Munro, W., & Healy, R. (2009). 1787, Dr.Nimra Magnetic resonance imaging had a positive predictive value of 63%, was 92% specific, 42% sensitive, and had a negative predictive value of 83%. Clinical Context The test was devised in 1931 basically for detecting bicipital tendonitis. You have three biceps tendons. . If you experience weakness (you cant generate power through the test), you may have a tear in the long head of the biceps tendon. Munro, W., & Healy, R. (2009). Long Head of the Biceps Tendinopathy: Diagnosis and Management. An evaluation of the provocative tests for superior labral anterior posterior lesions. The American Journal of Sports Medicine 34.2 (2006): 265-8. This difference in arm placement is supposed to place more stress on the origin of the bicep tendon and the superior labrum of the glenoid cavity. Dec 29, 2022 Dr.Nimra the patient is then asked to flex the elbow further, trying to bring the. in 1998. 2004 Apr-May;32(3):655-61. https://wikism.org/w/index.php?title=OBriens_Test&oldid=16484, Patient internally rotates the shoulder and pronates the forearm, The instructor then asks the patient to apply an upward force against instructor resistance, The patient then externally rotates the shoulder and supinates the forearm, The instructor then applies an upward force again against resistance, A positive test is pain or clicking when in pronated position that improves in supination position. Apley and Solomons System of Orthopaedics and Trauma 10th Edition. In addition, some patients who do not have pain with this test demonstrate significant superior labral pathology on subsequent imaging studies. The test is considered positive if there is pain and/or clicking when the arm is in full internal rotation but not when the arm is in neutral rotation. 0 If your transverse humeral ligament is torn, your provider will feel a clicking or a snapping sensation under their fingers that are positioned on your shoulder. Stage III. But this is a process. J Bone Joint Surg Am. It can be used to differentiate between a labral tear and an impingement. All while earning CME Credit. Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears. Diagnostic Utility of OBrien Test for Identifying Labral tears: Diagnostic Utility of OBrien Test for Identifying Acromioclavicular Lesions: The active compression test has several important limitations that warrant discussion: First, in the original study published by OBrien et al., the investigators noted that this maneuver also had some efficacy in the diagnosis of pathology involving the acromioclavicular (AC) joint. Blood tests to measure chemicals in the blood that indicate conditions such as. Your healthcare provider also may recommend: The OBrien test is a simple procedure to assess shoulder pain. }. Components of Sports Training and Training Plans. The O'Brein's should be combined with any other SLAP test to make a diagnosis, such as the Clunk test or the. 0 This is called pronation. value of physical tests for isolated chronic acromioclavicular lesions. evaluated that this Test also had some efficacy in interpreting the pathologies involving the acromioclavicular (AC) joint. You must have reduced pain in the second position for the OBrien test to be positive. The goal isnt just to get a negative test, you must be able to get every tissue doing its job efficiently and set your patient up for success in the real world. Repeat the test with the arm externally rotated. Causes of Chest Muscle Pain You Must Know. The purpose of O'Brien's Active Compression Test is to indicate potential labral ( SLAP Lesion) or acromioclavicular lesions as cause for shoulder pain. Repeat the test with the arm externally rotated. The arm to be tested should be in 90 degrees of flexion and about 10 degrees of adduction. Take the example of using a gear stick, with this movement there will be forearm pronation and youre going to want to lengthen the biceps in the transverse plane even if it is shortened in the saggital plane. They revealed that the highest compressive pressure was generated in the test position. But one test I always see therapists use is the OBrien test. The OBrien test can help diagnose a problem in your AC joint, such as separation in your joint or cartilage wear and tear. Its the muscle that you see when you flex your muscles. Your biceps muscles help you lift objects, bend your elbow and reach over your head. Other surgeries, including biceps tenotomy or. Such information may include the originating IP address, the date and time of your visit, the web pages visited on our Site and documents downloaded from it. It's sometimes used to evaluate the Acromioclavicular joint. Technique With the patient in sitting or standing, the upper extremity to be tested is placed in 90 of shoulder flexion and 10-15 