In most cases, though, other symptoms will indicate dislocation. If it is evening, watch the symptoms and seek care in the morning. You may also have: Some swelling and bruising to your shoulder Numbness, tingling, or weakness in your arm, hand, or fingers What to Expect Surgery may or may not be needed after your dislocation. Iowa Orthop J. Remedies range from things you can do for yourself and treatments a doctor, For many people, a slightly pinched nerve causes no discomfort. Causes include injury from trauma or repetitive strain injury, nerve damage or compression in the neck or upper back, or a blockage in the bloodstream. Apply ice or cold packs right away to prevent or reduce swelling. Mayo Clinic does not endorse companies or products. The patient will experience significant pain and will often resist the smallest movement of any part of the arm. This can require urgent surgery. Exercises that strengthen the rotator cuff muscles will also help protect against dislocation by providing extra stability to the shoulder joint. There may be other problems that need tending to that only a doctor can diagnose. The shoulder is inherently unstable joint due to the shallow glenoid articulating with a small part of the humeral head. Having a dislocated shoulder is very painful. It takes a strong force, such as a sudden blow to the shoulder, to pull the bones out of place. This occurs when the shoulder joints just partially pops out from its normal anatomical position and there is not much stretch of the surrounding ligamentous structures as a result of partial dislocation of . In: StatPearls. "Very hard" means you can't move it at all in any direction without causing severe pain. Symptoms may include pain, swelling, numbness, tingling, weakness, changes in temperature or color, and changes in your range of motion. Although evidence supports their validity as measures of pain intensity, f You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. The shoulder joint is the most frequently dislocated joint of the body. In addition, tearing of cartilage, a rubbery tissue that covers and protects the ends of bones, is possible. An orthopedist should keep an eye on older and chronic patients. Bruises often look blue. It is a particularly important pathology to be able to recognize in the field due to the prevalence of the injury as well as the high recurrence rate. J Shoulder Elbow Surg. You do not need to call an ambulance unless: You cannot travel safely either by driving yourself or by having someone else drive you. The shoulder joint can also be weakened by repetitive motion, such as pitching in baseball. 2009;39(2):118-123. Causes shown here are commonly associated with this symptom. Rothman Orthopaedic Institute. After your doctor has a clear understanding of your injury, your treatment will begin. These bones are held together by muscles, tendons, and ligaments. Whether you can get immediate medical attention or are hours away from help, there are basic things you can do for a dislocated shoulder. If it does, you should feel immediate relief. InStatPearls [Internet] 2022 Aug 8. A common shoulder dislocation, known as acromioclavicular (AC) joint dislocation, has been found to be able to heal on its own without surgery. A car crash in which any vehicle involved was going more than. Many shoulder pain sufferers qualify for Social Security disability because they have a "major dysfunction of a joint." In order to qualify pursuant to this Blue Book listing, a claimant must show that he has one of the following conditions: Partial shoulder dislocation. Symptoms [8] of a dislocated shoulder include extreme pain, weakness, swelling, bruising or redness, muscle spasms, numbness or tingling, . Once the shoulder is back in place, any severe pain stops almost immediately. May result from significant limb swelling following an injury or an excessively tight bandage or cast. Icing the area can help reduce pain and swelling. Cleveland Clinic offers expert diagnosis, treatment and rehabilitation for bone, joint or connective tissue disorders and rheumatic and immunologic diseases. Cancer that has spread to the bones of the shoulder or spine. If a dislocation is severe enough, it is. http://www.uptodate.com/home. A bed's firmness is rated on a scale of 1-10, with one being the softest and ten the hardest. If not treated properly, a dislocated shoulder can lead to long-term joint instability and deformity. An unexplained pain in your shoulder can mean many things, including dislocation. (Informed by current CDC guidelines.). Its possible for a dislocation and a break. Went snowboarding 9 days in a row in a sling with no pain. 2007; 