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August 5, 2014 Issue

Clinical Practice Points

Medical Knowledge
Patient Care

One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome. A Pragmatic, Randomized Trial

This trial found that patients with the shoulder impingement syndrome who received 1 to 3 corticosteroid injections and those receiving 6 sessions of manual physical therapy had similar improvements in shoulder pain and function. Patients who received a corticosteroid injection sought more shoulder-related health care throughout the 1-year follow-up.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review causes of shoulder pain that make up the rotator cuff syndrome, including rotator cuff tendinitis and shoulder bursitis. Use the concise information in ACP Smart Medicine: Rotator Cuff Tendonitis for information on important physical examination findings, figures, and more.
  • Discuss the findings of this randomized trial. Ask your learners what is meant by a “pragmatic” trial, and how does it differ from an explanatory trial. Which one assesses efficacy and which one assesses effectiveness, and what’s the difference? What are the advantages and limitations to each?

Medical Knowledge

Asbestos and Smoking as Risk Factors for Idiopathic Retroperitoneal Fibrosis. A Case–Control Study

This case–control study found that asbestos exposure and smoking were strong risk factors for retroperitoneal fibrosis.

Use this study to:

  • Review what retroperitoneal fibrosis is and what entities are thought to trigger it (e.g., malignancy, surgery, infection).
  • Review the diseases known to be caused by asbestos exposure. What is the relationship between asbestos exposure and smoking in asbestosis and in this study of idiopathic retroperitoneal fibrosis?
  • Ask your learners how a case–control study is used to identify risks for a rare disease. What are the limitations? Why is the small number of cases with exposure to asbestos but not smoking in this study a limitation?

Medical Knowledge
Patient Care

Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians

In this guideline on the diagnosis of obstructive sleep apnea in adults, the American College of Physicians recommends a sleep study for patients with unexplained daytime sleepiness, polysomnography for diagnostic testing in patients with suspected obstructive sleep apnea, and portable sleep monitors in patients without serious comorbid conditions when polysomnography is not available for diagnostic testing.

Use this guideline to:

  • Review what symptoms and physical examination findings should prompt consideration of sleep-disordered breathing.
  • Ask your learners if they know how to order a sleep study. Which one? What are the limitations of a monitor that does not have electroencephalographic leads? What are the advantages to a portable monitoring system?
  • Invite a sleep specialist to review the types of tests available and go over what polysomnogram tracings look like in obstructive sleep apnea. There are example figures in ACP Smart Medicine: Obstructive Sleep Apnea to use for teaching.

Medical Knowledge
Interpersonal and Communication Skills
Systems-based Practice
In the Clinic logo


This concise review discusses the evaluation and treatment of dementia, covering key issues such as whether to screen for dementia, how effective are available treatments, advice about driving, and more.

Use this review to:

  • Ask what conditions should be considered in a patient with signs suggestive of dementia.
  • What blood work should be considered, and when should imaging be performed?
  • Review the diagnostic criteria for Alzheimer disease.
  • Ask what behavioral and pharmacological interventions should be considered.
  • Download the already prepared teaching slides to help with your teaching.
  • Use the multiple-choice questions at the end to introduce key subjects and to provide breaks during your teaching session. Then, log on and enter your answers to earn CME credit for yourself.

Our Profession


The American Board of Internal Medicine: Evolving Professional Self-regulation

Maintenance of Certification: Beauty Is in the Eyes of the Beholder

Recent changes in the board certification process are a topic of much debate. One of these commentaries presents the American Board of Internal Medicine’s perspective on these changes in the certification process and their importance to professional self-regulation. The other describes why many believe that the current process is burdensome and not beneficial and offers suggestions for an assessment process that better reflects the skills necessary to be a good internist.

Use these commentaries to:

  • Review the current requirements for maintenance of certification (MOC) with your senior residents. Do they know what will be required of them to maintain their certificates after they complete their residency and pass their initial board certification examination? Ask if they know what the requirements are for continuing medical education (CME).
  • Ask your learners if they think MOC should be a continuous process or if demonstrating medical knowledge on an examination at set intervals is sufficient. Do they think a closed-book, secure examination is an appropriate means of assessing competence? Why or why not?

