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Meenakshi Aggarwal MD PGY2 Family Medicine AAFP Journal Review March 20th, 2008

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Meenakshi Aggarwal MD PGY2 Family Medicine AAFP Journal Review March 20th, 2008. Discussion. Chronic Shoulder Pain Evaluation Diagnosis Treatment Testicular Cancer Diagnosis

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Meenakshi Aggarwal MD

PGY2 Family Medicine

AAFP Journal Review

March 20th, 2008

  • Chronic Shoulder Pain




Testicular Cancer



chronic shoulder pain
Chronic Shoulder Pain
  • Pain present for > 6 months regardless of whether the patient has previously sought treatment
  • Rotator cuff disorders
  • Adhesive capsulitis
  • Glenohumeral OA
  • Glenohumeral instability
  • AC joint pathology
  • Other chronic pain
rotator cuff disorders
Rotator cuff disorders
  • Tendinosis
  • Full or partial thickness tears
  • Calcific tendinitis
shoulder muscles movements
Shoulder Muscles Movements

Fwd Flex - Deltoid, Pec maj, Coracobrach, Biceps

Extension -Deltoid, Teres maj, Teres min, Lat dorsi,

Abduction - Deltoid, Supraspin, Infraspin, Subscap,

Adduction - Pec maj, Lat dorsi, Teres maj, Subscap

Int rotation - Pec maj, deltoid, Lat dorsi, Subscap

Ext Rotation - Infraspin, Deltoid, Teres min

clinical diagnosis
Clinical Diagnosis
  • Medical history



Location of the pain

Factors aggravating the pain

Previous treatments

physical examination
Physical Examination
  • Inspection
  • Palpation
  • Range Of Motion and strength tests
  • Provocative Tests



range of motion
Range Of Motion:

External Rotation

Internal Rotation


Forward Extension

Forward Flexion

provocative tests
Provocative Tests:

Hawkin’s Impingement Test - Indicates rotator cuff tear or tendinopathy


Drop Arm Rotator Cuff Test:Indicates large rotator cuff tear

Raise arm to 160 degrees. Patient is then asked to slowly lower

the arm to the side. Positive test: Inability to control the lowering

phase and dropping of the arm.


Empty Can Supraspinatus Test:

Positive test is indicated by weakness

compared with the other side.

Indicates supraspinatus tear or


Cross Body Adduction Test:

Shoulder is passively adducted

across the body. Pain may indicate

AC joint pathology including chronic

sprain or OA.


Apprehension Test:

Arm is abducted to 90 degrees and

shoulder flexed to 90 degrees. Pain

and sense of instability with further

ER may indicate shoulder


Ext Rotation/ Infraspinatus

Strength Test:

Arms are held to the side

with elbows flexed to 90 deg,

Positive test is inability to ext

rotate against resistance.

Indicates infraspinatus or TM

tear or tendinopathy

diagnostic imaging
Diagnostic Imaging
  • Plain X-rays: TOC* for OA of AC joint and glenohumeral joint, calcific tendinitis
  • MRI: TOC for rotator cuff disorders
  • Arthrography: TOC for labral pathology found in chronic shoulder instability
  • CT Scan: TOC for bony disorders (arthritis, tumors and occult fractures)
  • Ultrasonography

* TOC: Test of choice


Q) Which one of the following statements about glenohumeral instability is correct?

A. Onset typically occurs in patients older than 40 years.

B. There is usually no history of subluxation or dislocation.

C. There may be a history of a "dead arm" or numbness over the lateral deltoid on physical examination.

D. There is usually no history of trauma or collision sports.

Answer: C

injections steroids anesthetic
Injections: Steroids + Anesthetic
  • Subacromial Injections: Rotator Cuff pathology
  • Intra-articular injections: Adhesive capsulitis
  • AC Joint Injections: Osteoarthritis
  • Glenohumeral Joint Injections: OA, rheumatoid arthritis, adhesive capsulitis

Q) Which one of the following statements about adhesive capsulitis is correct?

Patients not responding to treatment within one month should be referred for surgical intervention.

B. Subacromial steroid injections have been shown to improve long-term outcomes.

C. The natural history of the condition is to improve spontaneously after one to two years.

D. Pain medication should be withheld to the greatest extent possible, given the chronic nature of the condition.

Answer: C

photo quiz
Photo Quiz:
  • Churg-Strauss Syndrome
  • Eosinophilia-myalgia Syndrome
  • Strongyloidiasis
  • Wegener’s Granulomatosis
  • Well’s Syndrome

Answer: A


Testicular Cancer

  • Most common cancer in the men 20-35 years of age
  • Annual incidence: 4 per 100,000
  • Accounts for 1-2% of all neoplasms in men
risk factors
Risk Factors
  • Cryptorchidism
  • Tobacco
  • Family History
  • Infertility
  • White race
  • History
  • Physical Exam
  • Diagnostic Tests
testicular self exam
Testicular Self Exam

Patient places the index and middle fingers under the testicle with the thumbs placed on top. Patient should roll the testicle gently between the thumbs and fingers feeling for lumps. Patient shouldn't feel any pain when doing the exam.

  • Do we REALLY need to know?
tumour markers
Tumour Markers
  • Beta HCG
  • Alpha fetoprotein
  • Lactate Dehydrogenase
role of a family physician
Role Of A Family Physician
  • Diagnose
  • Evaluate Recurrence
  • Future complications
  • Infertility issues: Encouraging the patient to bank sperms

Q) Which one of the following is the preferred initial diagnostic test for a patient with a scrotal mass?A. Magnetic resonance imaging.B. Computed tomography.C. Ultrasonography.D. Positron emission tomography.

Answer: C


Q) Which one of the following statements about the clinical diagnosis of testicular cancer is correct?

Intra testicular masses should be considered testicular cancer until proved otherwise.

B. Pain on palpation rules out malignancy.

C. Most patients present with symptoms of metastatic disease.

D. Scrotal swelling is uncommon.

Answer: A