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  • Normal shoulder movement. Also, character of the pain does not change with movement of the shoulder.
  • Sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints. Thin capsule. Subacromial bursa. Rotator cuff tendons attach to humeral tuberosities.
  • Supraspinatus – abduction (also with deltoid). Infraspinatus and teres – external rotation. Subscapularis – internal rotation.
  • Can see atrophy with chronic RA. Shoulder joint can hide a lot of fluid because of capsule redundancy.
  • Flexion – arms outstretched, up in front. Abduction – to the side. External rotation – either the penguin, or putting hands behind back (like relaxing). Internal rotation – have pt use thumb to touch the highest point on the spine. Apley scratch test does both abduction and external rotation – reach behind head and touch the superior angle of the opposite scapula. Can touch the inferior angle of the opposite scapula for testing of internal rotation and adduction.
  • Preventing scapula from moving isolates the GH joint. When abducted – internal rotation is pointing down, external rotation is pointing up.
  • Bicipital tendonitis – pain at long head of the biceps.s
  • Will talk about common shoulder problems now.
  • Sx = pain over outer deltoid, particularly with overhead activities or reaching. 10% pts have pain over anterior deltoid.
  • Painful arc maneuver = Neer impingement test. Prevent scapular movement by placing hand down on shoulder. Then with the patient’s elbow flexed at 90 degrees, raise the arm and look for pain/guarding. With impingement, see pain variably from 45-120 degrees.
  • XR – loss of space between acromion and humeral head can indicate degenerative thinning or a large rotator cuff tear. Can see erosive changes at greater tubercle. More frequently, can see calcification in the rotator cuff tendone but not specific. MRI – can look for compression of the supraspinatus tendon or the subacromial bursa by spurs, low-lying acromion, osteophytes.
  • Pendulum, then weighted pendulum. Injection = pure impingement is mechanical and won’t respond to steroids. Could do a lidocaine injection first. If this works, then could consider steroids. Surgery – acromioplasty (either open or arthroscopic).
  • If the tear is parallel to the tendon fibers, pt will have shoulder pain, pain with direct pressure, pain aggravated by activities (reaching, lifting, pulling, pushing). If tear is large and transverse in direction, then pt will have weakness, dramatic loss of function.
  • U/S limitations include with fat patients or small tears.
  • No overhead positioning, reaching, lifting. Steroid injection could possibly weaken tendon, but Up to Date says there is no influence on tendon healing. Rotator cuff is NOT necessary for most normal activities of a sedentary life.
  • Show how to do the exam: place your arm on their shoulder and rest their affected side on your arm. Then passively push the AC joint together by pushing on the arm. 2 nd degree – partial dislocation. 3 rd degree – full dislocation.
  • Lose abduction and rotation. Loss of GH joint capsule distensibility. Contrast with rotator cuff tendonitis – main sx is pain, not loss of movement.
  • After lidocaine, pts with frozen shoulder still have limited range of movement, unlike tendonitis.
  • X-rays: could see evidence of calcific tendonitis or degenerative changes that would suggest problems that could eventually lead to frozen shoulder.
  • Exercise – (1) weighted pendulum exercises, (2) passive stretching. Up to 50% will respond to exercise therapy.
  • Biceps – elbow flexion and supination.
  • Bicipital groove is about 1” below the anterolateral tip of the acromion. Pts can seem weak because of pain.
  • Usually proximal end of the long head ruptures.
  • Surgery rarely necessary since flexion strength only minimally decreased and it usually ends up being a cosmetic issue. Can get slight improvement in elbow flexion and supination.
  • RA – morning stiffness, better with activity. Shoulder sx in RA is common, especially in late stages of dse.