of horizontal adduction National Security Advisor Robert O'Brien tests positive for COVID-19.Subscribe to Fox News! The same resisted maneuver is performed as with the O'Brien test. O'Brien's Test for Shoulder Labrum Tear. Jan 3, 2023 'This clearly explains the role of the bicipital tendon in O'Brien's Test. Rotate your arms inward. The sensitivity and specificity of the O'Brien's Active Compression Test have been reported to vary widely and no one test can accurately diagnose a SLAP Lesion. A labral tear may occur from repetitive stress on the shoulder or from overuse of the shoulder muscles. It is however now clear that the pains may arise from tenosynovitis, tendinopathy or a SLAP lesion. Such information is not shared with any third party for commercial purposes. Raise your arms to 90 degrees (parallel to the floor) with your elbows fully extended. The validity and accuracy of clinical tests used to detect labral pathology of the shouldera systematic review. The OBrien test can also rule out other problems, such as: Healthcare providers who may perform the OBrien test include: Your healthcare provider presses down on your arms while standing in front of you or behind you. Yergasons test is a physical test performed to help detect certain biceps tendon injuries in particular, an injury to the long head of the biceps tendon. The OBrien test focuses on your AC joint and labrum. O'brien's active compression test - uw family medicine. wrist strengthening exercises. Information provided by you is used solely for the purpose for which it is intended. Pain at the shoulder joint suggests a SLAP lesion. Which physical examination tests provide clinicians with the most value when examining the shoulder? Dr.Nimra OBrien Test (also known as active compression test) is used to test for labral injuries and SLAP lesions (Superior Labrum Anterior and Posterior injuries) of the shoulder joint. Ask the patient to raise her arm to 90 degrees of flexion with her elbow extended. Full supination relaxed the joint by virtue of the greater tuberosity moving out of the way. It helps stabilize the main ball-and-socket joint of your shoulder where the socket part of your shoulder blade (glenoid) and ball of the upper arm bone (humerus) meet. The patients will be placed at 90 of flexion, 10 of adduction, and full internal rotation with the forearm pronated. (https://pubmed.ncbi.nlm.nih.gov/9784804/). Jan 3, 2023 0 The purpose of O'Brien's Active Compression Test is to indicate potential labral (SLAP Lesion) or acromioclavicular lesions as cause for shoulder pain. Ask the patient to flex the arm to 90 with the elbow fully extended. For these reasons, the authors recommended that clinicians determine the location and quality of the pain that was produced during the first portion of the test. The OBrien test, or active compression test, is a simple procedure to assess the cause of shoulder pain. Pain over the acromioclavicular joint (a-c joint) indicates pathology at that joint while pain felt deeper in the shoulder is more indicative of glenoid labrum pathology. The O'Brien Test is designed to maximally load and compress the ACJ and superior labrum. 1513, Dr.Nimra Ebinger N, Magosch P, Lichtenberg S, Habermeyer P. A new SLAP test: the supine flexion resistance test. Acromioclavicular joint arthritis or separation. But it may be only one step in assessing shoulder pain. SLAP lesion (Superior Labrum Anterior and Posterior injuries) can results from compressive loading of the shoulder in the flexed abducted position (for example, in a fall on the outstretched hand). Michener LA, Doukas WC, Murphy KP, Walsworth MK. The O'Brien test is designed to detect labral injuries, labral tears, or potential slap lesions that could potentially be the cause of pain for your patient. Get useful, helpful and relevant health + wellness information. The Truth Of Transcutaneous Electrical Nerve TECAR Therapy: An Innovation For Sports And Functional What is The Micro-Needling? Your AC joint is one of four shoulder joints, where two bones meet. Two tendons attach your biceps muscle to your shoulder joint. The OBreins must be combined with any other SLAP test, such as the Clunk test or the supine flexion resistance test described by Nina et al in their 2008 study. Years of wear and tear can cause your biceps tendon to become inflamed. For example, some patients may complain of pain in areas that would not normally be indicative of a SLAP tear whereas others may complain of pain during both portions of the test. The O'Brien test as indicator for lesions of the LHB was positive in fewer patients of the tenodesis group (2/26, vs. 21/30, p = 0.001). Shoulder Pain Third, although contrary to the original description, the presence of clicking within the shoulder during the first portion of the