Shoulder Examination: Difference between revisions

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'''Original Editor '''- [[User:Leonid Klichinsky|Leonid Klichinsky]]  
'''Original Editor '''- [[User:Leonid Klichinsky|Leonid Klichinsky]]  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; </div>  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; </div>  
== Introduction  ==
== Subjective  ==
== Subjective  ==


=== Patient History ===
=== Patient Intake ===
Taking a detailed patient history is important. Listen carefully to the patient’s past medical history (PMHx) and history of presenting condition (Hx PC). The narrative given by the patient contains much of the information needed to rule out red flags and guide the shoulder examination.


'''Self report'''
The patient may report pain local to the involved shoulder. The symptoms may extend toward the scapula, axilla, anterior chest, along the clavicle, or down the humerus. When taking the patients history it is also important to ask if they have pain or symptoms in other regions such as their cervical or thoracic spine, or elbow. The patient may also report difficulty with overhead activities, lifting objects, activities of daily living, sports or recreational activities.&nbsp;There are several presentations that may differ depending on the suspected pathology.
* Patients with suspected [http://www.physio-pedia.com/index.php5?title=Shoulder_Instability glenohumeral instability] or labral pathology may have feelings of “looseness or instability” particularly in abducted and externally rotated positions.&nbsp;
* Patients with suspected <span style="color: windowtext;">[http://www.physio-pedia.com/index.php5?title=Adhesive_Capsulitis adhesive capsulitis] may report intense global shoulder pain initially combined with a progressive loss of range of motion.&nbsp;</span>
* <span style="color: windowtext;">Patients with suspected <span style="color: windowtext;">[http://www.physio-pedia.com/index.php5?title=Subacromial_Impingement subacromial impingement] or rotator cuff impairment may report feelings of weakness, heaviness and/or pain. </span></span>
<br>Shoulder History Exam Questions: These questions may assist the clinician in determining potential pathologies. Please refer to the User's Guide to Musculoskeletal Examination<ref>Flynn T, et al. Users’ guide to the musculoskeletal examination fundamentals for the evidence-based clinician. Evidence in Motion; 2008 .</ref>&nbsp;&nbsp;for more information.
# Does moving your neck change your symptoms?
# Do you ever feel unstable during arm movement?
# When you do actions with your arms over your head, does this aggravate your pain level?
# Is it difficult to move your arm?&nbsp;
# When performing actions with your arms over&nbsp;your head, do your arms feel heavier? <br>


<br> The patient may report pain local to the involved shoulder. The symptoms may extend toward the scapula, axilla, anterior chest, along the clavicle, or down the humerus.The patient may also report difficulty with overhead activities, lifting objects, activities of daily living, sports or recreational activities.&nbsp;There are several presentations that may differ depending on the suspected pathology.
=== Outcome Measures ===
 
*Shoulder Pain and Disability Index (SPADI)
Patients with suspected [http://www.physio-pedia.com/index.php5?title=Shoulder_Instability glenohumeral instability] or labral pathology may have feelings of “looseness or instability” particularly in abducted and externally rotated positions.&nbsp;Patients with suspected <span style="color: windowtext;">[http://www.physio-pedia.com/index.php5?title=Adhesive_Capsulitis adhesive capsulitis] may
*Disabilities of the Arm Shoulder and Hand (DASH)  
report intense global shoulder pain initially combined with a progressive loss of range of motion.&nbsp;Patients with suspected <span style="color: windowtext;">[http://www.physio-pedia.com/index.php5?title=Subacromial_Impingement subacromial impingement]
or rotator cuff lesions may report feelings of weakness, heaviness and/or pain.
</span></span>
 
<br> Shoulder History Exam Questions:
 
These questions may assist the clinician in determining potential pathologies. Please refer to the User's Guide to Musculoskeletal Examination<ref>Flynn T, et al. Users’ guide to the musculoskeletal examination fundamentals for the evidence-based clinician. Evidence in Motion; 2008 .</ref>&nbsp;&nbsp;for more information.
 
