Decoding Shoulder Pain: Dr Gavin Nimon's insights on Diagnosis and Treatment

Speaker 1: 0:28

Good day and welcome to the Aussie Med Ed, the Australian Medical Education broadcast, where we get to interview specialists in a variety of medical areas, asking their opinion on their certain conditions, obtaining their insight into how they diagnose and treat that condition. These COVID times it's a way of replacing the relaxed discussion around the hospital by allowing the listener to put forward questions to be answered addressed on their behalf. I hope you enjoyed the whole program. Welcome once again to Aussie Med Ed.

In this episode we're going to present an orthopedic topic, an area of shoulder surgery which is my area of expertise. As such, in this episode I've decided to discuss the issue of shoulder pain, both the assessment of patients with the conditions, the various causes of it, how to make the diagnosis and investigations required, and the treatment of the most common causes of shoulder pain, that being the rotatoculf spectrum, including impingement and bursitis, tendinopathy and rotatoculf tears. I'm Gavin Nyman, an orthopedic surgeon based in Adelaide and South Australia. I'm the host of this podcast. I'd like to begin this podcast by acknowledging the traditional custodians of the land which this podcast has been produced and pay my respects to the elders, both past and present. Okay, a little bit about myself. I'm a orthopedic surgeon, having graduated from the University of Adelaide, worked in the United Kingdom for a period of time before heading back to Australia. I'm a fellow of the Royal Australasian College of Surgeons and also the Royal College of Surgeons of Edinburgh, and also a fellow of the Australian Orthopedic Association. I hold the senior lecturer position at the University of Adelaide and I'm involved in medical student teaching, particularly the fourth years and sixth years at university. It's my passion for orthopedics as well as teaching that's made me introduce this idea of doing this podcast, and this is actually introduced the topic of my choice, that being shoulder pain, which is a very common question that's put to me as a senior lecturer.

So shoulder pain is really the most common thing that I would see in my orthopedic practice. It's really a very common question put to me by general practitioners and medical students on how you assess it and how you treat the various causes of it. Really, I start off by saying that the first, most important part of it is to actually exclude other causes of shoulder pain, as the cause In other words, depending on where the pain is actually experienced depends on whether it's actually shoulder pain or it's arising from some other area. For example, I put down the fact that the pain felt down the medial board of the scapula or in the posterior triangle of the neck is more likely to be related to the cervical spine, as well as pain on the front of the chest wall being more likely to be related to the ribs or from a muscular cause. Shoulder pain is generally felt on the front of the shoulder or laterally. Pain on the front of the shoulder is seen to arise from the glenic hemo joint, or pain laterally is more in the subacromial area, in the bursal region. One must never forget that cardiac causes can also cause shoulder pain, particularly left sided shoulder pain as well. So when we start looking at a shoulder cause, we look at the actual side of pain, and if the pain is actually either the medial board of the scapula or lower in the chest wall or in the exilla, I start thinking that it might not be related to the shoulder in itself. When we come to the causes of shoulder pain, it's really important to know the various diagnoses, and I actually like to divide this up into a simplified pattern. Really, unless you know the various diagnoses that occur in a condition, you can't actually make a diagnosis. Example being let's you know what you're looking for when you go to assess a patient, so you can't form a formal diagnosis because you don't know the various options of diagnoses are. The way I think about it is how a patient might present. They might either come through a clinic and see them in outpatients, or they might come through emergency as a traumatic presentation, and thus we divide the traumatic presentations into things that have been caused by a trauma, such as a fracture or dislocation, and sometimes infection can present in this way. They could recall a small trauma, or they may come through casualty with severe pain, but really I divide the traumatic presentations into fractures, dislocations and infections, including this group could be acute ruptures of tendons as well. Well, the length of conditions are usually ones that present in a clinic and they relate to the condition in itself, and the shoulder relates to either rotata cuff spectrum, that being bursitis, tendinopathy with secondary rotata cuff tears, or then secondary osteoarthritis, or it can relate to arthritis of the hemal joint or another part of the joint in the shoulder, or also late, to frozen shoulders. So let's put this in a simplified fashion If a patient presents in a traumatic fashion I either had a fall or a major trauma or injury then that's a traumatic presentation. And when we think of a traumatic presentation, we think what can be a fracture, is it a dislocation or is it an infection? So, if someone falls on the football field, could it be a fracture or dislocation? Okay, what could be fractured? Obviously, the most obvious cause is a bone. What bones have made up the shoulder? There's three bones really, that being