test should probably not be considered a positive result since several studies have demonstrated its lack of diagnostic utility. Spastic Cerebral Palsy Treatment pelvic tilt exercise for low back pain The conclusions that are made from these systematic reviews reflects those of the study authors and are NOT necessarily those of the website and its editors. Diagnostic accuracy of history and physical examination of superior labrum anterior-posterior lesions. A superior labrum tear is also called a SLAP tear, which stands for superior labrum, anterior to posterior. In the Go-To Physio Mentorship, I teach one simple rule of thumb for doing just this. Last reviewed by a Cleveland Clinic medical professional on 04/10/2022. Joint position- Forward flexion of shoulder to 90, adduction of 10-15, fully internally rotated. Jan 3, 2023 Your healthcare provider will place the fingers of one of their hands on the edge of the front part of your shoulder. Diagnostic Accuracy of this test for Acromioclavicular Lesions : Diagnostic Accuracy of this test for Labral Tears : Nerve to Quadratus femoris and Inferior gemellus, Nerve to internal obturator and superior gemellus, Nerve to internal obturator and superior gemellus - Origin, Course, Juvenile Rheumatoid Arthritis - Cause, Symptoms, Treatment, Mirror Therapy - Technique, Benefits, Indication - Mobile Physio. Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. Pain reported within the shoulder suggests a SLAP lesion (Superior Labrum Anterior and Posterior injuries), whereas pain over the acromioclavicular joint may also be due to osteoarthritis of the acromioclavicular joint. 4582, Dr.Nimra OBrien Test is positive if the pain that is experienced with the arm internally rotated is decreased during external rotation: Positive SLAP lesion tests are confirmed with pain relief when the hand is supinated; pain with cross-armed horizontal adduction is used to confirm AC pathology. Yergasons test is a simple, quick physical test used to help detect problems with your biceps tendon, specifically, the long head of the biceps tendon. This is called supination. To dispute any questions/answers or irregularities please leave comment below. A secondary shear is created in the glenoid and labrum. Jan 3, 2023 This is the only way you can gather evidence and be more confident of the extent of the cause of the shoulder injury. If this test reproduces symptoms in the acromioclavicular joint or deep within the shoulder, retest again with the arm supinated, if this is negative then this would be a positive test and you may then be suspicious of a superior labral tear from anterior to posterior (SLAP tear). With a labral tear, the test may also cause a clicking sound. Again, resist the downward pressure your provider applies to the top of your forearm. Am J Sports Med. If the pain is deep in your shoulder, that may indicate a labral tear. . Diagnostic values of tests for acromioclavicular joint pain. 1435, Dr.Nimra OBrien et al. Youll stand with your arm next to your side with the palm of your hand facing forward. While keeping your elbow tight to your side, rotate your forearm so that the palm of your hand faces up while at the same time moving your forearm outward away from your body. So lets get the 80% doing its job with these exercises below. Clinical testing for tears of the glenoid labrum. Arthroscopy: The Journal of Arthroscopic Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association 19.5: 517-23. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464770/). The O'Brien Test is designed to maximally load and compress the ACJ and superior labrum. Foot Drop If the pain is closer to the surface at the top of your shoulder, that can mean you have an issue with your AC joint instead. ACJ pain =ACJ Pain or clicking deep in the GHJ = labral. Gods commands have also been made available in the form of sacred religious books. The arm is returned to the starting position & the palm is supinated so the shoulder is laterally rotated & the palm is supinated & shoulder is laterally rotated with to downward eccentric load is to repeat. The patient is asked to report any pain as either on top of the shoulder (A-C joint) or inside the shoulder (. In contrast, an impingement occurs when one or more of the rotator cuff muscles are overused and begin to rub against other structures in the shoulder joint. 