Can You?

Only a few weeks after leaving general practice and starting specialty training, I was entering the clinic when a man approached me holding out a drawing depicting his pain. He was a good artist and had drawn an arm and torso with a star burst right out of the top of the shoulder and radiating down the arm. In this joint, pain radiation is a very late sign, if it happens at all. In contrast to many joints whose pain is felt at a distance from it, the AC is one of the “honest” joints whose pain is located precisely at the joint itself. He told me that he had carried that drawing for two years and shown it in all the clinics he'd been rotated through, but no one could help him.

"Please. Can you?"

Only a few simple, easily performed hands-on tests implicate the AC joint and predominantly distinguish its pathologies from other structures:

The top of the joint is tender.

Mobilizing it reveals painful restriction.

The pain is almost invariably markedly increased when the arm is passively

...horizontally adducted across the chest, which compresses the joint.

It took me only about half-a-minute to perform the tests right where he stood. I relieved much of his pain with a manipulation (which confirmed the diagnosis), and I then injected the joint with a small amount of cortisone because it had been inflamed for so long. He smiled at me gratefully, gave me the drawing and was gone. Two years!

It was only one of such episodes I would walk into that I’d never expected to encounter. Even after my three times in medical school.