#Does moving your neck change your symptoms?
#Do you ever feel unstable during arm movement?
#When you do actions with your arms over your head, does this aggravate your pain level? 
#Is it difficult to move your arm?&nbsp;
#When performing actions with your arms over&nbsp;your head, do your arms feel heavier? <br>
'''Outcome Measures'''
 
*Disabilities of the Arm Shoulder and Hand(DASH)  
*American Shoulder and Elbow Surgeons Self-Report (ASES)  
*American Shoulder and Elbow Surgeons Self-Report (ASES)  
*Extremity Disability Index  
*Extremity Disability Index  
*Shoulder Pain and Disability Index
*Simple Shoulder Test (SST)
*Simple Shoulder Test  
*Constant-Murley Shoulder Outcome Score (CMS)  
*Constant-Murley Shoulder Outcome Score (CMS)  
*University of Pennsylvania Shoulder Score (U-Penn)
*University of Pennsylvania Shoulder Score (U-Penn)


=== Special Considerations ===
=== Special Questions ===
Patients with shoulder pain should be questioned for the presence of red or yellow flags. A thorough medical history and possibly the use of a medical screening form is the initial step in the screening process. The chart below highlights some of the most common red flag conditions for patients with shoulder pain.


==== '''Red Flags'''  ====
==== '''Red Flags'''  ====
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Determine if patient's symptoms are reflective of a visceral disorder or a serious potential life-threatening illness such as cancer, visceral pathology or fracture.<ref>Murphy D, Hurwitz R. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. 2007; 8: 1, 75 .</ref>  
Determine if patient's symptoms are reflective of a visceral disorder or a serious potential life-threatening illness such as cancer, visceral pathology or fracture.<ref>Murphy D, Hurwitz R. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. 2007; 8: 1, 75 .</ref>  


<br> Potential Shoulder Regional Referral Patterns:  
Potential Shoulder Regional Referral Patterns:  


Left Shoulder  
Left Shoulder  
Line 79: Line 74:


==== '''Yellow Flags'''  ====
==== '''Yellow Flags'''  ====
Yellow flags are factors that increase a patient’s risk for developing long-term disability.
Psychosocial Factors may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition of an acute condition to a chronic, disabling condition. Some attitudes and beliefs to look out for are[[Cervical Examination|:]] <ref>Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008</ref>
* Pain is harmful or disabling
* Pain must be eliminated before returning to activity
* Passive attitudes towards therapy
* Patient utilization of extended rest, reduced activity level and withdrawal from daily activities
* Patient reports of extreme pain intensity
* High intake of alcohol or other substances
The [[Fear‐Avoidance Belief Questionnaire|Fear Avoidance Belief Questionnaire]] (FABQ) is a tool to assess yellow flags among patients. The FABQ predictive validity is debatable, and is best for the FABQ-W when evaluating workers compensation patients.  The overall test-retest reliability is excellent, ICC= .97.
Depression Screening tools such as the Beck Depression Inventory (BDI) or the Depression Anxiety Screening Scale (DASS) are useful in screening patients for depression. Psychometric properties of the BDI: a cut-off score of ≥5 for screening, Sn = 90.9%, Sp = 17.6 %. A cut-off score of ≥22 for diagnostic utility, Sn = 27.3%, Sp = 90%.
The [[Pain Catastrophizing Scale]], helps determine if the patient is exaggerating their pain and symptoms and the severity of the situations as a whole. Cronbach alpha values reported for the total Pain Catastrophizing Scale (PCS) (α=.87) and factor scales (Rumination α=.87; Magnification α=.60; Helplessness α=.87) were found to be satisfactory. The total PCS score showed strong temporal validity <ref>Osman A et al. The Pain Catastophizing Scale:Further Psychometric Evaluation with Adult Samples. Journal of Behavioral Medicine. 2000; Vol.23(4): 351-365.</ref>. In a patient population with acute whiplash there was found to be a significant moderate correlation between pain pressure threshold and the pain catastrophizing scale as well as cold pain threshold and the pain catastrophizing scale <ref>Rivest K et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Journal of Manual Therapy. 2010; Vol 15:154-159.</ref>.


*Passive coping tendencies
*Depression
*Fear Avoidance Beliefs
*Pain Syndromes
*Concurrent Psychological Illness
*Worker’s Compensation
*Lack of family/community Support<br>
'''Clear the Cervical Spine'''  
'''Clear the Cervical Spine'''  


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Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromioclavicular and glenohumeral joint, or calcific tendonitis.  
Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromioclavicular and glenohumeral joint, or calcific tendonitis.  