the three bones being the clavicle, the scapula and the proximal humerus. If there's a dislocation, what can be dislocated? The obvious answer is a joint, the joints that actually make up the shoulder. There's three of them, again following the rule of threes. There's a sternocular vicular joint, which is a fairly stable joint and doesn't often dislocate but can occur on occasions. There's the AC joint, which is a very common cause of dislocations. Or there's a glenohumeral joint itself, which is the main proximal humerus, dislocating out of the glenoid socket. Infection can involve either the bones or the joints and, as such, a patient may present with a traumatic episode recalling some major trauma. But really the infection has been brewing all along. In other words, once or twice a year you might see a primary infection. It's usually more commonly occurs than someone who's been immunocompromised, or in a younger age group or the older age group or if they've had a surgical procedure. The elective conditions really relate more to the main conditions that affect the joint itself. So we don't have a simplified pattern to try and think of the elective conditions but really you have to know the actual individual joint and when it comes to the shoulder, the main causes of elective presentations relate to the rotator cuff. Rotator cuff has a group of muscles that encircle the glenohumeral joint which provide stability to the shoulder and also find movements. They comprise the four muscles being the supraspinatus, infaspinatus, sub scapularis and teres minor. All of them help control the shoulder joint. In itself the supraspinatus is a depressor of the human head to allow the dill toward, to allow abduction of the shoulder. The subscapularis main function is internal rotation of the shoulder, while the infusmenutus main function is external rotation of the shoulder, along with teres minor, which also external, rotates with the arm in the abducted position. All these can present with pain. Retardocuff conditions present really as one of three or four main ways. There's the primary bursitis which occurs in the younger person when they've done a lot of overhead work and they experience pain naturally in their arm worse when abducting between 70 to 120 degrees of range of motion. As you get a bit older, the tendons themselves degenerate slightly and as such the same thing occurs, but the pain tends to linger on longer and doesn't settle quite so quickly and can often be bothering the patient more at night. As the patient deteriorates in age and hastened by other factors such as excessive overhead work or by smoking, which can degenerate to collagen fibres in the tendon, the person can go on to develop rotatocuff tears and, as with any joint, as the rotatocuffs tear then the joint becomes a little bit more unstable, which predisposes it to develop secondary arthritis. So rotatocuff spectrum presents in that same four fashion bursitis, tendinopathy, rotatocuff tears and then secondary arthritis. Other conditions that can occur in the shoulder are osteoarthritis, and this usually presents with pain foot more anteriorly in the shoulder, affecting the linear human joint. As the arthritis deteriorates, the range of motion slowly deteriorates as well. The patient might experience some crepitus or bony crepitus. That's such that they've been extremely rotate their arm. They feel or hear some noises in their shoulder. Now these noises can also be felt in the subacromial space with rotatocuff tears and this is known as a soft tissue crepitus, as opposed to the bony or hard crepitus you get with osteoarthritis. Osteoarthritis can also affect the other two joints in the body the sternocleovicular joint and that usually presents more common in ladies, as they notice it because their neckline is usually lower and they're looking in that area while they put necklace on and they'll see a lump appear at the sternocleovicular area and often some discomfort will make and then also lacticle the ac joint and this is more common, particularly in general underplayed sport or they've done a lot of push ups, such as push ups, put a lot of force through the ac joint. That can cause the ac joint to degenerate and this can lead to a lump appearing at the acromio-colivicular joint or pain when they're abducting more above the 70 degree range, they're looking more at 150 to 180 degrees or n range of motion. It's also experienced when cross arm adductions, in other words when the arm is pushed across the chest, or known as also as a scarf test when assessing that particular movement. The third main conditions that occur in the shoulder is the frozen shoulder conditions, and this is an unusual condition. It's very common. No one really knows why it occurs. There's a lot of theories and it's more associated with diabetes as well, as I have seen it in people who have had previous radiotherapy or ladies post breast cancer treatment. It needs to be differentiated from those two arthritis the both arthritis and frozen shoulders present can present with stiff shoulders. But frozen shoulder usually follows a simple pattern of initially a lot of pain felt, predominantly anteriorly or laterally in the shoulder, although some, particularly at night, it's a searing pain. It's often very emotional pain, such as the patient feels almost teary because they're exhausted from it, and then slowly the pain improves. But before the pain improves the shoulder actually becomes stiff. So it goes through a painful phase, then a painful and stiff phase, and the pain slowly settles and at this stage the patient starts feeling better