  • Transcript

    • 1. Physical Examination of the Shoulder Lisa Chiou, MD, MPH Primary Care Conference
    • 2. Goals <ul><li>Review some of that anatomy from medical school </li></ul><ul><li>Discuss common shoulder problems </li></ul><ul><li>Practice focused physical exam </li></ul>
    • 3. Shoulder pain <ul><li>Common in all age groups </li></ul><ul><li>Intrinsic disorder (85%) vs referred pain </li></ul><ul><ul><li>C-spine nerve impingement (disc herniation or spinal stenosis) </li></ul></ul><ul><ul><li>Peripheral nerve entrapment distal to spinal column (long thoracic, suprascapular) </li></ul></ul><ul><ul><li>Diaphragm irritation, intrathoracic tumors, and distension of Gleason’s capsule/gall bladder </li></ul></ul><ul><ul><li>Myocardial ischemia </li></ul></ul><ul><ul><li>Pancoast tumor </li></ul></ul>
    • 4. Review of shoulder anatomy <ul><li>Bones </li></ul><ul><ul><li>Scapula </li></ul></ul><ul><ul><li>Clavicle </li></ul></ul><ul><ul><li>Humeral head </li></ul></ul><ul><ul><li>Posterior rib cage </li></ul></ul><ul><li>Joints </li></ul><ul><ul><li>Sternoclavicular </li></ul></ul><ul><ul><li>Acromioclavicular </li></ul></ul><ul><ul><li>Glenohumeral </li></ul></ul><ul><ul><li>Scapulothoracic </li></ul></ul>
    • 5. Glenohumeral joint <ul><li>25% humeral head surface in contact with glenoid </li></ul><ul><li>Joint space thinning seen with OA </li></ul><ul><li>Humeral head coverage increased to 75% with glenoid labrum </li></ul>
    • 6. More shoulder anatomy <ul><li>Ligaments </li></ul><ul><ul><li>Coracoclavicular </li></ul></ul><ul><ul><li>Acromioclavicular </li></ul></ul><ul><ul><li>Glenohumeral </li></ul></ul><ul><ul><ul><li>Superior GH </li></ul></ul></ul><ul><ul><ul><li>Middle GH </li></ul></ul></ul><ul><ul><ul><li>Inferior GH </li></ul></ul></ul><ul><ul><ul><li>Coracohumeral </li></ul></ul></ul><ul><li>Subacromial bursa </li></ul><ul><li>Subdeltoid bursa </li></ul>
    • 7. Rotator cuff muscles <ul><li>Supraspinatus, infraspinatus, teres minor, subscapularis </li></ul><ul><li>Form cuff around humeral head </li></ul><ul><li>Keep humeral head within joint (counteract deltoid) </li></ul><ul><li>Abduction, external rotation, internal rotation </li></ul>
    • 8. Shoulder exam #1 <ul><li>Visualize from front and back </li></ul><ul><li>Asymmetry </li></ul><ul><ul><li>Pts with rotator cuff tears hold shoulder higher </li></ul></ul><ul><li>Atrophy </li></ul><ul><ul><li>Sign of chronic glenohumeral joint pathology </li></ul></ul><ul><li>Effusions </li></ul><ul><ul><li>Shoulder joint can hide a lot of fluid </li></ul></ul>
    • 9. Shoulder exam #2 <ul><li>Palpation </li></ul><ul><ul><li>Along clavicle </li></ul></ul><ul><ul><li>SC and AC joints </li></ul></ul><ul><ul><li>Acromion, subacromial region </li></ul></ul><ul><ul><li>Coracoid process (short head of biceps) </li></ul></ul><ul><ul><li>Bicipital groove (long head of biceps) </li></ul></ul><ul><ul><li>Trigger points in neck, trapezius, scapular region </li></ul></ul>
    • 10. Active range of motion <ul><li>Forward flexion </li></ul><ul><li>Abduction/adduction </li></ul><ul><ul><li>Painful arc of abduction – sensitive, not specific </li></ul></ul><ul><li>External rotation </li></ul><ul><li>Internal rotation </li></ul>
    • 11. Passive range of motion <ul><li>Immobilize the scapula to prevent rotation </li></ul><ul><ul><li>Use one arm to push down on shoulder </li></ul></ul><ul><ul><li>Use other arm to do the PROM exercises </li></ul></ul><ul><li>Abduction </li></ul><ul><li>Internal and external rotation </li></ul><ul><ul><li>Have arm at patient’s side and abducted to 90 degrees </li></ul></ul>
    • 12. Rotator cuff strength testing <ul><li>Supraspinatus </li></ul><ul><ul><li>“ Pour out a Coke” </li></ul></ul><ul><li>Infraspinatus and teres minor </li></ul><ul><ul><li>“ Act like a penguin” </li></ul></ul><ul><li>Subscapularis </li></ul><ul><ul><li>“ Scratch your back” </li></ul></ul>
    • 13. Impingement maneuvers <ul><li>Impingement sign </li></ul><ul><ul><li>At 90 degrees of abduction with elbow flexed to 90 degrees, do internal (downward) and external (upward) rotation </li></ul></ul><ul><li>Hawkins’ test </li></ul><ul><ul><li>At 90 degrees of elbow flexion, do internal rotation by pushing down on pt’s forearm </li></ul></ul><ul><li>Neer’s test </li></ul><ul><ul><li>At full elbow extension, internally rotate and flex the arm </li></ul></ul>
    • 14. Biceps strength testing <ul><li>Arms outstretched with palms up at level of shoulder </li></ul><ul><li>Forced supination of hand with elbow flexed at 90 degrees </li></ul>
    • 15.  
