有膝痛與無膝痛組各7位)與12位無固定運動習慣之健康對照組，進行基本資料、日常活動量紀錄、膝關節功能評估、膝關節局部壓痛閾值、下肢結構、膝旋轉活動度、膝部肌力以及步行與剪步急停動作過程中，膝部肌肉活動之測量。之後以單因子變異數分析檢測除肌肉活動訊號以外之測量參數的組間差異。至於與肌肉活動相關的測量參數則以克─瓦氏單因子變異數分析進行組間之比較。關於各組慣用腳與非慣用腳間之比較則以配對樣本t考驗進行分析。結果• 本研究結果顯示籃球組之日常活動量顯著高於對照組(p < 0.05)，膝關節局部壓痛閾值則未呈現顯著組間差異。至於下肢結構，於股四頭肌角度並未呈現顯著之組間差異，而有關膝旋轉角度方面，則於籃球組之急停腳顯著小於其非急停腳(p < 0.05)。就膝旋轉活動度而言，不論在組間或兩腳間均未呈現顯著差異。至於膝部肌力之比較，就膝屈肌與膝伸肌而言，無膝痛籃球組不論於急停腳或非急停腳均顯著強於對照組(p < 0.05)；而急停腳之膝內旋肌肌力(測試姿勢膝屈曲30度)亦呈現顯著的組間差異，無膝痛籃球組顯著大於有膝痛籃球組以及非籃球對照組(p < 0.05)。而就兩腳間之比較而言，無膝痛籃球組呈現慣用腳膝屈肌顯著大於非慣用腳的現象(p < 0.05)；有趣的是，其膝內旋肌肌力竟然反而呈現急停腳(非慣用腳)顯著大於非急停腳的現象(p < 0.05)。至於動態肌電訊號方面，不論於步行或剪步急停動作過程中，顯著的組間差異主要均呈現於股外側肌之肌肉活動。討論與結論•籃球組經過長期剪步急停訓練，已呈現膕肌過度使用而短縮的相關徵狀。雖然此現象基於運動愛好者產生耐痛力提高傾向而無法於膕肌之壓痛閾值測量結果得到證實，然而籃球組急停腳之膝旋轉角度檢測結果卻已呈現顯著膝內旋之結構。有關膝部肌力方面，無膝痛籃球組之膝屈肌與膝伸肌肌力顯著大於對照組，其慣用腳之膝屈肌與膝伸肌肌力亦普遍大於非慣用腳；相反的，籃球組膝內旋肌肌力卻呈現非慣用腳(急停腳)大於慣用腳之趨勢，尤其是無膝痛一組已呈現顯著差異。可見經過長期剪步急停訓練，其膝內旋肌肌力已顯出增強現象。另外，有膝痛籃球組之膝外旋肌肌力卻亦呈現非慣用腳顯著大於慣用腳之現象，也許是反映出利用拮抗肌同步收縮以避免疼痛的代償機制。而步行及剪步急停動作過程中無膝痛籃球組於著地期股外側肌肌肉活動顯著偏低，反之有膝痛籃球組之膝部肌肉活動則呈現偏高的趨勢。顯示當膕肌等負責瞬間膝關節穩定度的深層肌肉非常發達時，股外側肌於急停動作中將呈現參與度降低而肌肉使用效率提高的現象；反之一旦產生膝痛，股外側肌之參與度將大幅提高以提供足夠的膝關節穩定度，顯示有膝痛籃球組之膕肌可能已出現問題因而無法提供足夠的膝關節穩定度。這個結果明白的指出股外側肌在膝關節失穩狀態的重要性，並已間接證明籃球運動中膕肌過度使用的可能性。