in themselves, even though the shoulder is still quite stiff. Eventually the stiffness does resolve, although there's evidence that it never fully resolves, such that there's always a slight degree of minor stiffness. Here are the three main conditions that affect the shoulder. The fourth one, of course, is a double condition. Is pain referred from the neck, as we've discussed right at the beginning. Along with these traumatic presentations and elective presentations, there's variations of conditions as well. Recurrent dislocations are really an elective presentation of recurrent traumatic episodes and that's also another cause of presentations to an orthopedic surgeon. But as a part of that. You can also get subluxation episodes, which are minor, elective presentation, but really is an instability, or the labour itself, which is a stabilizing structure inside the shoulder joint around the edge of the glean would, may have torn and these labour tears can present with pain felt in the shoulder, particularly in certain positions, such as when throwing an item such as a ball, or when sleeping or putting the arm in the abducted extreme rotated position. Label tears used to be thought to be very common cause of shoulder pain, but nowadays it's thought that it's probably less likely the cause of a shoulder pain in itself and more likely an incidental finding. It certainly can be a cause of shoulder pain and particularly in patients that aren't getting better with other measures but are less common than initially thought. As part of the label tears, the long-hender bicep stender attaches to the superior aspect of the labrum. The pull of the bicep stender on the labrum can cause issues. This is the mechanism that's thought to be the cause of labortez, causing pain in the self, and one of the treatments can be releasing the biceps tendon off the labrum and reattaching outside the shoulder. Apart from that, the actual biceps itself can also become inflamed and tendinopathic and that can cause pain. This itself causes pain anteriorly in the shoulder along the long head of biceps path, which is really in the bicepial groove, which is the space between the greater tuberosity and lesser tuberosity in the proximal humerus. This can easily be felt when the arm is palpated anteriorly and the forearm and the shoulders externally and internally rotated, you'll feel the bicepial groove fairly easily. Biceps pain itself is often associated with rotator cuff spectrum and as such, the actual bicep tendon may be treated at the time of rotator cuff surgery if surgery is warranted. So as a shoulder surgeon, I've been asked to make the diagnosis of what causes the shoulder pain and I start off by saying could it be coming from the neck? Could it be coming from the chest wall itself? And in the older person it's always important to exclude cardiac cause for the left shoulder pain, in particular, once we're pretty sure it's shoulder, we're in the shoulders of causing pain. Is it more anteriorly, more with the glenohumor joint, or is it more lactically fitting with the rotator cuff spectrum? The history helps a lot. Obviously, an older person is more likely to have arthritis than a younger person. In the middle age group, ie the 20 to 50 year old is more likely to have a frozen shoulder scenario. Obviously, if they present after a traumatic episode, we're thinking of traumatic causes such as fractures, dislocations or the development of infection which has been hidden by a traumatic cause, ie the person with infection may recall some minor trauma which has triggered off their pain. If they present an elective presentation with an insidious onset, we're thinking more of those three main diagnoses. However, these chronic causes or these elective presentations can present after minor trauma, so we always need to keep them in mind as well. Arspectrical history always has to be taken into account as well, ie family history of dislocations or previous history of other joints being dislocated. Also, medications thereon might be worthwhile and if they're a smoker, also work factors need to be taken into account. If they do overhead work, taking a history for an exam purpose is always important to know what previous treatment they've had as well. It's always important to know whether they've received physiotherapy or received medication, whether they've tried a steroid injection into the shoulder and also whether they've had surgery. When we come to examination, we look at the look-fill-move technique. We look from the front, the side and the back. We look at the neck posture. I like to exclude the neck as a cause of shoulder pain. From the start I usually start with flexion, extension, lateral flexion, lateral rotation of the neck and a combined manoeuvre of all three extension, lateral flexion and external rotation of the neck it can cause the neuroframing to close up. This is known as Spirling's Test or a neuroframinal compression. It's a good way of excluding cervical spine entrapment as a cause of shoulder pain. If the patient experiences shoulder pain or paracetia on the hand when they do that manoeuvre, you've got to think the cervical spine is a cause. When we look at the shoulder itself, we look from the front and the side. On the back we're looking at the shape of the clavicle, the shape of the sternocovlicula and the chromoclavicula joints, any swelling in these areas, the actual shape of the deltoid. On the back we can look at the super spinatus fossil and the infant spinatus fossil looking for wasting. And from the side we can look at the posture of the arm and if there's any of the associated