    • 16. Impingement syndrome <ul><li>Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion </li></ul><ul><li>Repetitive overhead motions </li></ul><ul><li>Main cause of rotator cuff tendonitis </li></ul><ul><li>Can lead to bursitis, partial or full rotator cuff tears </li></ul>
    • 17. Sx of impingement syndrome <ul><li>Usually gradual onset </li></ul><ul><li>Outer deltoid pain, especially with reaching or overhead movements </li></ul><ul><li>Night pain </li></ul><ul><li>Difficulty sleeping on affected side </li></ul><ul><li>Nearly identical symptoms as tendonitis </li></ul>
    • 18. Exam for impingement <ul><li>Pain with painful arc maneuver </li></ul><ul><li>Crepitus above 60 degrees </li></ul><ul><li>Subacromial tenderness (lateral) </li></ul><ul><li>No pain with external/internal rotation, abduction, elbow flexion </li></ul><ul><ul><li>Distinguishes impingement from tendonitis </li></ul></ul><ul><li>Normal glenohumeral ROM </li></ul><ul><li>Normal strength </li></ul>
    • 19. Radiology for impingement <ul><li>X-rays usually not needed </li></ul><ul><ul><li>Reasonable to get if chronic symptoms </li></ul></ul><ul><li>MRI can rule out other pathology </li></ul><ul><ul><li>Wait at least 24 hours after an injection </li></ul></ul><ul><ul><li>Osseous abnormalities </li></ul></ul><ul><ul><li>Need to clinically correlate MRI findings </li></ul></ul>
    • 20. Tx of impingement <ul><li>Rest </li></ul><ul><li>Ice </li></ul><ul><li>Stretching, then strengthening </li></ul><ul><ul><li>Pendulum for 5-10 minutes QD </li></ul></ul><ul><ul><li>Can increase space under acromion by ½” </li></ul></ul><ul><li>Don’t use arm sling </li></ul><ul><li>Subacromial injection </li></ul><ul><li>Surgical referral if no improvement after 3-6 months </li></ul>
    • 21. Rotator cuff tendonitis <ul><li>Some argue this is same as impingement </li></ul><ul><li>Acute or chronic </li></ul><ul><ul><li>Acute – more likely to have calcific deposits </li></ul></ul><ul><li>Pain along lateral arm (outer deltoid) </li></ul><ul><li>Pain with numerous activities, lying on the affected side, overhead movements </li></ul><ul><li>RF – relative overuse, age, osteophytes, trauma, inflammatory processes (RA) </li></ul>
    • 22. Exam for impingement <ul><li>Painful arc of abduction (active) </li></ul><ul><ul><li>60-120 degrees </li></ul></ul><ul><li>Impingement signs </li></ul><ul><li>Impingement test </li></ul><ul><ul><li>Subacromial lidocaine injection </li></ul></ul><ul><ul><li>Can then test again for weakness </li></ul></ul>
    • 23. Radiology for tendonitis <ul><li>Nothing is diagnostic </li></ul><ul><li>Plain films not necessary </li></ul><ul><ul><li>Get if chronic or recurrent </li></ul></ul><ul><ul><li>Might see calcifications </li></ul></ul><ul><li>If significant loss of strength or ROM, get MRI </li></ul><ul><ul><li>Rule out tear </li></ul></ul><ul><ul><li>Hard to see tendon calcifications </li></ul></ul>
    • 24. Tx of tendonitis <ul><li>Rest </li></ul><ul><li>Heat or ice </li></ul><ul><li>Ultrasound (physical therapy) </li></ul><ul><li>NSAIDs </li></ul><ul><li>Subacromial steroid injection </li></ul>
    • 25. Rotator cuff tear <ul><li>50% pts do not have preceding trauma </li></ul><ul><li>Usually in supraspinatus </li></ul><ul><li>Wide size range, plus partial vs full </li></ul><ul><li>Shoulder weakness, pain, loss of motion </li></ul><ul><li>Common mechanisms of injury: </li></ul><ul><ul><li>Falling onto outstretched arm, onto outer shoulder directly, heavy pushing/pulling </li></ul></ul>