89:2124-2131. Or pass it along to someone in your life who might find themselves needing these instructions one day. It occurs when the arm is in an abducted and externally rotated position. COVID-19: Check your symptoms and find the right care. After you have relieved your initial pain, rehabilitation exercises will help you prevent future dislocation. Dislocated shoulder To evaluate for shoulder instability, a doctor will perform an examination after a history is taken. (2014). As soon as your shoulder is lodged back into your joint, your pain should subside. If you're having a heart attack, there are several. Extreme twisting of the shoulder joint can pop the ball of the upper arm bone out of the shoulder socket. Have you had shoulder surgery in the past month? (2014). Avoid flexion with adduction and internal rotationc. Heres why this happens, tips for identification, treatment, and more. When the joint is disrupted, the muscles surrounding it are stretched and go into spasm. If you need to use a sling for more than 48 hours, you may have a more serious injury that needs to be checked by a doctor. The bleeding stops on its own or with pressure. Calcium buildup in the tendons of the shoulder. Move your hips and legs, and let that motion gently swing your arm back and forth. Have you had numbness, tingling, or weakness in your arm, hand, or wrist for more than an hour? The patient complains of a sharp anterior shoulder pain and tingling in the hand and drops the arm suddenly. Any event forceful enough to badly break a large bone (like an arm bone or leg bone). The shoulder joint is incredibly susceptible to dislocation because of its mobility. Shoulder problems develop from everyday wear and tear, overuse, or an injury. He is the director of adult spinal deformity & complex spinal reconstruction at Massachusetts General Hospital and is on the faculty at Harvard Medical School. It depends on your age and how often your shoulder has been dislocated. Shoulder pain and common shoulder problems. Shoulder injuries most often occur during sports activities, work-related tasks, projects around the home, or falls. The Health Encyclopedia contains general health information. However, once a shoulder dislocates, the joint might be prone to repeat dislocations. Weakness is being unable to use the arm or hand normally, no matter how hard you try. Introduction Shoulder pain is a highly prevalent condition. (You can also use them as you help someone correct their shoulder dislocation.). Wang RY, Arciero RA, and Mazzocca AD. To further evaluate the shoulder, an MRI may be ordered. The doctor may determine that surgery is needed if bones or tendons are injured. http://www.uptodate.com/home. This can be a painful, sometimes frequent injury and may require surgery to fix. If you cannot reach your doctor or you don't have one, seek care in the next hour. Last reviewed by a Cleveland Clinic medical professional on 03/19/2018. Top Contributors - Sherin Mathew, Johnathan Fahrner, Haley Stevenson, Lucinda hampton, Admin, Rachael Lowe, Kim Jackson, Scott A Burns, Wanda van Niekerk, Naomi O'Reilly, Venus Pagare, Candace Goh, Claire Knott, Khloud Shreif, Evan Thomas, WikiSysop and Fasuba Ayobami, Shoulder dislocation (correctly termed a glenohumeral joint dislocation) involves separation of the humerus from the glenoid of the scapula at the glenohumeral joint. For others, symptoms can include pain, numbness, and general weakness in the shoulder, A dislocated toe is an injury that can happen with certain impacts to or twisting of your toes and feet. Smoking slows healing because it decreases blood supply and delays tissue repair. A dislocated shoulder can occur from a fall or blow to the shoulder. Mine didn't go back in by itself, so they had to knock me out at the hospital to get it back in. Pain or swelling may make it hard to move, but that is not the same as weakness. Coyle M, Jaggi A, Weatherburn L, DanielI H, Chester R. Miller BS, Sonnabend DH, Hatrick C, O'Leary S, Goldberg J, Harper W, et al. 1 to 3: Mild discomfort. A dislocated shoulder leaves your arm appearing slightly out of place. A failed spinal fusion requiring it to be re-fused will recalibrate that. Do you know the signs of a dislocated finger? Don't massage the affected area if it causes pain. 2014;22(12):761-71. doi:10.5435/JAAOS-22-12-761. A cadaveric study. [2] See also Therapeutic Exercise for the Shoulder. Dislocated shoulder symptoms can include: A visibly deformed or out-of-place shoulder Swelling or bruising Intense pain Inability to move the joint Shoulder dislocation can also cause numbness, weakness or tingling near the injury, such as in the neck or down the arm. If