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Unilateral increases in glenohumeral translation in the presence of shoulder pain and disability can ultimately lead to the diagnosis of glenohumeral joint instability treatment plant buy namenda 5 mg otc. Originally described by Jobe medicine cups order 5 mg namenda visa,11 the subluxation/relocation test is designed to identify subtle anterior instability of the glenohumeral joint treatment lice cost of namenda. Dr Peter Fowler has also been given credit for the development and application of this test medicine youth lyrics purchase genuine namenda. Chapter 11 Evaluation of Glenohumeral, Acromioclavicular, and Scapulothoracic Joints 183 A A B Figure 11-6 Subluxation relocation test. A, Subluxation applied at end-range external rotation and 90 degrees of coronal plane abduction. B, Demonstrates the relocation portion of the test maintaining end-range external rotation and abduction position. B, Posterior humeral head translation test using the posterolateral direction of translation. This modification has been proposed by Hamner et al55 to increase the potential for contact between the undersurface of the supraspinatus tendon and the posterior superior glenoid. In each position of abduction (90, 110, and 120 degrees of abduction), the same sequence of initial subluxation and subsequent relocation is performed as previously described. Reproduction of anterior or posterior shoulder pain with the subluxation portion of this test, with subsequent diminution or disappearance of anterior or posterior shoulder pain with the relocation maneuver, constitutes a positive test. Production of apprehension with any position of abduction during the anteriorly directed subluxation force phase of testing would indicate occult anterior instability. The primary ramifications of a positive test would indicate subtle anterior instability and secondary glenohumeral joint impingement (anterior pain) or posterior or internal impingement in the presence of posterior pain with this maneuver. Although this may at first appear to be solely a semantic issue or exercise in nomenclature, it instead gives the clinician the ability to identify and subsequently treat each type of impingement (primary or secondary) differently and with a greater degree of success. Cheng and Karzel62 have shown increases of up to 120% in the inferior glenohumeral ligament complex with laboratory simulation of a superior labral injury in cadaveric specimens. Although many tests have been advocated for labral testing including the Clunk test,63 Crank test,64 and Anterior Slide Test,65 it is beyond the scope of this chapter to review these in their entirety. The clinician then produces a downward pressure similar to that performed during manual muscle testing using two fingers of pressure on the ulnar styloid process. The patient is then asked whether this produces pain and, specifically, where this pain is produced. Utilization of the special tests discussed in this brief overview allows the clinician to test the static and dynamic stabilizers of the glenohumeral joint to obtain an accurate diagnosis that will enable a comprehensive plan of care for both rehabilitation and preventative conditioning programs. One additional area that needs further and more specific discussion, however, is the role of postural evaluation of the scapulothoracic joint for the overhead-throwing athlete. Typically, the dominant shoulder is significantly lower than the nondominant shoulder in neutral, nonstressed standing postures, particularly in unilaterally dominant athletes like baseball and tennis players. Although the exact reason for this phenomenon is unclear, theories include increased mass in the dominant arm, leading the dominant shoulder to be lower secondary to the increased weight of the arm, as well as elongation of the periscapular musculature on the dominant or preferred side secondary to eccentric loading. Another typical finding often observed during the postural evaluation is the finding of "tennis shoulder," a term used by Priest and Nagel70 in their research. As they explained, "It is said that oarsman of ancient galleys developed a corporeal deformity when rowing only on one side of the ship, and that a favor the slave master could bestow upon an oarsman was to alternate him from one side of the ship to the other, allowing maintenance of symmetrical physique. The position of the shoulder girdle and scapula is one of depression, protraction, and often downward rotation. Tennis shoulder exists in unilaterally dominant athletes, such as tennis players, baseball players, volleyball players, and individuals who ergonomically use one extremity without heavy or repeated exertion of the contralateral extremity. The hands are placed on the iliac crests of the hips such that the thumbs are pointed posteriorly. Placement of the hands on the hips allows the patient to relax the arms and often enables the clinician to observe focal pockets of atrophy along the scapular border, as well as more commonly over the infraspinous fossa of the scapula. Thorough visual inspection using this position can often identify excessive scalloping over the infraspinous fossa present in patients with rotator cuff dysfunction, as well as in patients with severe atrophy who may have suprascapular nerve involvement. Impingement of the suprascapular nerve can occur at the suprascapular notch and spinoglenoid notch and from paralabral cyst formation commonly found in patients with superior labral lesions. Further diagnostic testing of the patient with extreme wasting of the infraspinatus muscle is warranted to rule out suprascapular nerve involvement. This pattern of dysfunction involves anterior tilting of the scapula in the sagittal plane, which produces the prominent inferior angle of the scapula.
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