    • 26. Sx of rotator cuff tear <ul><li>Shoulder weakness </li></ul><ul><li>Localized pain over upper back </li></ul><ul><li>Popping/catching sensation when shoulder is moved </li></ul><ul><li>Night pain is characteristic </li></ul><ul><li>Sx vary depending on direction of the torn tendon fibers </li></ul><ul><ul><li>Parallel: pain </li></ul></ul><ul><ul><li>Transverse: weakness, loss of function </li></ul></ul>
    • 27. Exam for rotator cuff tear <ul><li>Range of motion </li></ul><ul><li>Strength </li></ul><ul><li>Drop arm test </li></ul><ul><ul><li>Arm abducted with elbow straight </li></ul></ul><ul><ul><li>See if pt can smoothly lower arm </li></ul></ul><ul><ul><li>If arm drops, then test is positive for tear </li></ul></ul><ul><ul><li>Highly specific but only 21% sensitive </li></ul></ul>
    • 28. Radiology for rotator cuff tears <ul><li>Interpret carefully </li></ul><ul><ul><li>34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tears </li></ul></ul><ul><ul><li>Abnormal rotator cuff signal after trauma may represent strain rather than tear </li></ul></ul><ul><li>X-rays </li></ul><ul><ul><li>Look for high riding humeral head </li></ul></ul><ul><li>Ultrasound </li></ul><ul><ul><li>Highly operator dependent </li></ul></ul><ul><li>MRI </li></ul>
    • 29. Rotator cuff tears
    • 30. Tx of rotator cuff tears <ul><li>Ice, NSAIDs, restrict aggravating motions </li></ul><ul><li>Weighted pendulum </li></ul><ul><li>No arm slings </li></ul><ul><li>Steroid injection if persistent sx </li></ul><ul><li>Surgery – refer if young pts, full/large tears, dominant arm </li></ul><ul><ul><li>Best if done within 6 weeks </li></ul></ul><ul><li>Acromioplasty and debridement </li></ul>
    • 31. Acromioclavicular injury <ul><li>Arthritic changes </li></ul><ul><li>AC joint separation </li></ul><ul><li>Anterior shoulder pain or deformity </li></ul><ul><li>Preceding trauma </li></ul><ul><li>Often pts hold arm close to chest and resist rotation and elevation </li></ul><ul><li>With OA, may have grinding or popping sensation with reaching overhead/across chest </li></ul>
    • 32. Exam for AC joint injuries <ul><li>Joint enlargement or deformity </li></ul><ul><li>Joint tenderness </li></ul><ul><li>Pain with crossed body adduction </li></ul><ul><li>Joint widening with downward arm traction in pts with 2 nd or 3 rd degree joint separation </li></ul>
    • 33. Tx of AC joint injury <ul><li>Reduce pressure and traction to allow ligaments to re-attach </li></ul><ul><li>Acute: ice, NSAIDs, shoulder immobilizer for 3-4 weeks </li></ul><ul><li>Persistent: steroid injection </li></ul><ul><li>Refer to surgery if no improvement after 2 injections </li></ul>
    • 34. Adhesive capsulitis <ul><li>Loss of motion +/- pain due to stiff GH joint </li></ul><ul><li>Is usually reversible </li></ul><ul><li>May have preceding trauma </li></ul><ul><li>Most common cause (10%) is rotator cuff tendonitis </li></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Disuse (i.e. pts with arm in sling) </li></ul></ul><ul><ul><li>Low pain thresholds </li></ul></ul><ul><ul><li>Poor compliance with exercise therapy </li></ul></ul>
    • 35. Rare associations <ul><li>Hyper- or hypothyroidism </li></ul><ul><li>Parkinson’s disease </li></ul><ul><li>Antiretrovirals (PPIs) </li></ul><ul><li>Recent neurosurgery </li></ul>
    • 36. Exam for adhesive capsulitis <ul><li>Clinical diagnosis </li></ul><ul><li>Range of motion is smooth and pain-free, then stops suddenly </li></ul><ul><li>No further passive ROM possible </li></ul><ul><li>Normal strength in the pain-free range </li></ul><ul><li>Can test strength again after lidocaine injection </li></ul>
