Documentation: Forward Flexion, External rotation with arm at side, Internal rotation by hand up spine (Glut-T4). Document both active and passive.
3 Joints-sternoclavicular, acromioclavicular, glenohumeral
Rotator Cuff-SItS: Supraspinatus, Infraspinatus, Teres Minor (Attach to
greater tuberosity) and subscapularis (attaches to lesser tuberosity)
Deltoid-elevates head of the humerus and abducts the shoulder
Scapulothoracic Articulation allows 65 degrees of shoulder abduction
irrelevant of glenohumeral joint.
Essential Surface Anatomy
greater tuberosity-just below ac joint
bicipital groove-most easily palpated with arm externally rotated
Glenohumeral disorders (adhesive capsulitis: age 40-65, median 50-55; osteoarthritis: 60)Adhesive capsulitis (“frozen shoulder”) and true glenohumeral arthritis are often preceded by a history of non-adhesive capsulitissymptoms, are characterised by deep joint pain, and restrictactivities such as putting on a jacket (impaired external rotation).Adhesive capsulitis is more common in people with diabetes andmay also occur after prolonged immobilisation. On examinationglobal pain is present, along with restriction of all movements,both active and passive.
Acromioclavicular disease (teenage to 50) Acromioclavicular disease is usually secondary to trauma or osteoarthritis; dramatic joint dislocation can occur after injury(teenage to 30 years). Pain, tenderness, and occasionally swellingare localised to this joint, and there is restriction of passive,horizontal adduction (flexion) of the shoulder, with the elbowextended, across the body. Acromioclavicular osteoarthritismay also cause subacromial impingement.
Referred mechanical neck pain (common) Typically there is pain and tenderness of the lower neck and suprascapular area, referred to the shoulder and upper limb area; shoulder movement may be restricted. Movement of the cervicalspine and shoulder may reproduce more generalised upper back,neck, and shoulder pain. Upper limb paraesthesia may occur.18 Treatment is with relative rest and analgesia, and return tonormal activities should be encouraged. Physiotherapy may behelpful.
stress test by bringing elbow to opposite shoulder and then palpating
Subluxations and Dislocations-loss of coracoclavicular ligament
1st degree-sprain, pain but no subluxation
2nd degree-sublux of acromioclav ligament with coracoclav intact.
tenderness with moderate swelling, normal x-rays are normal, stress x-
rays with 15 lb weight suspended at wrist(not in hand). AP film with
separation if distal clavicle by not more than half its diameter.
3rd Degree-complete dislocation with upward displacement of distal
clavicle. greater than 1/2 cm between coracoid aqnd clavicle or inf
border of clavicle is above ac joint.
type i-sprain of the ac ligs(sling/swathe)
2-disruption of ac lig, sprain of cc (reduce clav, kenney-howard sling)
3-both ligs disrupted
4-post clav displacemnt
5-clav displaced far superior
6-clav displaced downwards
3-6 ortho consult for possible surgery
Type I (a): Ligamentous strainno deformity, but tenderness of AC joint
Type II (b): Rupture of acromioclavicular ligamentcan have slight deformity on physical examination
Type III (c): Rupture of both acromioclavicular and coricoclavicular ligamentsignificant deformity on physical examination, bottom of clavicle at or above top of acromion on x-ray
1st degree-sprain, mild pain/swelling. ICE/Sling
2nd degree-sublux of clavicle completge rupture of sternoclavicular and
sprain of costaclav. Figure of 8 and sling
3rd degree-complete rupture c clav dislocation, caused by injuries that
roll shoulder backwards. Posterior dislocations can cause pneumos, or
tracheal compression. Reduce clavicle by (17-9A)
Anterior Shoulder Dislocation
Best Site: Shoulderdislocation.net
<a name="cunningham_technique” id=”%3Ca_href%3D%22cunninghamhtm%22%3Ecunningham_technique%3C%2Fa%3E” class=”sectionindex”>
There are four types of anteroinferior shoulder dislocation, denoted by the final position of the humeral head. Subcoracoid dislocations constitute 70% of all dislocations.5,6 Subglenoid dislocations (Fig. 2) are the second most common, 30%.5 Subclavicular and intrathoracic dislocations are associated with fractures and violent forces.7 Luxatio erectae is regarded as a pure inferior dislocation and is not discussed here.
