Pain Secondary to Instability

As stated from the outset of this chapter, we believe that the best approach to problems with the evaluation of the shoulder is to begin with the patient's chief complaint, allowing it to immediately focus the clinical examination. It may seem odd, then, to describe a few tests for instability in a section on pain, but as pain is often the chief complaint in the athlete with instability, we remain consistent in our approach. Instability can coexist with conditions such as internal impingement or SLAP tears, which often present as posterior pain when the patient is in maximum abduction and external rotation. In addition, athletes are not immune from the diagnosis of MDI, which can present with pain. Thus, although we recommend tests that traditionally produce instability, pain in these positions may have instability as the underlying cause.

Relocation Test for Pain (Posterior Impingement Test)

This test is performed by placing the patient supine in maximum abduction and external rotation (Fig. 16-17). If this position pro

Figure 16-17 Relocation test for pain (posterior impingement test). A, With anterior translation; B, with posterior stabilization.

Figure 16-17 Relocation test for pain (posterior impingement test). A, With anterior translation; B, with posterior stabilization.

duces posterior pain that is relieved by a posteriorly directed force on the humerus, and again recreated by removing the pressure and allowing the humerus to slide forward, then a diagnosis of internal impingement and/or posterosuperior labral pathology may be considered. Paley et al26 demonstrated contact of the undersurface of the rotator cuff and the posterosuperior glenoid in the relocation position in 100% of patients undergoing arthroscopy for internal impingement. It should be noted that this test is differentiated from a standard apprehension test, which is a measure of instability and described later.

Inferior Sulcus Test for Pain

This test is performed by applying downward pressure on the humerus, at both 0 and 90 degrees of abduction. Patients with MDI will usually have reproduction of their symptoms with this maneuver with a positive sulcus sign (Fig. 16-18). It is critical to keep in mind that a positive sulcus sign or visible dimpling between the inferior acromion and superior humeral head in and of itself is not enough to establish the diagnosis of MDI. Patients with a combined SLAP and Bankart lesion will often show an increase in the sulcus sign, as do some asymptomatic patients.

It is therefore important to differentiate between shoulder laxity, which is a sign, and instability, which is a symptom. As MDI requires inferior instability plus at least one other direction of instability, the reproduction of the patient's pain with a sulcus test suggests the diagnosis.

The inferior sulcus test can also be used to diagnose pain secondary to rotator interval laxity and pathology. A sulcus sign (with the shoulder in the standard position of adduction and neutral rotation) that does not disappear when the sulcus is again tested in adduction and 25 to 30 degrees of external rotation indicates a deficient or lax rotator interval.

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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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