appropriate, try home treatment while you are waiting for the appointment. Published February 2016. A traumatic first time anterior shoulder dislocation shows a peak incidence in men aged 16-20 and in women aged 61-70 Refer patients with suspected dislocation to emergency services for reduction Risk of experiencing recurrent dislocation is greater in patients age 40, in men, and in people with hyperlaxity Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated. There are other reasons for color and temperature changes. If your shoulder has dislocated from the joint, its important that you see your doctor right away to prevent further pain and injury. Usually no surgery is necessary, especially if the shoulder was dislocated for the first time. Bruising and swelling may occur soon after the injury. McMahon PJ, et al, eds. This is usually performed in the Emergency Department following sedation and appropriate analgesia. This content does not have an English version. Dislocated shoulder symptoms can include: Shoulder dislocation can also cause numbness, weakness or tingling near the injury, such as in the neck or down the arm. The VA awards disability compensation for each Shoulder and Upper Arm condition that is service-connected.The DoD will also rate service-connected conditions as long as they also make the service member Unfit for Duty.For Reservists, the condition must have occurred in or resulted from an injury in the Line of Duty to qualify.. Did you just suffer from a high impact injury (e.g., a fall, collision, accident or sports trauma)? J Bone Joint Surg Am. If you have some organs of both sexes, you may need to go through this triage tool twice (once as "male" and once as "female"). Dislocated shoulder. In patients with shoulder instability, the X-rays may show some telltale signs of dislocation. But if you think that you might have a more severe problem, use first aid until you can be seen by a doctor. It takes about 6-8 weeks for the shoulder to move after being dislocated. A dislocated shoulder is very painful. The most common cause of a dislocated shoulder is some type of injury. Sometimes people don't want to call 911. In addition, surgery may be required for additional injuries that occur at the time of dislocation, such as damaged blood vessels or a rotator cuff muscle tear. When the shoulder bones are . Iatrogenic is an illness or condition caused by medical treatment. Injuries are the most common cause of shoulder pain. Mayo Clinic Staff. include protected health information. Accessed June 9, 2022. Traumatic causes of acute shoulder pain and injury in children and adolescents. [1,2] Apply traction to the shoulder as mentioned in the Stimson technique above. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Products for Daily Living from Mayo Clinic Store. Mayo Clinic does not endorse companies or products. Did the shoulder or collarbone get twisted out of shape or pop out of its normal position? In a partial dislocation, the upper arm bone is partially in and partially out of the shoulder socket. If we combine this information with your protected Dislocated shoulder. Read our, Determining If You Have a Dislocated Shoulder, 5) Carefully Position Your Arm and Get Medical Attention. Maintaining muscle strength and flexibility can help prevent shoulder dislocations. He also received an MP Residency in Family Medicine, University of Illinois at Chicago, Associate Professor of Medicine, Brigham and Womens Hospital. Explanations change for how the injury happened. The process of "popping" a dislocated shoulder back into place is called reducing the shoulder. You can start gentle exercise with the aid of moist heat to help restore and keep flexibility. Treatment depends on: Many things can affect how your body responds to a symptom and what kind of care you may need. Clinical overview: Shoulder dislocation. Results: The mean EROE score was 93.8, with 98% of results being good or excellent, and the mean Rowe score was 95.0, with 98% good or excellent results. Do you think the problem may be causing a fever? Bruising and swelling may occur soon after the injury. Unfortunately, the structure of the shoulder joint makes it vulnerable to dislocation. Dislocation with no or minimal trauma can occur in people who have an unusually unstable shoulder joint. The numerical scale: Measures pain on a scale of 1-10. AAROM to achieve a full range of motion when stretching is permitted, passively stretch the posterior joint capsule through the use of joint mobilizations or self-stretching. Getting a separated shoulder or a dislocated shoulder is painful and debilitating. Your healthcare provider discusses with you