　Background and Purpose. Although anterior knee pain is very common, the mechanism for the development of anterior knee pain is still controversial. It has been widely attributed to abnormal quadriceps angle (Q-angle), however, it was also proposed that anterior knee pain is a multi-factoral problem and not only limited to malalignment in the frontal plane. Recently, malalignment in the transverse plane, namely knee version (KV), was considered to be the main cause for the development of idiopathic anterior knee pain (IAKP) that failed to conservative management. Further, popliteus is referred to the main internal rotator of the knee that is in charge of stabilizing knees at cutting or stopping. People involved in frequent cutting or stopping are considered to be at higher risk for accumulated microstrain of popliteus. Hypertrophy and adaptive shortness of popliteus associated with rotational malalignment might also be found and responsible for the development of IAKP in this group. However, there is still lack of evidence investigating the role of knee rotational alignment in the development of IAKP. The purpose of this study is to provide evidence to demonstrate the role of rotational malalignment in the development of IAKP by investigating KV-related parameters in people at risk for IAKP. Methods. 14 professional basketball players with or without idiopathic anterior knee pain (7 for each group) and 12 healthy control subjects in low activity level were recruited for the evaluation of activity level, Lysholm knee scale, pain pressure thresholds (PPT) for local tenderness, knee alignment, range of motion (ROM) for knee rotation, strength of knee muscles, and electromyography (EMG) of related knee muscles during walking and cutting activities. Several oneway ANOVA procedures were conducted for examining all variables except EMG parameters, and Kruskal-Wallis oneway ANOVA procedures were conducted for EMG parameters to compare the group differences. The differences between dominant leg and non-dominant leg (cutting leg) were examined by using paired t tests. Results. No significant differences in PPT, Q-angle, or ROM of knee rotation were found among three groups or between both knees for the basketball groups. However, basketball groups demonstrated significantly smaller KV for the cutting legs in comparison with the non-cutting legs (p < 0.05). Moreover, basketball group without knee pain showed significantly higher knee flexor and extensor strength in both legs than the control group (p < 0.05), and significantly stronger knee internal rotator in cutting leg at knee flexion 30 degrees than other groups (p < 0.05). As to bilateral comparisons, basketball group without knee pain demonstrated significantly stronger knee flexors yet significantly weaker knee internal rotators in dominant leg (p < 0.05). In addition, significantly lower vastus lateralis (VL) activation was found in basketball group without knee pain, while significantly higher VL activation was found in basketball group with knee pain history during walking, side-cutting, or cross-cutting. Discussion and Conclusion. Basketball groups undergoing long-term cutting training have demonstrated the sign of adaptive shortness at popliteus in their cutting legs. Although this was not proven with the decrease in PPT, basketball groups in this study have demonstrated apparent knee internal rotational alignment with decreasing KV in their cutting legs. Our results of bilateral comparison showing significantly stronger internal rotators in the non-dominant legs (cutting legs) especially for painless basketball group have also supported the hypothesis with respect to the hypertrophy of popliteus resulting from long-term cutting training. On the other hand, significantly stronger external rotators were also found in the cutting legs of the basketball group with knee pain. This seems to propose a compensatory mechanism for pain-avoidance phenomenon with the alternative motor control strategies of increasing knee stability by increasing the co-contraction of the antagonists. In addition, the significantly decreased VL activation found in painless basketball group and the significantly increased VL activation found in painful basketball group during walking or cutting have further suggested another compensatory mechanism for the inadequate control of knee stability. In these athletic tasks that dynamic knee stability is highly demanded, the popliteus might play an important role in providing extra stability for the knee joints. The results of stronger knee internal rotators namely popliteus found in the cutting legs of basketball players might provide an explanation for the reduced activation of VL found during cutting in the basketball players without knee pain. In contrast, significantly increased VL activation found in the knee pain group during cutting seems to be associated with the additional knee stability in need. It is not surprising that the insufficient knee stability happens to result from accumulated microstrain of popliteus after long-term cutting training. The study has provided evidence to prove the possibilities of overused popliteus after long-term cutting training. The compensatory mechanisms were also suggested to stimulate the proposition of the preventive strategies. The role of KV in the development of IAKP has also been demonstrated in depth.

中文摘要…………………………………………………………………III
英文摘要…………………………………………………………………VI
誌謝………………………………………………………………………X
表目錄……………………………………………………………………XIV
圖目錄……………………………………………………………………XV
第一章、 簡介與文獻回顧………………………………………………1
第一節、 前側膝關節疼痛之成因…………………………………1
第二節、 膝關節結構異常之指標…………………………………2
第三節、 膝旋轉結構的定義………………………………………4
第四節、 膝旋轉結構在常見膝關節問題中所扮演的角色………4
第五節、 影響膝旋轉結構的因素…………………………………6
第六節、 膕肌的功能性解剖特色…………………………………8
第七節、 膕肌於日常活動之貢獻…………………………………9
第八節、 剪步急停運動訓練………………………………………10
第九節、 長期剪步急停訓練對膝關節可能造成的影響…………12
第十節、 長期剪步急停訓練以及結構異常於特發性膝痛之發展史中可能扮演的角色…………………………………………13
第二章、 研究背景………………………………………………………14
第一節、 研究動機…………………………………………………14
第二節、 研究目的…………………………………………………15
第三節、 研究問題…………………………………………………15
第四節、 研究假設…………………………………………………16
第三章、 研究方法………………………………………………………17
第一節、 研究對象…………………………………………………17
第二節、 研究儀器與設備…………………………………………17
第三節、 研究流程…………………………………………………20
第四節、 測試方法…………………………………………………21
第五節、 資料處理與分析…………………………………………28
第六節、 資料統計與分析…………………………………………35
第四章、 結果……………………………………………………………36
第一節、 受試者基本資料…………………………………………36
第二節、 膝關節局部壓痛閾值……………………………………37
第三節、 下肢結構與膝旋轉活動度………………………………37
第四節、 膝部肌肉之最大等長肌力………………………………40
第五節、 動態肌電訊號……………………………………………44
第五章、 討論……………………………………………………………59
第一節、 基本資料…………………………………………………59
第二節、 膝關節局部壓痛閾值比較………………………………59
第三節、 下肢結構與膝旋轉活動度之比較與相關性……………61
第四節、 膝部肌肉最大等長肌力…………………………………65
第五節、 動態肌電訊號之表現……………………………………69
第六章、 結論……………………………………………………………79
第一節、 臨床應用…………………………………………………80
第二節、 研究限制…………………………………………………81
第七章、 參考文獻………………………………………………………82
自述………………………………………………………………………92

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