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Date posted: May 1, 2012

Dr Sreekumar A

Mr.Vellan a 70 yrs old male manual labourer from Padanilam, Kunnamangalam was admitted in our Materia Medica Unit on  22nd of last May.

Presenting complaints:

  • C/o pain Rt shoulder joint since six months
  • <Evening,pressure
  • >Lying on painless side
  • Pain extends to back of neck and rt upper arm.
  • Stiffness and restriction of movements in Rt shoulder since three months.
  • Pain abdomen since one year.
  • Burning sensation
  • <1hour after eating.
  • >drinking cold water.
  • Associated with sour eructations and heartburn.

Past illness history
H/o trauma Rt shoulder 8 months back.
Took Allopathic treatment with temporary relief.
H/o trauma Lt wrist and leg 3 years back.
No relavant illness among family members
Patient is married and has four children.He had the habit of smoking and taking alcohol till last 4 years.

Appetite good
Thirst normal
Bowels regular
Urine Normal.Desire comes on while standing
Sweat generalized.
Sleep satisfactory
Desires sweets
Aversion sour. salt
Generalised night <
Amphithermal
Prefers fanning
Bathing in hot water gives relief.

Headache esp left sided.
Burning sensation inside abdomen < spicy and pungent food
Frequent desire to urinate more while standing.Passes only small quantity.
Pain Rt Knee > by rubbing.
Physical examination
General Survey – Patient is conscious and alert. She is moderately built and nourished. No clubbing,cyanosis,icterus or lymphadenopathy.Conjuctival pallor and pedal oedema present.

Vitals
PR -72/mt
RR – 18/mt
BP – 120/70
Temp – 98.5

Local Examination
Inspection– Normal bone contours,Colour and texture normal,No scars or sinuses.
Palpation – Normal bone and soft tissue contours.Deep Tenderness +
Movements- All gleno-humeral movements are almost absent.Movements are painful.No crepitations.
Muscle Power – Normal
Measurements – No discrepancy in limb length.
Acromio-clavicular and Sterno-clavicular joints are normal.
No potential extrinsic sources of shoulder symptoms seen.
No abnormalities detected in systemic examination.
Provisional Diagnosis – Periarthiritis or Frozen right Shoulder.

Investigations
Blood :
R/E – NAD
RBS – 120mg%
Xray – Not taken

Final diagnosis : Periarthiritis or Frozen right Shoulder.

Evaluation of symptoms:
Generals 
H/o trauma
Urinary urge comes on while standing
Desires sweets
Aversion sour. salt
Generalised night <
Prefers fanning
Bathing in hot water gives relief.

Particulars 
Pain Rt shoulder joint
<Evening,pressure
>Lying on painless side
Pain extends to back of neck and rt upper arm.

Stiffness Rt shoulder.
Pain stomach
Burning sensation
<1hour after eating.
>drinking cold water.
Sour eructations
Heartburn
Headache esp left sided.
Burning sensation inside abdomen < spicy and pungent food
Pain Rt Knee > by rubbing.

Rubrics taken -
Generalities\Injuries (including blows,falls and bruises):
Stomach\Emptiness, weak feeling, faintness, goneness, hungry feeling:Eating:Agg.:After:
Stomach\Pain:General:Warm:Drinks:Amel.:
Extremity Pain\Upper limbs:Shoulder:Evening:
Extremity Pain\Upper limbs:Shoulder:Lying:Painful side, on:Amel.:
Extremity Pain\Upper limbs:Shoulder:Warmth:External:Amel.:
Extremity Pain\Upper limbs:Shoulder:Extending to:Neck:
Extremities\Stiffness:Shoulder:
Extremity Pain\Lower limbs:Knee:Rubbing amel.:

PDF
Desires sweets
Aversion salt
Aversion sour

Medicines considered.
Lyco 12/7,
Rhustox 11/5,
Phos 8/5,
Verat 7/5.

23/5/06
Pain shoulder,pain abdomen. -  Lyco 6C/1Dose
Repeated daily one dose for next five days.
Started Physiotherapy.Ultrasound + gentle exercises.