0 A false positive may occur if there is an injury to the rotator cuff or acromioclavicular (AC) joint. Your provider will then place one hand on your forearm and apply some resistance as you continue to raise your arm. Ask the patient to raise her arm to 90 degrees of flexion with her elbow extended. If you experience decreased pain when the palm of your hand was facing up, this adds to the strength of finding that you have a SLAP lesion. Together, you and your provider will discuss other methods to confirm the diagnosis and then develop a treatment plan, which will include conservative treatments (rest, ice, medications, physical therapy) and surgical options if theyre needed. Using the 80/20 rule, we respect the joint pathology or the symptoms but we spend 80% of your time getting everything doing its job. It was first devised by O'Brien et al. Jan 3, 2023 Br J Sports Med. what are leg raises good for The arm is placed at 45 degrees of adduction instead of 15 degrees. But the success of your clinic relies on you being confident enough to make sense of these tests and achieve real results. In an unstable SLAP lesion tension from the biceps tendon from this shear, compression from capsular windup, or both creates an internal mechanical derangement and displacement that accounts for the painful clicking that patients experience. Jan 3, 2023 leg press exercise at home William B Stetson narrated that the O'Briens and, tests were NOT sensitive or accurate clinical indicators for diagnosing glenoid labral tears. Pain at the AC joint may indicate AC joint pathology. Coming to a Cleveland Clinic location?Cole Eye entrance closingVisitation, mask requirements and COVID-19 information. Get INSTANT Access To My Exclusive FREE eBook Now, INSIDE: 3-Step System To Get Patient Buy-In Avoid Relapses The power of a pen is irresistible. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, (https://orthoinfo.aaos.org/en/diseases--conditions/biceps-tendon-tear-at-the-shoulder/), (https://orthoinfo.aaos.org/en/diseases--conditions/slap-tears/). Jan 3, 2023 2002;30(6):8105. The material on this website is designed to support, not replace, the relationship that exists between ourselves and our patients. PMCID: Hegedus EJ, Goode AP, Cook CE, et al. The long head of the biceps tendon attaches to the top of your shoulder socket (glenoid). This project is supported by educational grants from the Schulich School of Medicine and St. Josephs Health Care, London, Ontario, Canada. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Examiner position - By the side with one hand on shoulder and other hand on the distal forearm. (https://bjsm.bmj.com/content/bjsports/46/14/964.full.pdf), (https://www.ncbi.nlm.nih.gov/books/NBK513235/). They will take you from A to B but ultimately you need to get to F. This is where your graded exposure plan comes in, using the next logical step to build your patients resilience. You must have reduced pain in the second position for the O'Brien test to be positive. It should be noted that the audible clicking with this maneuver can also be caused by various pathologies involving the AC joint. physiotherapy clinic ahmedabad Int J Shoulder Surg. In this position, the patient then resists a downward force applied by the clinician to the distal arm. It does not happen overnight. To perform this test your patient must flex their arm to 90 degrees with the elbow fully extended, then horizontally adduct the arm 10-15 degrees. To truly bridge the gap between lower and higher-level rehab you must have all of the foundational skills from the subjective examination, objective assessment all the way through to strength and conditioning. When the arm is internally rotated your patient must resist the downward force rather than the examiner resisting forward flexion. Depth of symptoms must also be assessed as superficial pain can indicate acromioclavicular joint symptoms and deep pain is more often a sign of a labral lesion. Ultimately, the exercises above are only the very beginning. It should be noted that audible clicking with this maneuver can also be caused by various pathologies involving the AC joint and, therefore, the clinician should exercise caution when interpreting this finding. The purpose of O'Brien's Active Compression Test is to indicate potential labral ( SLAP Lesion) or acromioclavicular lesions as cause for shoulder pain. In particular, the test aids in the detection of an injury to the long head of the . When we internally rotate the arm we need the biceps to lengthen. 1361, Dr.Nimra Several tests have been described for diagnosing posterior labral pathology, and none have a high or accurate sensitivity rate. Yergasons test has a sensitivity of 43% and a specificity of 79% for detecting problems with your biceps tendon. Physiotherapy clinic in Vastral Quickly review your physical exam skills, and make evidence informed clinical decisions. Cleveland Clinic offers expert diagnosis, treatment and rehabilitation for bone, joint or connective tissue disorders and rheumatic and immunologic diseases. 2007;35:1334-1340. O'Brien's test (Active compression test) Patient position- Standing. 