scars we then move the fill. It's very easy to fill around the shoulder or palpate the region. You can start the sternocovlicula area and palpate along the clavicle to the chromoclavicula joint, which is a little bump on the lateral end of the clavicle In this area where you'd put your handle of your rucksack on to help stop the rucksack falling off your shoulder. Going slightly lateral to that, you'll feel the edge of the chromium and then even more lateral to the subacromia of space. The humal head seems to sit anterior in this area. So if you fill the actual anterior, posterior dimensions of the chromium and then you'll find the humal head is actually sitting in the anterior 50% of this area, underneath the chromium. You can fill down the lateral aspect of the shoulder in the subacromial area called the subacromial bursa, and if you palpate with one hand along the anterior aspect of the proximal humerus while you internally and externally rotate the shoulder, you'll feel the bicepular groove and the tendon Medial to that and just below the ac joint is the coracoid and going posteriorly you'll feel the supraspinase fossa, filling for muscle bulk and infaspinase fossa and then move to motion or moving the shoulder. We go for the active motion first and if there's any reduced range of motion, actively within a passive motion we look at forward flexion, which is in the frontal plane, extension, which is going backwards, lateral abduction, usually with the hand externally rotated, and then we can do internal and external rotation with the arm by the side, which is a great way of assessing if there's stiffness in the clean and humal joint. Because if there is stiffness in the shoulder itself, there won't be or there will be limited external rotation, particularly assessed with the arm by the side. The reason is that the actual scapula can actually compensate for most of a lot of the shoulder motion and can fool a young examiner. However, because the scapula is stuck to the posterior chest wall, external rotation of the shoulder is not possible because the scapula has got nowhere to move to Certainly. Forward flexion is helped by the scapula rotating in the coronal plane and internal rotation of the shoulder is helped by the scapula curling around the lateral side of the chest wall. If there is limited active motion within assessed passive motion and I like to assess this by holding the scapula with my opposite hand. So if I'm examining a right shoulder, I'll put my left hand on the inferior border of the scapula and then help the forearm up in the forward flexion and abduction, assessing whether there is reduced range of motion, both passively. If the passive motion is reduced and if the scapula moves early, we're thinking a stiff, clean and humal joint. This will be seen both on forward flexion and abduction, again reinforced by external rotation with the arm by the side. If there is a stiff, clean and humal joint, both passively and actively, then I'm thinking a condition which causes stiffness in the joint, which is either osteoarthritis or frozen shoulder. An easiest way to assess between the two is by either feeling some bony crepitus or identifying on X-ray that there is arthritis. If the passive motion is very good but the active motion is limited, then I'm thinking either the rotator cuff is completely torn or a very large tear, or there's a neurological issue, such as a C5 nerve root arising from the cervical spine, causing weakness of motion, particularly external rotation or abduction. If, however, the active range of motion and passive range of motion are very good, but there's a painful arc in the 70 to 120 degree range of motion, I'm going to set on belief that the most likely cause of this will be the rotator cuff spectrum and, depending on the patient's age and also depending on whether they've got weakness of motion, would help me to differentiate between bursitis, tendinopathy and rotator cuff tear. If the pain, however, occurs at any range of motion, particularly if cross arm abduction, such as doing the scarf test, this would make me think AC joint pathology. If, however, the pain is predominantly anteriorly and directly over the bicep standard, I'm thinking more bycipital pain or bycipital tendinopathy. That's, by combination of a good history excluding other causes of shoulder pain, as well as a simple examination, looking at both inspection, palpation and motion, actively and passively, we can get a pretty good idea of what the underlying condition is. Once we've finished the basic look-fill move, we go to special tests and then they start off with if we're looking at rotator cuff spectrum testing muscle power, and I like to test the external rotation of the arm, the arm abducted by the side, as a way of assessing infisperinatus muscle, tendon muscle strength. I assessed internal rotation, ie with the elbow forward flexed and the palm pushing onto the belly as a belly press test, and this is a way of assessing the subscapularis. Whilst assessing subscapularis with the arm internally rotated in the plane of the scapula, which is slightly forward flexed and slightly abducted, and at about 70 degrees of abduction, I'm pushing up against the owner board of the forearm and this is a way of assessing subscapularis power. All the special tests which we need to assess are shoulder instability If there's been a history of shoulder instability or dislocation, or if there's a story of pain felt anteriorly in the shoulder or a sensation of the shoulder subluxing, or if the experience of pain went throwing, then a way to assess shoulder instability is by assessing