specific treatment for a shoulder dislocation, based on: Maintaining muscle strength and flexibility can help prevent shoulder dislocations. Pain that's coming from somewhere else in your body (referred shoulder pain). The condition in which there is partial dislocation of the shoulder is called as shoulder subluxation. The shoulder's mobility and ball-in-socket mechanism makes it the most likely joint in the body to become dislocated. You are in an area where heavy traffic or other problems may slow you down. Then, progress to the larger musculature such as the deltoids, latissimus dorsi, and pectorals. Overuse injuries include: Overuse and acute injuries are common causes of shoulder symptoms. This inflammation is called, Inflammation of the tough, ropy fibers that connect muscles to bones (. Most people regain full use of their shoulder within a few weeks. For me anyway, a kidney stone is a walk in the park compared to a shoulder dislocation. But bruises are often the first sign of possible abuse. After two weeks, you should be able to return most activities of daily living. Partial or full fusing of the shoulder joints. It might dislocate completely or partially. Causes. 1 The CMS is a 100-point scale composed of several individual parameters. [6], X-ray are is often enough to make a diagnosis of shoulder dislocation, however CT and MR are often needed to assess for the presence of subtle fractures of the glenoid rim or ligamentous/tendinous injuries respectively.[2]. By clicking Accept All Cookies, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts. Injuries or trauma to your upper arm can cause sudden and serious pain in your triceps, biceps, or shoulder. New masking guidelines are in effect starting April 24. For a list of covered benefits, please refer to your Evidence of Coverage or Summary Plan Description. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. After the shoulder heals, a physical therapist assigns exercises to stretch the shoulder and restore mobility. There is a problem with Common symptoms of a shoulder dislocation include: 3 Severe shoulder pain Swelling and bruising of your shoulder or upper arm Numbness and/or weakness in your arm, neck, hand, or fingers Trouble moving your arm Your arm looks to be out of place Muscle spasms in your shoulder The shoulder joint has the greatest range of motion of any joint in the body. These receive a code of 5203. Depending on the technique, pain medication is often required. U.S. National Library of Medicine: MedlinePlus. DOI: 10.1177/102490791201900113; Vasudevan T, et al. This can be serious. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. Through restoring your shoulder's range of motion and physical strength, your risk for dislocation decreases. Separation of the shoulder. The shoulder joint is incredibly susceptible to dislocation because of its mobility. Does your child seem to be protecting the arm or not using it normally? Some bone and joint problems can cause a fever. Breakdown of the cartilage that protects and cushions the shoulder joints (. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. There can be partial dislocation of the shoulder. If you are a Mayo Clinic patient, this could Jonathan Cluett, MD, is board-certified in orthopedic surgery. Cervical radiculopathy. Am J Sports Med. The mean VAS pain score was . But women are somewhat more likely than men to have other symptoms like shortness of breath, tiredness, nausea, and back or jaw pain. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dislocated shoulder. There are several possible techniques for reduction. First-time anterior shoulder dislocations: has the standard changed? Are you having trouble moving your shoulder? Typical time periods in a sling range for 3-6 weeks if under the age of 40 and 1-2 weeks if older than the age of 40. If your shoulder is pulled back too hard or rotated too far, the top of your arm might pop out of its socket. Policy. Learn how we develop our content. (2014). Based on your answers, you need emergency care. Younger people are at a greater risk of having shoulder instability and recurrent dislocation in the future, while those who are middle-aged are more vulnerable to tearing rotator cuff muscles at the time of dislocation. Scores are interpreted as follows: 0: Relaxed and comfortable. It occurs when a childs elbow is pulled and partially dislocates. It is very hard to move your arm. This injury occurs most often from a blow to a shoulder or a fall onto a shoulder or outstretched hand or arm. Less common causes include: Treatment for a shoulder injury may include first aid, physical therapy, and medicine. information submitted for this