Humanism and Professionalism


On Being a Doctor: Trying to Save a Health Care System: Colombian Residents Go on Strike

In her essay, Dr. Gottfried describes the anxiety she felt for patients in need of care when medical residents in Colombia went on strike to protest legislation they believed was detrimental to patients’ health.

Use this essay to:

  • Play an audio recording of this essay, read by Dr. Michael LaCombe.
  • Ask your learners if they think physicians should be allowed to go on strike. If so, should there be limits to the circumstances in which strikes are permitted? Do doctors have an obligation to continue providing urgently needed care under all circumstances?
  • Ask your learners what they would have done if they were in Dr. Gottfried’s situation at the time of the strike. Would they have felt comfortable walking out of the hospital? Would they have felt like “scabs” for staying in the hospital?


A 42-year-old woman is evaluated for a 10-day history of right shoulder pain, located posteriorly and superiorly, that becomes worse with overhead activities. She has no history of trauma. She recently painted her basement ceiling. She has no weakness or paresthesia of her right arm and has never had this problem before. She has been taking ibuprofen as needed for the pain.

On physical examination, vital signs are normal. There is no shoulder asymmetry and no tenderness to palpation of bony structures or soft tissue structures. There is full range of motion (other than with internal rotation, which is limited by pain) and strength is 5/5 throughout the right arm, with sensation intact. She is able to slowly lower her extended arm from over her head to her side (negative drop-arm test). There is pain with abduction of the right arm between 60 and 120 degrees. The patient is asked to hold the arm extended anteriorly at 90 degrees with the forearm bent to 90 degrees (at 12 o’clock), as if holding a shield. When the arm is internally rotated to cross in front of the body, the patient feels pain in the shoulder (positive Hawkins test).

Which of the following is the most likely diagnosis?

A. Acromioclavicular joint degeneration
B. Adhesive capsulitis
C. Rotator cuff impingement
D. Rotator cuff tear

Correct Answer
C. Rotator cuff impingement

Key Point
Rotator cuff impingement syndrome due to underlying tendinitis is a common cause of nontraumatic shoulder pain; characteristic findings are pain with arm abduction and a positive Hawkins test.

Educational Objective
Diagnose rotator cuff tendinitis.

This patient most likely has rotator cuff impingement syndrome from underlying tendinitis. She presented with pain in her shoulder that began after performing the repetitive overhead motion of painting, and her pain is most pronounced with abduction of her arm. On examination, her pain occurs between 60 and 120 degrees of abduction, which supports the diagnosis of rotator cuff tendinitis. She also has a positive Hawkins test, which has a high sensitivity (92%) but poor specificity (25%) for rotator cuff impingement.

Acromioclavicular joint degeneration is typically associated with trauma (in younger patients) or osteoarthritis (in older patients). Palpable osteophytes may be present, and radiographs, if obtained, may demonstrate degenerative changes. It characteristically presents with pain that occurs with shoulder adduction and abduction above 120 degrees. This diagnosis is unlikely in this patient given that she has no history of trauma and that there is no acromioclavicular joint tenderness on examination.

Adhesive capsulitis is caused by thickening of the capsule surrounding the glenohumeral joint. Adhesive capsulitis presents with loss of both passive and active range of motion in multiple planes and patient reports of stiffness, which are not present in this patient. Also, pain is typically slow in onset and is located near the insertion of the deltoid muscle.

Rotator cuff tears are usually accompanied by weakness and loss of function. Examination findings include supraspinatus weakness, weakness with external rotation, and a positive drop-arm test. The absence of weakness along with the negative drop-arm test argues against the presence of a rotator cuff tear in this patient.

House J, Mooradian A. Evaluation and management of shoulder pain in primary care clinics. South Med J. 2010;103(11):1129-1135. PMID: 20890250

This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.


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