the stability tests. Now I would say the most important part of this is actually assessing the general patient's laxity as well. Make sure they can't hyperextend their fingers or their thumbs or their elbows, hyperextend their knees or be able to touch their palms, the ground easily with their flat of their palms. These are ligament laxity tests and if they have some instability issues, they usually have some degree of ligament laxity. If these are normal and the shoulder can also be assessed by assessing sulcus sign and this is where the patient is sitting on the side of the bed, the forearms resting on the lap and gentle downward traction can put pressure on the shoulder to see if a sulcus or a little gap appears between the acromion and the proximal humerus. It is normal to have a small degree of motion, but if it is excessive then it's a positive sign. We can test apprehension, which is the most important test. This is where the patient is lying flat or can be done standing. The arm is placed in abduction, external rotation and forward pressure is placed on the proximal humerus while the arm is externally rotated, and often the patient will feel some apprehension or guarding of the shoulder or be concerned that the shoulder could dislocate or feels painful If, while doing the same test by placing posterior pressure on the proximal humerus while I'm pressing anteriorly, this is known as a positive relocation test. Finally, we can test for posterior instability by pushing the shoulder backwards with the arm adducted and flexed across the chest. So in other words, the elbow is flexed at 90 degrees, the upper arm is placed across in front of the chest and the whole forearm is pushed backwards, trying to subluxulate the proximal humerus posteriorly. So the most common cause of shoulder pain obviously is the rotator cuff spectrum, that's, the bursitis or tendinopathy of an older patient, or rotator cuff tears. As stated before, they present predominantly with a pain, worse at night, often when doing overhead activities and usually with the arm in the 70 to 120 degree range of motion. In these scenarios the treatment really is such that you need to address the cause. If they're doing a lot of overhead work, you might need to back off on that. You need to treat the pain with analgesics and you might want to try an anti-inflammatory medication if the patient's suitable to try it. Usually, with the course of physiotherapy to retrain the rest of the muscles and tone up the musculature around it, the patient improves and a bit of period of rest and then with some rehabilitation following the physiotherapy, most patients improve and don't need anything further done. If the pain continues to bother them, then a trial of a corticosteroid injection can be performed. This is often done with under an ultrasound guidance so that the actual diagnosis can be confirmed. Following that, if, following a period of time and further physiotherapy, the patient continues to experience pain, that's when a second steroid injection can be tried. Usually we wouldn't try more than one or two of them. If this continues to bother the patient, then we would consider a referral to an orthopedic surgeon. One of the first tests we would like would be an X-ray. The X-ray will look at the degree of arthritis in the AC joint and whether this could be catching on the rotator cuff, the shape of the acromine, whether it's hooked or whether it's got an underlying spur, as well as to exclude any underlying arthritis in the proximal gleniohemal joint. Often, at the time of the ultrasound for the steroid injection, the radiologist identifies a rotator cuff tear. Now some of these are actually quite small and very miniscule and don't need anything further done. But if there's a larger tear, this may be something that could be addressed if the patient doesn't settle on their own. I'd state that most rotator cuff tears don't cause long-term problems. The vast majority of people can live with a rotator cuff tear and actually by rehabilitating with physiotherapy and building up the muscles around it, they actually don't even know they've got a problem. There was one school of thought that the rotator cuff tears can become bigger and cause issues later in life, but often these don't, and if they do become more painful and continue to bother the patient, that's when rotator cuff tear would not be addressed anyway. So usually we'd try these simple measures first. But if the patient's not settling either with a rotator cuff tear or without, then they'll be referred to an orthopedic surgeon where the X-ray would be assessing whether there's a subacromial spur, whether they see joint arthritis and also whether there's any. They would also want to exclude the underlying arthritis in the proximal glial hemodroint. Assuming there's either impingement from an underlying spur or ac joint arthritis or there's a rotator cuff tear, surgery might be considered and in that scenario what we would do, either open or arthroscopically would assess the rotator cuff, repair the tendon by roughing the bone of the greater tuberosity and tying it down using sutures or with or without anchors into the proximal shoulder and then take away any underlying bone catching on the tendon, either from the ac joint or the lateral chromium. This is known as a shoulder arthroscopic or open decompression or, say to me, cuff repair. And as part of that we may, if there is arthritis of the AC joint or chromicular joint, excise the latch-winded clavicle or if there's bicep tendinopathy or labial tear that's causing issues, either repair the labrum or release the