request. You can learn more about how we ensure our content is accurate and current by reading our. Do you have a shoulder injury or other shoulder problem? There could be other problems, such as a fracture or ruptured connective tissues, interfering with the reduction. If symptoms get worse or you have any concerns, call your doctor. The rotator cuff a group of muscles and tendons surrounding the shoulder joint are more likely to tear in older patients who have suffered shoulder dislocations. In: DeLee, Drez, & Miller's Orthopaedic Sports Medicine. Because it moves in several directions, the shoulder can dislocate forward, backward or downward. Causes of shoulder dislocations follow, including trauma, iatrogenic reasons, abnormal muscle contractions, and loose joints. Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. Surgery on the capsule or other soft tissues may be necessary, but usually at a later date. 2 It is divided into four subscales: pain, activities of daily living, strength, and range of motion. Do you think that the shoulder problem may have been caused by abuse? FARES method to reduce acute anterior shoulder dislocation: A case series and an efficacy analysis [Abstract]. Swollen Shoulder Symptoms, Causes & Common Questions. Healthline Media does not provide medical advice, diagnosis, or treatment. Following an acute anterior glenohumeral dislocation: With acute posterior glenohumeral dislocation: Posterior dislocations are hard to reduce, attempts at closed reduction need be performed in consultation with a treating orthopaedic surgeon. They may think that their symptoms aren't serious or that they can just get someone else to drive them. Prop up the area on pillows while you apply ice and anytime you sit or lie down. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Pain may be sudden and severe. The shoulder can dislocate in an anterior (95% of shoulder dislocations), posterior, inferior direction and completely or partially. The child may not know where he or she is. Try home treatment to relieve the symptoms. A dislocated shoulder needs prompt reduction. You can also apply an ice pack to help with the pain and swelling. 2023 Healthline Media LLC. Shoulder Popping Symptoms, Causes, & What to Do. Damage to one or more of the four tendons that cover the shoulder joint (, Pulling or pushing bones out of their normal position among the other bones that make up the shoulder joint (, Inflammation of the sac of fluid that cushions and lubricates the joint area between one bone and another bone, a tendon, or the skin. Usually made of calcium, these hard pellets block the flow of urine, making the kidney swell and causing waves of sharp pain at the mid-back, abdomen or sides and for men, pain at the end of. Call the doctor if there is swelling or pain in the shoulder, arm or hand that worsens over time, or if the arm or hand turns purple. A dislocated shoulder is an injury in which the upper arm bone comes out of the shoulder blade socket. A dislocated shoulder occurs when your upper arm bone pops out of the socket of your shoulder blade. Wang and colleagues, suggested a three-phase protocol:Phase 1 Immobilisation (up to 6 weeks). Turk J Emerg Med. Whenever you have questions or concerns about a medical condition, you should always contact your doctor or a healthcare provider. Home treatment often can help relieve minor aches and pains. 7 to 10: Severe discomfort/pain. Having a dislocated shoulder is very painful. As such, signs of this injury may be overt or subtle. The visual analog scale: Categorizes pain along a horizontal line, ranging from mild to severe. Kelley's Textbook of Rheumatology. Depending on your injury, it may be anywhere from a few days to three weeks. A frozen shoulder. Gallbladder cleanse: A 'natural' remedy for gallstones? X-rays are performed to image the shoulder. Your shoulder can dislocate in several ways: forward and downward dislocation, and backward dislocation. Miller M.D., et al, eds. It may follow an injury. 6th ed. If a bone is sticking out of the skin, don't try to push it back into the skin. Call 911 or other emergency services now. Dr. Michael Perez answered Internal Medicine 39 years experience Very painful: A dislocated shoulder is unable to move normally. This must be done with great care to avoid damaging tissues, nerves, and blood vessels in and around the shoulder joint. