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Shoulder Impingement Test

- Classic Neer Impingment Sign: (see impingement syndrome)
    - is tested by having the patient place his hand on the unaffected shoulder and gradually forward flexing the shoulder;
    - impingement sign is elicited w/ pt seated and the examiner standing;
    - scapular rotation is prevented w/ one hand while other hand raises arm in forced foward elevation causing greater tuberosity to impinge against the acromion;
    - raise the arm somewhere between flexion and abduction;
    - this maneuver produces pain in pts w/ impingement lesions of all stages (as well as partial frozen shoulder, instability, arthritis ect.)
    - if this motion is painful at 90 degrees of forward flexion it is a positive sign for impingement (primary impingement sign);
          - pain during abduction of the arm to 80 deg and internal rotation is a secondary impingement sign;
    - Hawkins modification:
          - looks for impingement in the plane of the scapula (which brings the greater tuberosity directly under the CA ligment);
          - forward flex the humerus and forcefully internally rotate the humerus;
          - this test may help determine whether the CA ligament is contributing to the impingement;          

- Impingement Test:
    - while the impignement sign will be positive in other shoulder conditions, injection of 10 cc of 1% lidocaine beneath anterior acromion will relieve pain in the case of an impingement syndrome;
          - note that this injection can also give the surgeon an idea of the patient's pain tolerance;
          - if there is excessive pain during the injection, then there may be excessive pain following surgery;
    - steroids:
          - consider adding steroids to the injection to provide the patient w/ long term relief as well as to better confirm the diagnosis;
                 - most patients w/ primary subacromial impingement will receive several months of good pain relief w/ steroid injection;
                 - if patients do not recieve relief, then consider another diagnosis such as AC joint arthrosis or secondary impingment;
          - consider adding 1 ml of triamcinolone
                 - hexacetonide is used for large joints, may cause hypopigmentation but has long lasting effect
                 - acetonide is for small and medium sized joints;
          - cautions: steroid injection may be contraindicated in brittle diabetic patients

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