    • 37. Radiology for adhesive capsulitis <ul><li>X-rays have limited use </li></ul><ul><ul><li>Might see calcifications or degenerative changes that would lead to frozen shoulder </li></ul></ul><ul><li>MRI </li></ul><ul><ul><li>Enhancement of joint capsule and synovial membrane </li></ul></ul><ul><ul><li>4 mm thickening is 70% sensitive and 95% specific </li></ul></ul>
    • 38. Arthrogram for adhesive capsulitis Normal capsule volume Frozen shoulder (contracted GH capsule)
    • 39. Tx of adhesive capsulitis <ul><li>Watchful waiting </li></ul><ul><ul><li>Up to 2 years for resolution </li></ul></ul><ul><ul><li>Incomplete recovery more likely in pts with DM, or pts with >50% loss of external rotation/abduction </li></ul></ul><ul><li>Steroid injection </li></ul><ul><li>Manipulation under anesthesia </li></ul><ul><li>Gentle exercise </li></ul><ul><li>Pain medications </li></ul><ul><li>Alternative therapies – i.e. acupuncture </li></ul>
    • 40. Biceps tendonitis <ul><li>Inflammation of long head of biceps </li></ul><ul><ul><li>Passes through bicipital groove of anterior humerus </li></ul></ul><ul><li>Usually due to repetitive lifting or reaching </li></ul><ul><li>Inflammation, microtearing, degenerative changes </li></ul><ul><li>Up to 10% pts will have spontaneous rupture </li></ul>
    • 41. Sx of biceps tendonitis <ul><li>Anterior shoulder pain </li></ul><ul><li>Worse with lifting or overhead reaching </li></ul><ul><li>Often pts point to bicipital groove </li></ul><ul><li>Usually no weakness in elbow flexion </li></ul>
    • 42. Exam for biceps tendonitis <ul><li>Bicipital groove tenderness </li></ul><ul><li>Look for subacromial impingement </li></ul><ul><li>Tendon rupture </li></ul><ul><li>Test biceps strength </li></ul><ul><li>Yergason test </li></ul><ul><ul><li>Elbows flexed with forearms in front </li></ul></ul><ul><ul><li>Pt actively resisting external rotation </li></ul></ul><ul><ul><li>Tendon may pop out of bicipital groove when downward pressure applied to forearm </li></ul></ul>
    • 43. Ruptured biceps tendon <ul><li>Usually rotator cuff tear also present </li></ul><ul><li>Get the “popeye” sign </li></ul><ul><li>Rarely get significant weakness </li></ul><ul><ul><li>Brachioradialis and short head of biceps provide 80-85% elbow flexor strength </li></ul></ul><ul><li>Tx is supportive </li></ul>
    • 44. Radiology for biceps tendonitis <ul><li>Usually plain films unnecessary </li></ul><ul><li>If tendon rupture present, then get plain films, U/S, or MRI </li></ul><ul><ul><li>Look for rotator cuff tendonitis or tear </li></ul></ul>
    • 45. Tx of biceps tendonitis <ul><li>Reduce inflammation </li></ul><ul><li>Strengthen biceps muscle and tendon </li></ul><ul><li>Prevent rupture </li></ul><ul><li>Ice, NSAIDs, avoid aggravating motions </li></ul><ul><ul><li>5-10% risk of rupture with noncompliance </li></ul></ul><ul><li>Weighted pendulum </li></ul><ul><li>Elbow flexion toning exercises </li></ul><ul><li>Steroid injection </li></ul><ul><li>Surgical referral if sx persist >3 months </li></ul>
    • 46. Glenohumeral osteoarthritis <ul><li>Same risk factors as with OA in other areas </li></ul><ul><ul><li>Trauma, obesity, age </li></ul></ul><ul><li>Less common than OA in weight bearing joints or spine </li></ul><ul><li>Pain, stiffness over months to years </li></ul><ul><ul><li>Anterior shoulder is most painful area </li></ul></ul><ul><li>Worse with activity </li></ul><ul><li>Distinguish from RA, adhesive capsulitis </li></ul>
