Examination of the Shoulder for Laxity and Instability

With laxity testing, it is important that the patient be as relaxed as possible. We use a consistent grading system (described later) and ask the patient whether he or she can appreciate the trans-lation.5 We then ask whether the translation reproduces the symptoms. It is important to note that although we use these tests primarily for laxity, grinding, clicking, or pain may represent labral tears or chondral defects.

Anterior Tests

Apprehension Test This test is performed with the patient either supine (fulcrum) or sitting (crank) by stressing the symptomatic shoulder in maximum abduction and external rotation (Fig. 16-25). The patient may exhibit guarding or other actions that may make the patient or the examiner apprehensive, resulting in a positive test. We believe that this is the best clinical test for anterior instability because it is easy to perform and is very sensitive for producing symptoms in the anteriorly unstable patient. We believe that it is also quite specific, with the exception that the apprehension position is a possible impingement position, and thus one must be specific in asking the patient the nature of his or her symptomatology. It should be remembered that pain in this position is different from the feeling that the shoulder is going to come out of the joint.

Figure 16-25 A, Apprehension test. B, Relocation test for instability.

Figure 16-25 A, Apprehension test. B, Relocation test for instability.

Relocation Test for Instability This test is performed just as was described previously for pain, except that a positive sign here is signified by apprehension or a feeling that the shoulder will come out if further external rotation is applied (see Fig. 1625). Such apprehension should disappear with a posteriorly directed force while holding the arm in the same degree of external rotation; with this posteriorly directed force, the arm can be moved into further external rotation without discomfort. We will often increase the external rotation slightly while holding the humerus back, then release this posterior pressure. This often reproduces the patient's symptoms exactly. We have found this test to be highly suggestive of anterior instability and place a great deal of emphasis on it during our examination.

Load and Shift Test The load and shift test is a test for laxity or translation of the shoulder. It is performed with the patient in the supine and seated positions at various levels of gleno-humeral abduction. In the seated position, the examiner stands behind the affected shoulder (Fig. 16-26). One hand is used to stabilize the scapula by grasping the anterior and posterior acromion between the fingers. The other hand grasps the humeral head and by applying compression along with anterior and posterior force, the translational movement of the humerus on the glenoid can be appreciated. Grading of this passive translation includes motion up the face (normal or grade 0), up the face to the glenoid rim (grade 1), over the rim but spontaneously reducible (grade 2), and over the rim into a position of fixed dislocation that will not spontaneously reduce (grade 3).5 This test can be repeated posteriorly, with a similar grading system. It is important to compare the translational grades to the asymptomatic side, as gross differences may suggest abnormal laxity.

The load and shift test may be repeated supine (our preference). In this position, the examiner holds the patient's wrist with one hand while the other hand grasps the humerus and again provides some load with translational force. The test is done with the arm at the side, at 45 degrees, and at 90 degrees. We will occasionally "dial in" the laxity by progressively abducting and also rotating the arm while performing the load and shift test. Patients who continue to translate at increased gleno-humeral abduction angles compared to the opposite side may indicate laxity of the inferior glenohumeral ligament. We always ask the patient whether he or she can appreciate the translation, and if the patient responds "yes," we ask whether this sensation reproduces the symptoms.

There are several aspects to this test that may limit its clinical utility. First, any patient who is at all guarded can make the

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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