Dislocations-abduction with external rotation.
Can not internally rotate humerus, so to test if reduced, lift arm and
let fall on stomach, if it can fall, back in.
assoc c axillary nerve injury (test by patch of skin just under ac joint ie. the regiment’s band supplied by the upper lateral cutaneous nerve or better yet, see if the patient can fire their deltoid with even minor arm ABduction) also evaluate distal hand neuro function.
Fractures occur in about 30% of cases.9,10 The most common are: 1. Hill Sach’s lesion (Fig. 3), seen in 5476% of cases, is a compression fracture that results in the formation of a groove in the posterolateral aspect of the humeral head.2,911 Also known as a hatchet deformity it is best viewed with internal rotation of the arm.9 2. Fractures of the anterior rim of the glenoid fossa (Fig. 4) or Bankart’s lesion12,13 (a separation of capsule and/or labrum from the anteroinferior rim, the term is often used to refer to bony disruption).2,10 It is the result of impaction of the humeral head against the anteroinferior glenoid labrum, and is associated with rupture of joint capsule and IGHL damage. It is more common in younger patients and has a strong association with recurrent dislocations (8587%).2,13,14 3. Avulsion fracture of the greater tuberosity (Fig. 5) is seen in 1016% of cases.5,9,10,15,16 4. Uncommonly, the coracoid process can be damaged by the humeral head resulting in painful non-union. 5. Humeral shaft fracture is rare, associated with significant forces.
AP (True AP, not C-XR view), axillary lateral and trans-scapular lateral (Y views.)
Also can get view c plate of x-ray behind butt and pt leaning backwards
just enough to have only shoulder over plate.
Evaluate films for Hill-Sachs deformity (impaction of humeral head in postero-lateral portion.
Also can see Bankart’s fracture, a fracture of the anterior glenoid. This injury needs ortho consult and probably CT scan of the shoulder.
Modified Axillary View-have patient lean forward (Emerg Radiol 2006;12:227)
Types of anterior glenohumeral dislocations.
A: subacromial; B: subglenoid; C: subclavicular; D: intrathoracic.
Rx-Scapular manipulation or Hennipen (externally rotate then abduct, if not successful, slowly adduct and internally rotate) (elderly Hennipen or stimson)
Hennepin-with patient seated, flex elbow and slowly externally rotate
arm to 90 degrees, stopping for a minute when painful. After reaching
90 degrees, if not in, slowly elevate arm and then lift humerus into
Stimson-place pt prone c armpit padded. strap wrist and add 10-15 lbs
of weight. After 20-30 min, if still not in, internally and externally
Scapular Manipulation-Push Tip of scapula medial and superior portion
lateral. can be combined with stimson or Hennepin.
Cunningham Method (Emerg Med 15:521, 2003)
1 Inform the patient of the procedure and the fact that it will be painless. It is important to relax the patient and confident reassurance is the first step towards this. 2 Sit the patient up with the back vertical. This can be done on a bed, chair or trolley, but preferably seated on a non-wheeled chair without arm rests. 3 Carefully support the arm while it is moved into the correct position, allowing the patient to help with the other arm. The correct position is with the arm adducted (next to the body) and pointing vertically down, the elbow is flexed at 90 degrees so that the forearm points horizontally and anteriorly. 4 The operator then squats /kneels to the side of the patient and facing the opposite direction to the patient. The operator then slips the hand between the patients forearm and body so that the patients wrist / hand is resting on the operators upper arm. *Do not make pulling movements at any time as this will elicit pain and result in spasm.* 5 Apply steady, very gentle traction (the weight of the operators forearm is quite enough) directly downwards once the patient is settled and pain free. Keep this gentle weight on the arm throughout, stop if any spasm or pain. Usually resting with the patients arm in this position will start to reduce the pain of spasm. 6 With the other hand, the operator then massages the trapezius, deltoid and biceps muscle sequentially, repeating this process and concentrating on the biceps brachii until the muscles are fully relaxed. A strong kneading of the biceps with the thumb anterior and the four fingers of the operator posterior to the arm is recommended. At this point the humeral head will relocate usually without any clear indication that the shoulder has reduced (no sound or clunk feeling). This means that the shoulder must be observed/checked regularly to confirm when relocation has occurred (with shoulder exposed movement can be seen as the step disappears.)