biceps from the labrum and reattach it outside the shoulder, known as a proximal biceps tinnodesis. This is where the long-headed biceps is tied down to the proximal humerus so that it doesn't retract. There's a lot of evidence that actually the biceps can be released without issues, although some people might notice a deformity and that can be concerning to the patient. But usually the vast majority of patients don't have any issues from having the biceps released. But often we try and attach it outside the shoulder so that doesn't cause any shoulder cosmetic abnormality. The second most common cause of shoulder pain is frozen shoulder. This presents with pain and then pain, the stiffness and then the pain goes away and it remains stiff. Usually, in the first few stages there's probably the worst time to treat the patient because the shoulder for some reason isn't flamed and often if treatment is done too early, the condition can just flare up once again. However, if despite time and the patient is not settling, treatment is offered. The most important treatment initially is both diagnosis to exclude anything sinister, and then reassurance that it will get better with time. Sometimes analgesics and hydrotherapy are useful, but if all that fails, then the options of treatment involve either a steel injection into the shoulder joint with or without a bit of fabric, a fluid being put in called a hydro dilatation to try and stretch the capsule up. Other options involve manipulating the shoulder joint or doing a telescopic release of the shoulder joint. All of these have benefits and merits. However, it's been proven a lot of these shoulders will improve with time even without any further treatment. The reason for treatment is to help try and help the patient get through the period and speed up the recovery. The final pain diagnosis in the shoulder joint selectively, is arthritis. Now I like to think of arthritis as being either primary osteoarthritis, secondary, following trauma or inflection or inflammation, or post metabolic cause, such as gout or hemochromatosis, or an inflammatory arthritis, such as rheumatoid or psoriatic arthritis. Either way, the main treatment of arthritis is initially well non-surgical, involving analgesics or, if it's an inflammatory condition, anti-inflammatory medication advised by the rheumatologist. But if the shoulder pain continues and there's a lot of deformity of the humerus and the glenarum joint, then a shoulder replacement may be warranted. Depending on whether the rotator cuff is intact or not depends on the type of shoulder replacements that is performed. With an intact rotator cuff we do a standard anatomical shoulder replacement where the ball is replaced with an artificial ball and the socket is replaced with an artificial socket. However, in the last 20 years, reverse shoulder replacements have become very common. These type of shoulder replacements involve replacing the proximal glenarum joint with still an artificial socket and an artificial ball, but the ball is placed on the socket side and the socket is placed on the ball side. That's why it's called a reverse shoulder replacement. The advantage of this is it compensates for any torn or deficient tendons that may occur with age or with rotator cuff tears, such that if you don't have a intact rotator cuff, if you do an anatomical shoulder placement and put the ball and socket in the anatomical position, there will be instability in the shoulder, just like we talked about before, with a torn rotator cuff leading the secondary arthritis. This instability will lead to loosening of the plastic socket. Therefore, the reverse shoulder replacement helps hold the ball in the linoid side and allows a deltoid to do the function for it. These are probably the most common ones being done nowadays in South Australia and Australia on the shoulder registry. So I think that hopefully that outlines my approach to treating a painful shoulder and hopefully it gives some direction to a medical student preparing for an exam and such that they can actually divide the actual different conditions into certain little pockets of conditions, such that they can help perform a diagnosis and then offer treatment options. Once again, I thank you very much for listening to my podcast and we look forward to the next episode where we'll be interviewing another specialist in the area on a different condition. Thank you very much and thank you for listening. The information provided today is designed to complement information provided to you in your local region and should supplement your readings and teachings in that area. Please don't take it as the only way of treating this condition or assessing a condition, but really is one of one of the various ways of assessing these conditions. Please be also be aware that the information provided today is really just general medical advice and isn't designed to actually be a source of medical information regarding your particular condition. Remember to consult your specialist or medical practitioner if you have concerns about condition raised in this podcast. Thanks once again for listening to our podcast. Aussie Med Ed or the Australian Medical Education Podcast Really enjoy hosting this podcast. I hope you find it useful to give a pragmatic approach to everyday conditions. If you have any questions or information you want to ask about us or you'd like to put a suggestion for a topic, please don't hesitate to email us at gabiniteedcomau. Once again, hope you enjoy listening to it and we look forward to hosting it next fortnight when we introduce a new topic. Thank you,