<br> Common radiographic views may include (this may vary depending on medical provider):  
Common radiographic views may include (this may vary depending on medical provider):  


*Supraspinatus Outlet View  
*Supraspinatus Outlet View  
*Scapular Y-view
*Scapular Y-View
*Axillary view
*Axillary View
*Anterior-Posterior (AP) view
*Anterior-Posterior (AP) View
 
== Objective  ==


=== Observation  ===
=== Observation  ===
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Observation of a patient with a primary complaint of shoulder pain may include:  
Observation of a patient with a primary complaint of shoulder pain may include:  


*Static postures
*Static Postures
*Static scapular position
*Static Scapular Position
*Cervico-thoracic spine postures  
*Cervico-thoracic spine postures  
*Dynamic movement patterns  
*Dynamic movement patterns  
Line 236: Line 240:
*Levator Scapulae
*Levator Scapulae


'''Joint mobility assessment'''  
'''Joint Mobility Assessment'''  


Assessment of the mobility of the joint may indicate hypomobility with in the joint or elicit symptoms.  
Assessment of the mobility of the joint may indicate hypomobility with in the joint or elicit symptoms.  
Line 256: Line 260:
**Inferior
**Inferior


*Scapulothoracic joint (pseudo-joint)
*Scapulothoracic
**Elevation  
**Elevation  
**Depression  
**Depression  

Revision as of 20:12, 2 December 2017

Original Editor - Leonid Klichinsky

Top Contributors - Leonid Klichinsky, Laura Ritchie, Kim Jackson, Lucinda hampton, Naomi O'Reilly, Scott A Burns, Tony Lowe, Admin, Marleen Moll, Rachael Lowe, Matt Milburn, Kai A. Sigel, George Prudden, Rucha Gadgil, Rishika Babburu, Mariam Hashem, WikiSysop, Fasuba Ayobami and Jess Bell  

Introduction[edit | edit source]

Subjective[edit | edit source]

Patient Intake[edit | edit source]

Taking a detailed patient history is important. Listen carefully to the patient’s past medical history (PMHx) and history of presenting condition (Hx PC). The narrative given by the patient contains much of the information needed to rule out red flags and guide the shoulder examination.

The patient may report pain local to the involved shoulder. The symptoms may extend toward the scapula, axilla, anterior chest, along the clavicle, or down the humerus. When taking the patients history it is also important to ask if they have pain or symptoms in other regions such as their cervical or thoracic spine, or elbow. The patient may also report difficulty with overhead activities, lifting objects, activities of daily living, sports or recreational activities. There are several presentations that may differ depending on the suspected pathology.

  • Patients with suspected glenohumeral instability or labral pathology may have feelings of “looseness or instability” particularly in abducted and externally rotated positions. 
  • Patients with suspected adhesive capsulitis may report intense global shoulder pain initially combined with a progressive loss of range of motion. 
  • Patients with suspected subacromial impingement or rotator cuff impairment may report feelings of weakness, heaviness and/or pain.


Shoulder History Exam Questions: These questions may assist the clinician in determining potential pathologies. Please refer to the User's Guide to Musculoskeletal Examination[1]  for more information.

  1. Does moving your neck change your symptoms?
  2. Do you ever feel unstable during arm movement?
  3. When you do actions with your arms over your head, does this aggravate your pain level?
  4. Is it difficult to move your arm? 
  5. When performing actions with your arms over your head, do your arms feel heavier?

Outcome Measures[edit | edit source]

  • Shoulder Pain and Disability Index (SPADI)
  • Disabilities of the Arm Shoulder and Hand (DASH)
  • American Shoulder and Elbow Surgeons Self-Report (ASES)
  • Extremity Disability Index
  • Simple Shoulder Test (SST)
  • Constant-Murley Shoulder Outcome Score (CMS)
  • University of Pennsylvania Shoulder Score (U-Penn)

Special Questions[edit | edit source]

Patients with shoulder pain should be questioned for the presence of red or yellow flags. A thorough medical history and possibly the use of a medical screening form is the initial step in the screening process. The chart below highlights some of the most common red flag conditions for patients with shoulder pain.