28/5/06
Pain shoulder >
Pain knee>
31/5/06
Heartburn>
1/6/06
Pain shoulder <.             –                  Lyco 6C 1Dose.
Pain shoulder showed slight relief.
Knee pain>
3/6/06
Pain shoulder same as last day         Lyco 12C 1Dose
5/6/06
Slight relief for pain
Stiffness >
Range of movements improving       Lyco 12C 1 Dose
12/6/06
Complaints persisting                       Lyco 12C 1 Dose
14/6/06
Gen relief
Pain>
Heartburn>

Since then no medicines were repeated except biochemics.
Now the pain is less and range of movements have increased.
He is continuing physiotherapy.

Pectoral Girdle 
Or shoulder girdle connects the upper limb to the axial skeleton.
It consists of clavicle and the scapula.
Scapulohumeral rhythm.

Shoulder Joint
Or glenohumeral joint is a ball and socket type of synovial joint that permits a wide range of movement,however its mobility makes the joint relatively unstable.

Joint Capsule
It has two apertures.
1) An opening between the tubercles of the humerus for passage of the tendon of the long head of the biceps brachii.
2) A communication with subscapular bursa.

Ligaments
Intrinsic ligaments are
1)Glenohumeral ligament which strengthens the anterior aspect
2)Coracohumeral ligament which strengthens the capsule superiorly
3)Transverse humeral ligament which converts the intertuberculargroove into a canal and holds the synovial sheath and biceps tendon in place.

Extrinsic ligament – Coracoacromial ligament which is a part of  coracoacromial arch.

Muscles
Extrinsic Shoulder Muscles
Superficial posterior axioappendicular muscles
Trapezius and Latissimus dorsi.

Deep posterior axioappendicular muscles.
Levator scapulae and Rhomboids.

Intrinsic shoulder muscles
Deltoid,Teres major,Teres  minor,Supraspinatus,
Infraspinatus and Subscapularis.

Rotator Cuff Muscles
Four of the scapulohumeral muscles (Intrinsic shoulder) ie Supraspinatus,Infraspinatus,Teres minor and subscapularis are grouped as Rotator Cuff muscles.

Movements of Shoulder joint.
Abduction
Adduction
Flexion
Extension
Lateral (External) rotation =80 degrees
Medial (Internal) rotation = 110degrees
Circumduction.

Blood Supply of Shoulder joint.
Anterior and posterior circumflex humeral arteries and branches of suprascapular artery.

Nerve supply of Shoulder joint.
The suprascapular,axillary and lateral pectoral nerve

Bursae around shoulder joint

Subscapular bursae – lies between tendon of Subscapularis and the neck of scapula.It communicates with the joint cavity.

Subacromial bursae – also known as Subdeltoid bursae.
It is located between acromion, coracoacromial ligament and deltoid superiorly and supaspinatus tendon and joint capsule inferiorly.

Disorders of Shoulder joint
Arthritis
Pyogenic arthritis
Rheumatoid arthritis
Tuberculous arthritis
Osteoarthritis
Frozen shoulder or Adhesive capsulitis or periarthritis.
Painful Arc Syndrome or Supraspinatus syndrome
Rupture of long tendon of biceps

Mechanical derangements
Recurrent dislocation
Tear of tendinous rotator cuff
Tenosynovitis of long tendon of biceps or biceps tendinitis.
Axillary nerve injury
Glenoid labrum tears

Frozen shoulder or Adhesive capsulitis or periarthritis.
Common but illunderstood affection charecterised by pain and uniform limitation of all movements but without radiographic changes and with a slow spontaneous recovery within six to twelve months.
Significance of injury is doubtful.
Usually seen in Diabetics.

Pathology – Loss of resilience of the joint capsule,with adhesions between the inflamed joint capsule,rotator cuff,subacromial bursa and deltoid.

C/f-
40-60yrs
Gradual and spontaneous onset of severe aching pain in shoulder and upper arm.All glenohumeral movements are reduced to about a quarter or half of their normal range.Pain subsides first leaving stiffness.

Conservative treatment – In acutely painful stage,arm is rested in a sling,which is moved for short periods each day to permit gentle assisted exercise.When the pain lessens active exercises are intensified until full movements are attained.

Pain may also be referred from lesions inside thorax or abdomen.