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Try our AI assistant here. Psychological factors could play an essential role in the prognosis of chronic shoulder pain (CSP). The ASES incorporates a visual analog pain scale and functional ability questions and is rated on a 100-point scale, . Gently massage or rub the area to relieve pain and encourage blood flow. Dislocation requires medical attention to fix. . To begin, slowly extend the injured arm out to the side, raising the arm gently and bending the elbow so that the palm touches the top of the head. Understand swollen shoulder symptoms, including 8 causes & common questions. Accessed June 20, 2016. Philadelphia, Pa.: Saunders Elsevier; 2013. http://www.clinicalkey.com. Some experts advise switching between heat and cold treatments. After it was reset it went immediately to a 0 and gradually up to an annoyance. This dislocation results from contact sports, falls, bicycle accidents, and similar high-impact trauma. Br J Sports Med. Once your shoulder has been placed back into the socket joint, your healthcare provider may advise you to keep your shoulder immobilized in a sling or other device for several weeks after treatment. Begin strengthening exercise, strengthening exercises should be impairment-based. Published August 3, 2018. If the injury doesnt heal as expected, a doctor might order a scan to find tissue tears not seen earlier. A dislocated shoulder occurs when your upper arm bone pops out of the socket of your shoulder blade. [1], Extreme rotation can cause the humeral head to come out of the glenoid labrum. The stories shared below are not written by Buoy employees. Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. These include: For men and women, the most common symptom is chest pain or pressure. Should acute anterior dislocations of the shoulder be immobilized in external rotation? Because of this mobility, the shoulder is more likely to be injured or cause problems. Talk to your doctor about the options available to you. In addition to swelling and severe pain, a dislocated shoulder can cause muscle spasms. 4 to 6: Moderate pain. Alkaduhimi H, van der Linde JA, Flipsen M, van Deurzen DF, van den Bekerom MP. Most minor shoulder problems will heal on their own, and home treatment is usually all that's needed. Acute management of shoulder dislocations. As you wait to see your doctor, dont move your shoulder or try to push it back into place. The bleeding does not stop or slow down with pressure. This is a condition that limits shoulder movement. This puts the collarbone slightly out of alignment, and you may . Sports injuries. A partial dislocation is when the head of your upper arm is partially out of your shoulder socket. Navigation Menu - Opens a Simulated Dialog, William H. Blahd Jr. MD, FACEP - Emergency Medicine, areas where you may feel pain or other symptoms, Aspirin for Pain, Fever, and Inflammation, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), Quick Tips: Safely Giving Over-the-Counter Medicines to Children, Preventing Children's Injuries From Sports and Other Activities, Request for confidential communications forms, Learn more about link terms and conditions, Injuries to the tough, ropy fibers (ligaments) that connect bone to bone and help stabilize the shoulder joints (. The pain may also move up and down your arm,. To learn more about Healthwise, visit Healthwise.org. Do not proceed if there is any screaming, panic, or chaos. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://medlineplus.gov/shoulderinjuriesanddisorders.html), (https://medlineplus.gov/dislocations.html), (http://www.aafp.org/afp/2016/0715/p119.html), (http://orthoinfo.aaos.org/topic.cfm?topic=a00035), Numbness, tingling or weakness in the arm, hand or fingers, Immobility of the arm, or difficulty moving it. When an area turns blue, very pale, or cold, it can mean that there has been a sudden change in the blood supply to the area. Wait for an ambulance. Chronic shoulder instability. You shouldnt participate in sports or any strenuous activity until your doctor thinks its safe enough to do so. We do not endorse non-Cleveland Clinic products or services. It may ooze or trickle for up to 45 minutes. [5] Dead Arm syndrome indicates pathologic anterior instability. Do not try to put the arm back in its normal position yourself, since reduction can cause additional injuries, such as fractures, if done incorrectly. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. Surgical repair will be performed if closed reduction is unsuccessful. Anyone can dislocate a shoulder. If the arm is in a cast, splint, or brace, follow the instructions you got about how to loosen it. A shoulder dislocation is usually caused by a fall or blow to the shoulder. How long have you had problems with the shoulder? Any event that causes severe bleeding that you cannot control. 2004; 13: 589-592, Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, Wakabayashi I, et al.