Red Flags[edit | edit source]

Determine if patient's symptoms are reflective of a visceral disorder or a serious potential life-threatening illness such as cancer, visceral pathology or fracture.[2]

Potential Shoulder Regional Referral Patterns:

Left Shoulder

  • MI 68.7% of patients reported shoulder pain during an acute myocardial infarction[3]
  • Ruptured Spleen[4]

Both Shoulders

  • Pancoast’s Tumor[5]

Right Shoulder

  • Liver Disease[6]
  • Carcinoma,Cirrhosis, Hepatitis
  • Stomach
  • Hiatal Hernia[7]
  • Post Bariatric Surgery
  • Gastric Perforation[8]
  • Peptic Ulcer
  • Pancreas
  • Pancreatitis
  • Pancreatic Cancer
    • May be worse after fatty meal or associated with eight loss of Diabetes Mellitus
  • Gall Bladder
  • Cholecystitis
    • Typically accompanied by fever, or nausea/vomiting

Fractures

Fractures may result from trauma such as falls onto an outstretched hand. These are known as FOOSH injuries.

  • Commonly fractured both within the shoulder region
  • Humeral Fractures
    • Proximal or distal
  • Clavicle Fractures[9]
    • Fractures of the clavicle usually result from a direct blow to the shoulder giving axial compression. The middle 1/3 of the clavicle is most often broken with an incidence of ~80%. Distal clavicle fractures have an incidence of 10-15% and medial clavicle fractures have and incidence of 3 to 5%. Significantly displaced fractures are managed surgically.Mid-shaft clavicle fractures have a lower rate of mal-union and better functional outcomes at one year.[10] A trial of conservative management may be warranted for non-displaced clavicular fractures.

Yellow Flags[edit | edit source]

Yellow flags are factors that increase a patient’s risk for developing long-term disability.

Psychosocial Factors may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition of an acute condition to a chronic, disabling condition. Some attitudes and beliefs to look out for are: [11]

  • Pain is harmful or disabling
  • Pain must be eliminated before returning to activity
  • Passive attitudes towards therapy
  • Patient utilization of extended rest, reduced activity level and withdrawal from daily activities
  • Patient reports of extreme pain intensity
  • High intake of alcohol or other substances

The Fear Avoidance Belief Questionnaire (FABQ) is a tool to assess yellow flags among patients. The FABQ predictive validity is debatable, and is best for the FABQ-W when evaluating workers compensation patients.  The overall test-retest reliability is excellent, ICC= .97.

Depression Screening tools such as the Beck Depression Inventory (BDI) or the Depression Anxiety Screening Scale (DASS) are useful in screening patients for depression. Psychometric properties of the BDI: a cut-off score of ≥5 for screening, Sn = 90.9%, Sp = 17.6 %. A cut-off score of ≥22 for diagnostic utility, Sn = 27.3%, Sp = 90%.

The Pain Catastrophizing Scale, helps determine if the patient is exaggerating their pain and symptoms and the severity of the situations as a whole. Cronbach alpha values reported for the total Pain Catastrophizing Scale (PCS) (α=.87) and factor scales (Rumination α=.87; Magnification α=.60; Helplessness α=.87) were found to be satisfactory. The total PCS score showed strong temporal validity [12]. In a patient population with acute whiplash there was found to be a significant moderate correlation between pain pressure threshold and the pain catastrophizing scale as well as cold pain threshold and the pain catastrophizing scale [13].

Clear the Cervical Spine

The cervical spine can refer pain to the shoulder/scapular region. It is imperative that the cervical spine be screened appropriately as it may be contributing to the patient’s clinical presentation.

See Cervical Examination

Investigations[edit | edit source]

Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromioclavicular and glenohumeral joint, or calcific tendonitis.

Common radiographic views may include (this may vary depending on medical provider):

  • Supraspinatus Outlet View
  • Scapular Y-View
  • Axillary View
  • Anterior-Posterior (AP) View

Objective[edit | edit source]

Observation[edit | edit source]

Observation of a patient with a primary complaint of shoulder pain may include:

  • Static Postures
  • Static Scapular Position
  • Cervico-thoracic spine postures
  • Dynamic movement patterns
  • Scapulo-humeral rhythm
  • Functional tests
  • Hand behind head
  • Hand behind back
  • Cross body adduction
[14]
[15]
[16]
[17]

Palpation[edit | edit source]

Palpation of the shoulder region may provider the physical therapist with valuable information. The physical therapist should note the presence of swelling, texture, and temperature of the tissue.