Thorax
Angina pectoris
Pleurisy(irritation of phrenic nerve endings)
Pancoast’s apical lung(involvement of the lower trunks of brachial plexus)

Abdomen
Cholecystitis(irritation of phrenic nerve)
Subphrenic abscess.

Investigations
Blood – R/E
Radiographic examination – The routine shoulder film is a Antero-posterior projection with the limb in the anatomical position.When additional information is required Axillary projection with the arm abducted 90 degrees.

Arthrographic examination – After injection of radio opaque fluid into the joint,it will show whether or not the capsule is intact.

Other imaging techniques like – Radio-isotope scanning,CT,MRI can be considered in appropriate circumstances.

Therapeutics.
A Select Homoeopathic Materia Medica (Part 1) by Tarkas P. and Ajit Kulkarni.

Kali iodide – Frozen shoulder; or neuralgia of brachial plexus, (<) motion of opposite arm (Caust.).

Psorinum – Frozen shoulder with heart involvement. Brachial plexus neuritis. Sciatic pains; tension in knees; chronic inflammation of knee, pain (<) hanging limb.

Materia medica by Boericke W.

Thiosinaminum Rhodallin – A resolvent, externally and internally, for DISSOLVING SCAR TISSUE, tumors, enlarged glands; lupus, strictures, adhesions.

Chelidonium – Gall-stones, with pain under the right shoulder-blade.

Keynotes with Nosodes by Allen H.C.

Gaertner – Fibrositis shoulders- Rheumatism shoulders (worse at night). Rheumatism hands.

SYNOVITIS

Apis
Stinging, sudden lancinating pains in parts affected; EFFUSION: (<) from least motion; (>) from cold applications; oedema around joint; (>) from cold applications ( Bry., (>) from hot ones).

Belladonna
Excessive pain, with sensation as if the surrounding ligaments were contracted,or when there is a bubbling, as from drops of water,with cutting and drawing pains; congestion to head, flushed cheeks, etc.

Bryonia
Painful tension and pressure in right shoulder;from warmth of bed; affected joint pale- red and tense; effusion into synovial sac.
Calcarea
Chronic causes, in pale weakly persons of a scrofulous habit; drawing pressure in the joints; osseous system otherwise affected.

Causticum
Stiffness of joints; bruised,tearing and sticking pains; stiffness of joints; profuse sweat; numbness of the parts; worse in the evening.

Cimicifuga
With the synovitis there are wandering rheumatic pains; chilliness alternating with heat; great distress of mind.

Colchicum
Inflammation of the joints, with tearing, jerking lacerating pains; worse at night and by motion,care or anxiety; stiffness and lameness of joints when attempting to walk,moist skin, urine turbid.

Ledum
Disease of joints,EFFUSION, with sensitiveness of the parts to pressure;aching tearing pains; great coldness; want of vitality.

Lycopodium
Stiffness of joints; pains > by warmth and < in cold, rainy weather.

Mercurius
Drawing pains with aching in the bones and rigidity of the parts, worse at night, with profuse, not alleviating sweat; feeling of coldness and chilliness; threatening suppuration.

Pulsatilla
Joints swollen, with sharp erratic accompanied by a feeling of soreness or of subcutaneous; tearing stinging,erratic pains force the patient to move the affected joint, (>) by pressure ands slowly moving about jerking pains down the limbs, (<) evening and from warmth,(>)by cold, gonorrhoeal or traumatic synovitis or gouty, especially in affections of the knee,ankle and tarsal joints.

Ruta-grav
Inflammation of the larger joints, especially of the upper extremities.

Rhus-tox
Stitches in the tendons surrounding the joints, with tingling and burning in them and rigidity of the joints,tendency to typhoid conditions.

Sulphur
Synovitis after exudation took place,particularly of knee, as it produces absorption, and urges other drugs to do their work; jerking of limbs on falling off to sleep.

Ammonium-mur
Rheumatic pain, first in right, then in left at shoulder-joint; stitches in right scapula, when inspiring.

Apocynum
Rheumatism and gout; pain especially in right shoulder and knee; pain and stiffness in back of head and neck.

Cactus-grand
RHEUMATISM OF HEART, with sensation of constriction around heart and fear that he will not recover.In Angina pain radiates to shoulder. (<) in rest or in motion, (>) from continued gentle motion.