Hippocratic Technique-foot in armpit, fraught with peril.
Spaso technique: Place the patient in prone position and grasp the wrist and elevate the limb until it is vertical, then gently externally rotate the limb. Nudge the head back into the fossa.
Indications for surgery-possibly for glenoid rim fx or greater
tuberosity fx. more than 3 dislocations
Treatment after reduction-sling and swath for 3 weeks.
This can be accomplished with a sling and swath or a commercially available shoulder immobilizer. The duration of immobilization differs among different patient groups. Younger patients should be instructed to follow up within 1-2 weeks, and immobilization generally is maintained for approximately 3-4 weeks. Older patients will be immobilized for a considerably shorter period and should be instructed to follow up within 5-7 days to allow for early mobilization.
Complications-humeral head fx, bicipital tendon rupture, axillary or
other nerve injury, fx of humeral head of glenoid lip.
Apprehension Test-abduct to 90, externally rotate, push forward on humeral head.
29% had fracture, 76% of these were hill sachs. All of these fractures were successfully reduced in the ED.
12.6% had nerve dysfunction, 1/4 of these persisted after reduction. (JEM 24:2. 2003, p. 141-145)
Reduce c 20 cc 1% lido intra-articular and versed (JEM 22 (3)) and (Emerg Med J 19 (2):142 2002). Use 20 cc of 1% with long 20g needle just off the lateral edge of the acromion.d
Do we need prereduction films, probably not (Shuster, M., et al, Am J Emerg Med 17(17):653, November 1999 and Can J Emerg Med 4(4):257, July 2002) One argument against is a two part proximal humeral fracture. In this injury, dislocation of the humeral head can cause avascular necrosis of the head.
Techniques with the arm in the anatomical position The starting point for these techniques is with the humerus in the anatomical position, adducted against the torso. Adduction can be difficult or unobtainable in obese patients. Kocher’s method Originally described in 1870 Kocher’s method did not involve traction.19,20,32 Many texts have incorporated traction,25,27 which has been associated with complications,2830 yet in various case series the original technique has been used safely.31 Significant traction forces in combination with forced internal or external rotation place undue stress on the humeral shaft and neck. The original technique is: ‘Bend arm at the elbow, press it against the body, rotate outwards until resistance is felt. Lift the externally rotated upper arm in the sagittal plane as far as possible forwards and finally turn inwards slowly’.19 Variations include: Leidelmeyer’s external rotation technique, which describes the first manoeuvre of Kocher (elbow flexed, adduction of humerus, external rotation) and then adds traction24 Mount Beauty method, which describes downward traction followed by external rotation.33 An assistant stabilizes the scapula Snowbird technique This technique is essentially downward traction with the humerus in the anatomical position.34 The patient is sitting up straight with humerus in anatomical position, elbow flexed, and forearm supported by the unaffected limb or operator. The operator places a foot into a stockinette loop wrapped around the forearm. Downward traction from the foot is applied, with additional rotation or pressure from the operator’s hands if needed. The Cunningham technique This technique addresses static obstruction by posteriorly directed shrugging of the shoulders.35 This uses the rhomboids to retrovert the scapula reducing the obstruction of the glenoid rim and labrum to the returning humeral head. The dynamic obstruction of the spasming biceps is actively reduced by massaging the muscle at the mid-humeral level. The patient sits without slouching in a hard backed chair, the affected arm adducted to the body and the elbow fully flexed. The operator kneels next to the patient and places his wrist onto the patient’s forearm, the patient’s hand resting on the operator’s shoulder. The patient is asked to shrug the shoulders superiorly and posteriorly, which ‘squares off’ the angle of the shoulder (reducing scapular anteversion and the static obstruction of the glenoid rim). The biceps is massaged at mid-humeral level to specifically relax the muscle (removing dynamic obstruction). The head reduces quickly, painlessly and without traction. Techniques with the arm in the zero position Saha originally described the zero position as that ‘where the humero-scapular aligned axes coincide with the common axis of the cone muscle groups . . . the humerus is 165° overhead and 45° in front of the coronal plane . . . (the scapula) being at the limit of vertical rotation and forward migration on