    • 47. Unusual causes <ul><li>Hemochromatosis </li></ul><ul><ul><li>Think of this if patients develop OA in unusual places at unusually early ages </li></ul></ul><ul><li>Hemophilia </li></ul><ul><ul><li>Blood very erosive to joint </li></ul></ul>
    • 48. Exam for glenohumeral OA <ul><li>GH joint line tenderness and swelling </li></ul><ul><ul><li>Just below coracoid process </li></ul></ul><ul><ul><li>Use outward and upward pressure </li></ul></ul><ul><ul><li>Effusion may be very hard to see </li></ul></ul><ul><li>Decreased ROM </li></ul><ul><ul><li>External rotation, abduction </li></ul></ul><ul><ul><li>Endpoint stiffness </li></ul></ul><ul><li>Crepitus </li></ul>
    • 49. Imaging for glenohumeral OA <ul><li>Joint space narrowing (loss of articular cartilage) </li></ul><ul><li>Osteophytes </li></ul><ul><li>Humeral head sclerosis and flattening </li></ul><ul><li>Club-like deformity </li></ul>
    • 50. Tx of glenohumeral OA <ul><li>Low impact activities, and heat + stretching </li></ul><ul><ul><li>Let pain be the guide </li></ul></ul><ul><li>NSAIDs, acetaminophen, glucosamine, chondroitin </li></ul><ul><li>Intra-articular steroids </li></ul><ul><li>Intra-articular hyaluronate </li></ul><ul><li>Arthroplasty or total shoulder replacement </li></ul>
    • 51. Polymyalgia rheumatica <ul><li>Think of this with patients >60, especially if they have bilateral shoulder symptoms </li></ul><ul><li>Females>males </li></ul><ul><li>Europeans </li></ul><ul><li>Rare – 20-50 per 100,000 per year </li></ul>
    • 52. Symptoms of PMR <ul><li>Acute to sub-acute onset </li></ul><ul><li>Morning stiffness </li></ul><ul><ul><li>Patients can’t get out of bed </li></ul></ul><ul><li>Night pain </li></ul><ul><li>Proximal muscle involvement </li></ul><ul><li>20% have joint swelling </li></ul>
    • 53. PMR and giant cell arteritis <ul><li>Between 1-16% pts with PMR develop GCA </li></ul><ul><li>Nearly half of pts with GCA have co-existing PMR </li></ul><ul><li>Watch for jaw claudication, visual changes, scalp tenderness </li></ul>
    • 54. Shoulder weakness after viral illness
    • 55. Parsonage-Turner syndrome <ul><li>Brachial neuritis </li></ul><ul><li>Thought to be post-viral </li></ul><ul><li>Sudden onset shoulder pain that resolves </li></ul><ul><li>Weakness then develops </li></ul><ul><li>Suprascapular/long thoracic nerve involvement is common </li></ul><ul><li>Can get atrophy of supra/infraspinatus </li></ul><ul><li>Can have scapular winging </li></ul><ul><li>Months to years to regain strength </li></ul>
    • 56. Pain patterns #1 <ul><li>Lateral – most common </li></ul><ul><ul><li>Impingement syndrome </li></ul></ul><ul><ul><li>Rotator cuff tendonitis with tear if also weak </li></ul></ul><ul><ul><li>Frozen shoulder if also stiff, loss of movement </li></ul></ul><ul><li>Anterior </li></ul><ul><ul><li>AC joint </li></ul></ul><ul><ul><li>GH joint </li></ul></ul><ul><ul><li>Biceps tendon </li></ul></ul>
    • 57. Pain patterns #2 <ul><li>Posterior – least common </li></ul><ul><ul><li>Usually referred pain from C- spine </li></ul></ul><ul><ul><li>Can also be referred pain from rotator cuff tendonitis </li></ul></ul><ul><li>Poorly localized </li></ul><ul><ul><li>Neck </li></ul></ul><ul><ul><li>Nerves </li></ul></ul><ul><ul><li>Malingering </li></ul></ul>
    • 58. Thanks! And HUGE thanks to Dr. Greg Gardner!!

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