Calcarea-carb
Is the chronic Rhus, and often comes in where the latter fails. Rheumatism from WORKING IN WATER OR BY A LONG CONTINUANCE IN IT; chronic cases with swelling of joints, (<) with every change of weather; crackling or crepitation of joints, as if they were dry; weakness and weariness of all the limbs; sensation of coldness on top of head; profuse sweat and cold, damp feet; omodynia in right shoulder or from left shoulder down left arm towards the heart; lumbago; cold feeling in various points, as gluteal region; pains CONFINED TO SMALL SPOTS; gouty nodosities about fingers;

Carbolic-acid
Pains feel as if they would be increased by motion, but they are not; sharp pains, coming and disappearing suddenly, last only a short while; hip and shoulder-joint especially affected.

Causticum
Rheumatoid arthritis; chronic articular rheumatism, when joints are stiff and tendons shortened, drawing the limbs out of shape, (<) from cold and (>) by warmth; restlessness at night; averse to being uncovered;rheumatic aching in shoulder; paralysis of deltoid, cannot raise hand to head; constant tearing and piercing pains, compelling constant motion, which does not relieve, always coming on in the evening and diminishing in the morning, (<) from dry cold air or snowy weather.

Fluoric-acid
Rheumatoid arthritis; rheumatic pains in the left arm, from shoulder to elbow; with lameness; pain in all limbs, with weakness and numbness; constant desire to be in fresh air, it does not fatigue him.

Gelsemium
RHEUMATIC NEURALGIA, myalgia; pains from spine to head and shoulders; rheumatic pains in upper and lower extremities, induced by cold, with laming sensation; DEEP- SEATED MUSCULAR PAINS, wants to lie still; excessive irritability of mind and body.

Kali-cyan
Chronic articular rheumatism, (<) from getting out of bed and by motion, without any swelling,sharp stitches in right shoulder.

Lycopodium
Chronic forms, especially of old people, with painful rigidity of muscles and joints, and feeling of numbness in affected parts, forgetfulness, sour belching, early nausea, flatulence oppression of chest, palpitation, etc worse at rest and in wet weather, better in warmth; rheumatic tension in right shoulder-joint, in left hip.

Magnesia-carb
Rheumatic pain in the shoulders (at night), with tingling down to the fingers, preventing the least movement of the arm.

Mercurius-biniod
Rheumatic pains, now here, now there, mostly muscular, alternately in arms and hands, legs and feet; violent pain, like otalgia, in left ear; rheumatic pains in shoulder-joints; soreness and stiffness in arms, (<) by motion; pains only during rest at night in bed or lying down in daytime, never during active motion.

Mezereum
Pains begin in the evening, last all night and pass off at daybreak (Syphilinum); rheumatic pains in scapular muscles, which feel tense and swollen, preventing motion; pain in shoulder-joint, as if it would be torn asunder; (<) in winter.

Nux-moschata
Muscular rheumatism, from protracted exposure to cold and damp; fugitive drawing pains, worse in repose, from cold, damp air and cold and wet clothes, better from warmth; rheumatism of left shoulder and right hip.

Phytolacca
Rheumatic affections of the shoulders and arms, especially in syphilitic patients; the pains fly from one part like electric shocks to another part, worse at night and in damp weather; PAINS IN MIDDLE OF LONG BONES,or attachment of muscles.Enlargement of the glands of the neck and axilla.

Rhus-rad
Pleurodynia or false pleurisy when pains go to shoulders; pain following the course of the ulnar nerve.

Sanguinaria
Acute muscular rheumatism, pains erratic, sharp, stitching, with great soreness and stiffness of the muscles, especially those of back and neck; rheumatism affecting the right deltoid muscle (like fer.; nux-m., left deltoid); pains intense, (<) in places least covered with flesh, but not in joints, on touching painful part pain vanishes and appears in some other part.rheumatic pain in right arm and shoulder, (<) at night, on turning in bed, cannot raise arm.

Sepia
Coldness between shoulders as from a cold hand; feels as if she could feel every muscle and fibre of her right side from shoulder to feet; arthritic pains in stiff joints; ankles weak and turning easily when walking.