the chest wall. In this position the glenohumeral joint loses all active rotation’.36 Milch separated the muscles around the shoulder into cone groups.3 He noted that with the arm in elevation (full glenohumeral abduction and full scapular rotation/anteversion) the cone groups arrange in a similar direction along the humerus and lose their rotatory/transverse component. Milch’s technique used this overhead position as the critical point at which relocation could most easily occur. This was chosen as ‘the only position in which a single force, exerted along the axis of the humerus, is accurately directed to overcome each and all of the muscle actions at the same time’. This statement was used to explain the choice of position as a point of theory and not as an endorsement in the use of force during the manoeuvre. Indeed, in the supporting case studies he talks about elevating the arm ‘with the greatest gentleness’. Traction has been recommended as part of the Milch technique,6,7,37 but the original description does not use traction. Importantly, with the humerus in complete overhead abduction the scapular has rotated fully on the chest. This puts the humerus (in relation to the rotated scapula) in the zero position. The Milch technique ‘The patient lies in the supine position, while the surgeon takes his position on the side of the dislocation. First manoeuvre in a right sided dislocation the surgeon places his right hand upon the patient’s right shoulder, so that the fingers find firm support on the top of the shoulder, while the thumb is braced against the dislocated humeral head. Second manoeuvre the right hand fixes the head as the left hand gently abducts the arm into the overhead position. During this manoeuvre the head of the humerus is supported so that it cannot move form its dislocated position. As a consequence, instead of moving downward as the arm moves upward, the head rotates in place. Third manoeuvre once the arm has been brought into complete abduction in this overhead position, all cross stresses exerted by all the muscles have been eliminated; the head can be gently pushed over the rim of the glenoid and the dislocation reduced’.3 Variations include: 1. Patient prone with elbow flexed.38 2. Janecki’s ‘forward elevation’ combination manoeuvre29 begins with forward flexion to 90° (step one), then traction is applied and abduction increased (step two). The final position is the overhead position and the humeral head is pushed by direct pressure if reduction has not occurred (step three). 3. ‘Reduction in the position of maximum muscular relaxation’.6 Gentle traction is applied while the shoulder is abducted to 45° (step one). Traction is then increased with further abduction 120° and anteversion 30° (step two). External rotation is then applied (step three). Finally, direct pressure is applied on the humeral head in the axilla (step four). 4. Russell placed the patient supine with back at 30°.39 The patient moves his arm slowly to the overhead position and places his hand behind his head. Gentle traction is then applied to the flexed elbow while the humeral head is guided over the glenoid rim. The author uses a new modification of the technique that fixes the scapula. This limits the rotation (around a vertical axis) and anteversion (tilting forward) of the scapula that ordinarily occurs with glenohumeral movement during abduction past 30°. This allows the ‘zero position’ (used here to describe the critical angle between glenoid fossa and humeral head at point of relocation rather than Saha’s classically described position with the scapula in full rotation and anteversion) to be reached more easily, at about 100° abduction (no more than 120° abduction is possible at the glenohumeral articulation4). This technique is usually performed with the patient seated but has been used in the supine position and, as in the original, no traction is used. Modified Milch technique (for a right-sided dislocation) The patient is seated in a hard backed chair, the operator standing behind the affected limb. The left hand is placed over the trapezius and spine of scapula. This fixes the scapula and detects any scapular movement. The right arm is held by the wrist and gently abducted to 100°. External rotation is applied gradually as the arm is lifted. The humeral head can be gently pushed in a supralateral direction if relocation has not occurred. For a larger patient an assistant might be employed to fix the scapula, the operator in front of the patient using the left hand, leaving the right free to push the humeral head if needed. Techniques with the arm in lateral flexion Eskimo technique40 The patient is placed on the ground lying on the non-dislocated shoulder. Two persons