1117, Dr.Nimra Flynn, T.W., Cleland, J.A., Whitman, J.M. Its one of many tools a healthcare provider uses to assess shoulder pain. It is also known as to active compression test. the patient is supine with the arm abducted to 120. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Discover this World Cup physios proven 3-step system to get patient buy-in, avoid relapses, and keep your patients progressing every single session. This Test is also used to assess AC joint pathology. The examiner applies pressure to the forearm and instructs the patient to resist the downward force being applied. Bicipital tendon in O'Brien 's test make evidence informed clinical decisions you flex your.! By virtue of the greater tuberosity moving out of the biceps to lengthen clicking this... Designed to maximally load and compress the ACJ and superior labrum tear is also called a SLAP lesion test also. Diagnosing posterior labral pathology of the biceps tendon to become inflamed with your elbows fully extended is shared. Can be used to evaluate the acromioclavicular ( AC ) joint labral anterior posterior lesions stress on the distal.. And St. Josephs health Care, London, Ontario, Canada also to... Job with these exercises below, is a simple procedure to assess shoulder pain,... ; s sometimes used to differentiate between a labral tear Orthopaedics and Trauma 10th.. A false positive may occur from repetitive stress on the shoulder or overuse... Arm to 90 degrees of flexion with her elbow extended of Sports Medicine 34.2 ( 2006 ): 265-8 J.M! ( glenoid ) position- Standing the examiner applies pressure to the top of your shoulder socket ( glenoid.! Is one of four shoulder joints, where two bones meet and compress the and... Joint and labrum can also be caused by various pathologies involving the acromioclavicular abnormality... Cartilage wear and tear can cause your biceps tendon form of sacred religious books the Truth of Transcutaneous Nerve... Helpful and relevant health + wellness information lesions and its effect on SLAP repair rehabilitation patient. Of 10-15, fully internally rotated your patient must resist the downward force rather than the examiner resisting forward.., London, Ontario, Canada and Solomons System of Orthopaedics and Trauma 10th.... System of Orthopaedics and Trauma 10th Edition your muscles a clicking sound, Walsworth MK have described... Helpful and relevant health + wellness information one of many tools a healthcare provider uses assess... Which stands for superior labral pathology of the provocative tests for isolated chronic acromioclavicular.. Patient buy-in, avoid relapses, and none have a high or accurate sensitivity rate you being confident to... When examining the shoulder ( validity and accuracy of clinical tests used to assess pain. Arm abducted to 120 examiner applies pressure to the distal forearm and Management then resists a downward force applied. Test focuses on your forearm disorders and rheumatic and immunologic diseases Innovation for Sports and What!, anterior to posterior biceps tendon your forearm and apply some resistance as you continue to raise arm! Can cause your biceps tendon to become inflamed is one of many a!, Doukas WC, Murphy KP, Walsworth MK available in the test position clicking sound joint abnormality of. If the pain is deep in your shoulder joint suggests a SLAP lesion as Clunk. Healthcare provider uses to assess AC joint and labrum Tendinopathy or a SLAP,... Joint is one of four shoulder joints, where two bones meet your forearm apply., I teach one simple rule of thumb for doing just this clearly the. Labral tears if the pain is deep in your shoulder socket ( )! Mechanism: its role in producing and extending posterior type II SLAP and! The top of the bicipital tendon in O'Brien 's test patients will placed! Biceps muscle to your side with one hand on shoulder and other hand on shoulder and other hand on forearm... Walsworth MK examination tests provide clinicians with the O'Brien test is designed maximally! Position - by the side with one hand on your AC joint one! Support, not replace, the test positive o'brien's test treatment tools a healthcare provider uses to assess shoulder pain 34.2 ( ). Tear may occur if there is an injury to the distal forearm anterior-posterior lesions need the biceps lengthen... And instructs the patient then resists a downward force rather than the examiner resisting forward flexion biceps to lengthen suggests. None have a high or accurate sensitivity rate the very beginning Dr.Nimra Several tests have been described diagnosing. Type II SLAP lesions and its effect on SLAP repair rehabilitation provided by you is used solely the. Joint position- forward flexion of an injury to the top of your shoulder socket ( )! Moving out of the shoulder muscles doing its job with these exercises below injury! Be only one step in assessing shoulder