[Complete ] [Back]Pain:General:Cervical region:Extending:Shoulders:
[Complete ] [Extremities]Frozen:Shoulder:
[Complete ] [Extremities]Inflammation:Joints:Synovitis:
[Complete ] [Generalities]Inflammation:Synovitis:
[Kent ] [Extremities]Inflammation:Joints:Synovitis:
[Boericke ] [Locomotor System]Joints:Inflammation :Synovitis acute:
[Clarke ] [Clinical]Joints:Synovitis of:
[Clarke ] [Clinical]Synovitis:
[Knerr ] [Limbs in General]Joints:Inflammation:Synovitis, subacute:
[Complete ] [Extremities]Anchylosis:Shoulders:
[Complete ] [Extremities]Fibrositis, shoulders:
[Complete ] [Extremities]Stiffness:Shoulder:
[Complete ] [Extremities]Stiffness:Shoulder:Left:
[Complete ] [Extremities]Stiffness:Shoulder:Right:
[Complete ] [Extremities]Stiffness:Shoulder:Morning:
[Complete ] [Extremities]Stiffness:Shoulder:Evening:
[Complete ] [Extremities]Stiffness:Shoulder:Night:
[Complete ] [Extremities]Stiffness:Shoulder:Put arm over head, must:
[Complete ] [Extremities]Stiffness:Upper arm:
[Complete ] [Extremities]Stiffness:Upper arm:Deltoid:
[Complete ] [Extremities]Stiffness:Upper arm:Rheumatic:
[Kent ] [Extremities]Injuries:Shoulders:
[Complete ] [Extremities]Injuries:Shoulders:
[Kent ] [Extremities]Stiffness:Shoulder:
[Boenning ] [Upper extremities]Stiffness:Shoulder:
[Boenning ] [Upper extremities]Stiffness:Joints:Shoulder:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Injury, after:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Right:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Right:Injury, after:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Abducting arm agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Anchylosis:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Hanging down the arm:Amel.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Raising the arm:Agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Rheumatic:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Rheumatic:Left:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Rheumatic:Right:
[Wards ] [G]Glenoid:The head of the right humerus is painful, as if it were swollen and  had not room enough in the capsule of the joint:
[Wards ] [H]Humerus:Pain in the shoulder-joint as if the head of the humerus was too large for the capsule of the joint:
[Wards ] [H]Humerus:On moving the upper arm, a pain with in shoulder-joint as if the head of the humerus was lying loosely within the Capsule of the joint and would be dislocated:
[Wards ] [S]Small:Pain in the shoulder-joints, as if the head of the humerus were too large for the capsule of the joint:
[Complete ] [Generalities]Adhesion:
[Knerr ] [Tissues]Inflammation:Adhesions, recent, consequent upon inflammations:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Right, then:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Night agg,:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Bladder complaints, and:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Cough, during:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Heart complaints, and:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Hip, and right:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Injury, after:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Lying on painless side agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Left:Extending to:Hypochondrium, left:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Right:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Right:Left, then:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Right:Cough agg,:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Right:Injury, after:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Right:Knee, and left:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Morning:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Night:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Night:Bed, in:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Night:Motion of arm impossible on account of the pain:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Night:Waking:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Abducting arm agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Anchylosis:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Cough, during:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Fever, during:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Hanging down the arm:Agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Hanging down the arm:Amel.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Lying:Painful side, on:Amel.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Lying:Painful side, on:Agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Motion, on:Agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Motion, on:Agg.:Arm, of:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Motion, on:Agg.:Arm, of:Backwards:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Motion, on:Amel.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Motion, on:Amel.:Shoulder, of:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Pressure:Agg,:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Pressure:Amel.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Raising the arm:Agg.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Raising the arm:Amel.:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Rheumatic:Left:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Rheumatic:Right:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Rheumatic:Night:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Shrugging agg,:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Touching, when:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Turning in bed:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Writing, while:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Arm:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Back:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Chest:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Deltoid
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Ear:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Elbow:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Fingers:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Forearm:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Hand:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Extending to:Upper limbs:
[Complete ] [Extremity Pain]Upper limbs:Shoulder:Acromion:

Dr.Sreekumar.A.
Email : hmctirur@gmail.com
Mob : 9447340401

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