Additionally the physical therapist may observe asymmetry, sensation differences, and pain reproduction.

Key palpable structures include:

  • Acromioclavicular joint
  • Sternoclavicular joint
  • Rotator cuff muscle insertions
  • Long head of the biceps tendon

Neurologic Assessment[edit | edit source]

A comprehensive neurological examination may be warranted in patients that present with a primary complaint of shoulder pain. The presence of neurological symptoms including numbness and tingling may warrant this examination.


Screening Examination

  • C4 – Shoulder Elevation/Shrug
  • C5 – Shoulder Abduction
  • C6 – Elbow Flexion, Wrist Extension
  • C7 – Elbow Extension, Wrist Flexion
  • C8 – Thumb Abduction/Extension
  • T1 – Finger Abduction

Dermatomes

  • C4 – Top of Shoulders
  • C5 – Lateral Deltoid
  • C6 – Tip of Thumb
  • C7 – Distal middle Finger
  • C8 – Distal 5th Finger
  • T1 – Medial Forearm

Pathological Reflexes

  • Hoffman’s Reflex
  • Inverted Supinator Reflex

Deep Tendon Reflexes

  • Biceps Brachii – C5 Nerve Root
  • Brachioradialis – C6 Nerve Root
  • Triceps – C7 Nerve Root
[18]
[19]
[20]
[21]

Movement Testing[22][edit | edit source]

Active Range of Motion (ROM)

Glenohumeral Joint Motions

  • Horizontal Adduction
  • Horizontal Abduction
  • Flexion
  • Extension
  • Internal Rotation
  • External Rotation
  • Abduction/Adduction
  • Abduction in the plane of the scapula
  • Abduction/Adduction
  • Upward/Downward Rotation
  • Elevation/Depression

Passive ROM

May include each of the motions stated in the active ROM section. The therapist may opt to include overpressure to further stress the joint.

Muscle length assessment

Assessment of the flexibility of certain muscles may be warranted in patients with shoulder pain. These muscles may include, but are not limited to:

  • Latissimus Dorsi
  • Pectoralis Minor/Major
  • Levator Scapulae
  • Upper Trapezius
  • Scalenes (anterior/middle/posterior)

Muscle Strength

Resistive testing of the shoulder muscles typically includes the following motions:

  • Shoulder Flexion
  • Shoulder Extension
  • Shoulder Abduction
  • Horizontal Abduction
  • Horizontal Adduction
  • Internal Rotation
  • External Rotation

Resistive testing of the scapular stabilization muscles may include:

  • Upper trapezius
  • Middle trapezius
  • Lower trapezius
  • Serratus Anterior
  • Rhomboids
  • Levator Scapulae

Joint Mobility Assessment

Assessment of the mobility of the joint may indicate hypomobility with in the joint or elicit symptoms.

  • Glenohumeral
    • Anterior
    • Posterior
    • Inferior
    • Distraction
  • Acromioclavicular
    • Anterior
    • Posterior
  • Sternoclavicular
    • Anterior
    • Posterior
    • Superior
    • Inferior
  • Scapulothoracic
    • Elevation
    • Depression
    • Upward/downward rotation
    • Protraction/Retraction

Special Tests

Several special tests exist for particular disorders of the shoulder. Below are links to the specific pages for each pathology that describe the special tests:

References[edit | edit source]