now lift the patient by the dislocated arm, keeping the opposite shoulder suspended a couple of centimetres from the ground. If no reduction occurs direct pressure on the humeral head is applied. Stimson also described this technique as the ‘pendle method’.41 Hippocratic method The patient lies supine while the surgeon holds the arm applying traction. A ‘well stockinged foot’ in the axilla applies countertraction and is also used to lever the humeral head supralaterally. This technique is still recommended in some texts.25,26,37 Traction countertraction7,32,37,42 Traction is applied to the arm with the shoulder in abduction; an assistant applies firm countertraction to the body using a folded sheet. Techniques with the arm in forward flexion Stimson’s hanging arm technique13,43,44 The patient lies prone on a table with the affected arm hanging downward. A weight of 10 lb is applied to the wrist. Reduction occurs secondary to fatigue of the spasming muscles. Variations include: Step two of Janecki’s ‘forward elevation’ combination manoeuvre29 Lippert’s ‘modification of the gravity method’43 has the patient prone with the affected arm hanging vertically and the elbow flexed. Downward traction to the humerus is then applied through the forearm by the operator Rollinson used the hanging method in combination with a supraclavicular nerve block44 Spaso technique30 With the patient supine the arm is gently lifted vertically. While applying traction rotate the shoulder externally. Push the head of the humerus in the axilla. Techniques with the arm in forward flexion plus scapular manipulation Scapular manipulation This technique was described by Bosley in 1979:22 The patient is placed prone on the examining table with the shoulder in a position of 90 degrees of forward flexion and external rotation. The forearm is suspended from the table with the wrist secured and the elbow flexed. Traction on the forearm is maintained with 5 to 15 lbs for a variable period, usually less than five minutes. After the patient begins to relax, the surgeon pushes on the tip of the scapula medially (lifting it on occasion), while simultaneously rotating the superior aspect of the scapular laterally. The technique works by applying constant traction to the externally rotated humerus to reduce pressure of the humeral head on the glenoid rim (sitting supralateral to the dislocated head). This allows the abducted inferior tip of the scapula to be rotated bringing the scapular neck and glenoid fossa into correct alignment. Originally described with the patient prone this caused problems positioning uncooperative patients or women with large breasts.23 Variations include: Arm hanging vertically with weights hung from wrist45 Seated patient46 with one physician performing gentle traction in the forward flexion position with counterbalancing in the patient’s midclavicular region. A second physician manipulates the scapula Supine patient47 Boss Holzach matter This technique relies on movement of the scapula with the humerus fixed by axial traction.8 The scapula is rotated by the patient by actively shrugging the shoulders (anteriorly). The patient sits on an examination table, the wrists bound together and placed around the flexed (homolateral) knee. The head of the table is lowered and patient asked to lean back and hyperextend neck exerting anterior axial traction on the humeral head. The patient then shrugs the shoulders anteriorly increasing anteversion of the glenoid cavity. Techniques with the arm in abduction/forward flexion with external fulcrum Use of an external fulcrum in the axilla as leverage and/or countertraction has been recommended since Hippocrates.25,41 The choice of fulcrum and direction of traction varies: Nordeen uses the back of a chair in the axilla combined with downward traction48 Manes uses downward traction with the operator’s forearm as an external fulcrum49 Slump reduction technique.50 An assistant supports the axilla from behind while the physician applies longitudinal traction. If unsuccessful external rotation and then scapular manipulation are added White uses the back of a chair as an external fulcrum and abduction with downward traction51 (Emergency Medicine Australasia Volume 17, Issue 5-6, Oct 2005)
Journal of Emergency Medicine Volume 31, Issue 1 , July 2006, Pages 23-28 Validation of rule to limit x-rays
FARE MethodThe Journal of Bone and Joint Surgery (American). 2009;91:2775-2782. Younger patients should be immobilized for about 3 weeks. Those > age 60 should have early follow-up (5-7 days) to allow for early immobilization to avoid joint stiffness (Roberts: Clinical Procedures in Emergency Medicine, ed. 4, pg. 957)
Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial.
Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
BACKGROUND: An initial anterior dislocation of the shoulder becomes recurrent in 66% to 94% of young patients after immobilization of the shoulder in internal rotation. Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation. Our aim was to determine the benefit of immobilization in external rotation in a randomized controlled trial. METHODS: One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were randomly assigned to be treated with immobilization in either internal rotation (ninety-four shoulders) or external rotation (104 shoulders) for three weeks. The primary outcome measure was a recurrent dislocation or subluxation. The minimum follow-up period was two years. RESULTS: The follow-up rate was seventy-four (79%) of ninety-four in the internal rotation group and eighty-five (82%) of 104 in the external rotation group. The compliance rate was thirty-nine (53%) of seventy-four in the internal rotation group and sixty-one (72%) of eighty-five in the external rotation group (p = 0.013). The intention-to-treat analysis revealed that the recurrence rate in the external rotation group (twenty-two of eighty-five; 26%) was significantly lower than that in the internal rotation group (thirty-one of seventy-four; 42%) (p = 0.033) with a relative risk reduction of 38.2%. In the subgroup of patients who were thirty years of age or younger, the relative risk reduction was 46.1%. CONCLUSIONS: Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation. This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.( J Bone Joint Surg Am. 2007 Oct;89(10):2124-31)
Scalene block vs. procedural sedation by Blaivas (Acad Emerg Med 2011;18:922)
Greg Hendy Method:
Bledsoe ARC, also comes in cool version 20 degree internal to 70 external
Posterior Shoulder Dislocation
Arm is held in adduction and internal rotation, can not abduct.
Assoc. c fx of lesser trochanter.
Inferior Dislocation (Luxatio Erecta)
Caused by hyperabduction
Pt presents with arm in the asking a question position.
Assoc c brachial plexus and axillary artery damage
Rotator Cuff Tears
- Supra and infraspinatus atrophy
- Weakness with elevation and external rotation. Test with the Drop arm test-abduct to 90 degrees, slight pressure will cause pt to drop arm.
- Impingement sign-move the patient’s straightened arm to full abduction and 90 of elbow flexion. Move the patient’s arm across their body. If it causes pain, then positive.
Yerguson’s test with flexed elbow, have pt supinate against resistance, pain is positive
Biceps Tendon Rupture
Reduce by pulling both shoulders backwars. Fracture can injure subclavian as well as CN IV-VIII.
Need ortho only if neurovascular injury, skin tenting, or open fracture
Sling and refer
Assoc. c intrathoracic injury
May need CT Chest for Pneumo and pulm. Injuries
Get axillary view of shoulder
Treat c Sling
As discussed after the shoulder talk, scapulothoracic dissociation is a cool diagnosis that most of us don’t know too much about. Attached is the first case report and a couple more recent reviews. Here’s the abstract from the first case report:
closed forequarter amputation
as manifested by lateral displacement of the scapula and acromioclavicular separation, is a previously unreported injury in which there is a complete disruption of the scapulothoracic articulation without an overlying partial or complete amputation through the soft tissue. Associated with the disruption of the scapulothoracic articulation are injuries to the brachial plexus and the subclavian artery and vein; multiple open and closed fractures of the ipsilateral upper extremity are often present also. In the patient with severe multiple injuries, scapulothoracic dissociation may not be recognized immediately, with potentially fatal consequences. In this paper we present the cases of three patients with radiographic and pathological evidence of scapulothoracic dissociation and review the literature on related injuries.
Legg Reduction Maneuver (JAOA 2008;108(10):571)
seat patient with back against something firm at 45-90 degree angle
assitant pushes down on oppsoite shoulder
abduct arm straight out to 90
face their palm forward
flex elbow to 90
pull arm back so it is behind the coronal plane of the occipit
adduct arm fully flexing the elbow
internally rotate and adduct arm so it crosses the patients chest
Self Reduction of a Shoulder
From Trevor Jackson’s TJDogman:
This condition is “Brachial neuritis” or “Parsonage-Turner syndrome” an acute idiopathic neuropathy with predominantly motor rather than sensory findings. It presents initially with severe pain in the shoulder followed by weakness affecting various branches of the brachial plexus, with the upper trunk most commonly affected. (anatomy reminder) The condition can be bilateral, and 80% of patients will recover function although this may take two years.
I hadn’t heard of this condition before and a search of the standard EM texts wasn’t so helpful with only Tintinalli including it. I suspect this might be because many of these patients would be referred direct to neurologists rather than ED. I’ve posted this case mainly to share my illumination of something completely new, particularly given the puzzling nature of the presentation (use of dogma no. 3 didn’t help me this time) And the supraspinatus tear? Just an incidental finding that succeeded in throwing us off the scent!