  1. ↑ Flynn T, et al. Users’ guide to the musculoskeletal examination fundamentals for the evidence-based clinician. Evidence in Motion; 2008 .
  2. ↑ Murphy D, Hurwitz R. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. 2007; 8: 1, 75 .
  3. ↑ Song L, Yan HB, Yang JG, Sun YH, Hu DY. Impact of patients' symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. Chin Med J (Engl). 2010 Jul;123(14):1840-5
  4. ↑ Rutkow IM. Rupture of the spleen in infectious mononucleosis: a critical review. Arch Surg. 1978 Jun;113(6):718-20 .
  5. ↑ Tamura M, Hoda MA, Klepetko W. Current treatment paradigms of superior sulcus tumours. Eur J Cardiothorac Surg. 2009 Oct;36(4):747-53. Epub 2009 Aug 20 .
  6. ↑ Strauss E. Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Usefulness of liver biopsy in chronic hepatitis C. Ann Hepatol 2010;9 Suppl:39-42.
  7. ↑ Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery. Obes Surg. 2010 Mar;20(3):386-92. Epub 2009 Oct 24.
  8. ↑ Pappano DA, Bass ES. Referred shoulder pain preceding abdominal pain in a teenage girl with gastric perforation. Pediatr Emerg Care. 2006 Dec;22(12):807-9 .
  9. ↑ McKee MD. Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am. 2010 Apr;41(2):225-31
  10. ↑ Altamimi SA, McKee MD. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:1-8
  11. ↑ Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008
  12. ↑ Osman A et al. The Pain Catastophizing Scale:Further Psychometric Evaluation with Adult Samples. Journal of Behavioral Medicine. 2000; Vol.23(4): 351-365.
  13. ↑ Rivest K et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Journal of Manual Therapy. 2010; Vol 15:154-159.
  14. ↑ BJSM Videos. Shoulder Exam (2 of 9): Inspection and Palpation. Available from: http://www.youtube.com/watch?v=Xf52jbNA7wg [last accessed 25/01/14]
  15. ↑ BJSM Videos. Shoulder Exam (3 of 9): Range of motion. Available from: http://www.youtube.com/watch?v=d7HfaAlgaro [last accessed 25/01/14]
  16. ↑ BJSM Videos. Shoulder Exam (4 of 9): Scapular control (Is there scapular dyskinesia?). Available from: http://www.youtube.com/watch?v=pEY93k5XXL0 [last accessed 25/01/14]|}
  17. ↑ BJSM Videos. Shoulder Exam (5 of 9): AC joint examination. Available from: http://www.youtube.com/watch?v=-y_NUVmHe-E [last accessed 25/01/14]|}
  18. ↑ BJSM Videos. Shoulder Exam (6 of 9): Ruling out a SLAP tear (Kuhn's tests). Available from: http://www.youtube.com/watch?v=YMPZi2_Jy9o [last accessed 25/01/14]
  19. ↑ BJSM Videos. Shoulder Exam (7 of 9): Exam to detect a SLAP tear. Available from: http://www.youtube.com/watch?v=beVd-cX_TX8 [last accessed 25/01/14]
  20. ↑ BJSM Videos. Shoulder Exam (8 of 9): Examination for impingement (rotator cuff). Available from: http://www.youtube.com/watch?v=r8Rl0_KE3OA [last accessed 25/01/14]|}
  21. ↑ BJSM Videos. Shoulder Exam (9 of 9): Testing for instability. Available from: http://www.youtube.com/watch?v=Fz2g5gI3RGg [last accessed 25/01/14]|}
  22. ↑ Hislop HJ, Montgomery J. Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination. Saunders 2007, 8th edition
  23. ↑ Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis, 2000 59, 44-47.
  24. ↑ Murphy D, Hurwitz R. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. 2007; 8: 1, 75
  25. ↑ Song L, Yan HB, Yang JG, Sun YH, Hu DY. Impact of patients' symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. Chin Med J (Engl). 2010 Jul;123(14):1840-5
  26. ↑ Flynn T, et al. Users’ guide to the musculoskeletal examination fundamentals for the evidence-based clinician. Evidence in Motion; 2008
  27. ↑ Rutkow IM. Rupture of the spleen in infectious mononucleosis: a critical review. Arch Surg. 1978 Jun;113(6):718-20
  28. ↑ Tamura M, Hoda MA, Klepetko W. Current treatment paradigms of superior sulcus tumours. Eur J Cardiothorac Surg. 2009 Oct;36(4):747-53. Epub 2009 Aug 20
  29. ↑ Strauss E. Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Usefulness of liver biopsy in chronic hepatitis C. Ann Hepatol 2010;9 Suppl:39-42.
  30. ↑ Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery. Obes Surg. 2010 Mar;20(3):386-92. Epub 2009 Oct 24.
  31. ↑ McKee MD. Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am. 2010 Apr;41(2):225-31
  32. ↑ Altamimi SA, McKee MD. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:1-8
  33. ↑ BJSM Videos. Shoulder Exam (2 of 9): Inspection and Palpation. Available from: http://www.youtube.com/watch?v=Xf52jbNA7wg [last accessed 25/01/14]


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