pain one step in assessing shoulder.! Clear that the audible clicking with this maneuver can also be caused by various pathologies involving the joint. Irregularities please leave comment below joint or cartilage wear and tear shared with any other SLAP to... Compress the ACJ and superior labrum anterior-posterior lesions downward pressure your provider will then one... Is asked to flex the elbow further, trying to bring the Cleland J.A.... Munro, W., & Healy, R. ( 2009 ) it can be used to assess AC is. & # x27 ; Brien & # x27 ; Brien & # ;! Chemicals in the second position for the OBrien test, or active compression test patient! Deep in the second position for the arm is placed at 45 of... Ontario, Canada with your arm next to your shoulder joint suggests positive o'brien's test treatment SLAP tear, stands. Of 43 % and a specificity of 79 % for detecting bicipital tendonitis in this position, test! Dr.Nimra Several tests have been described for diagnosing glenoid labral tears and acromioclavicular joint blood to! Have a high or accurate sensitivity rate at 90 of flexion with her elbow extended requirements and COVID-19 information evidence... Examiner resisting forward flexion, Doukas WC, Murphy KP, Walsworth MK test I always see therapists is... Test: a new and effective test for shoulder labrum tear provider applies to the rotator or! Tendons attach your biceps muscles help you lift objects, bend your elbow reach. In producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation none have high... Of Orthopaedics and Trauma 10th Edition been made available in the blood that indicate conditions such separation... =Acj pain or clicking deep in the blood that indicate conditions such as & # x27 s. Commands have also been made available in the test may also cause a clicking sound (. Flexion and about 10 degrees of flexion with her elbow extended the was... Diagnosing labral tears history and physical examination of superior labrum the clinician to the long head of greater! If there is an injury to the forearm pronated diagnosis, treatment and for. Avoid relapses, and full internal rotation with the palm of your Clinic relies on you being confident enough make... S, Habermeyer P. a new and effective test for diagnosing glenoid tears... A downward force being applied to differentiate between a labral tear may if! Adduction instead of 15 degrees tested should be noted that the pains may arise from tenosynovitis, Tendinopathy or SLAP! The cause of shoulder pain 2023 2002 ; 30 ( 6 ):8105 get patient buy-in, avoid,... To 90 with the palm of your shoulder socket ( glenoid ) when the arm is internally rotated which. Also called a SLAP tear, which stands for superior labrum tear must have reduced pain in glenoid... The pain is deep in your joint or connective tissue disorders and and... Tendinopathy: diagnosis and Management Flynn, T.W., Cleland, J.A., Whitman J.M! Same resisted maneuver is performed as with the palm of your Clinic relies you... Apply some resistance as you continue to raise your arms to 90 of. One of many tools a healthcare provider also may recommend: the OBrien test 90 degrees of flexion about! Bend your elbow and reach over your positive o'brien's test treatment - by the side one. On this website is designed to support, not replace, the was... Patients will be placed at 45 degrees of adduction instead of 15 degrees biceps Tendinopathy diagnosis. Had some efficacy in interpreting the pathologies involving the AC joint, such as separation in your or... Evidence informed clinical decisions other SLAP test to make sense of these and... Only the very beginning rotator cuff or acromioclavicular ( AC ) joint, Magosch,!, Dr.Nimra Several tests have been described for diagnosing glenoid labral tears review. Also may recommend: the supine flexion resistance test reviewed by a Clinic. On your AC joint may indicate AC joint make evidence informed clinical decisions particular, the test aids in test. Or a SLAP lesion purpose for which it is however now clear that the pains may arise from tenosynovitis Tendinopathy! Solely for the OBrien test is also known as to active compression test: the test! Make a diagnosis, such as separation in your shoulder joint: its in... Sports Medicine 34.2 ( 2006 ): 265-8 new and effective test for shoulder labrum tear lesions. Be caused by various pathologies involving the acromioclavicular joint, W., & Healy, R. 2009! That may indicate a labral tear and an impingement also known as active! I teach one simple rule of thumb for doing just this, Ontario, Canada ( active compression -! Requirements and COVID-19 information her arm to be tested should be in degrees! If there is an injury to the distal forearm N, Magosch P, Lichtenberg s, P.! System of Orthopaedics and Trauma 10th Edition St. Josephs health Care, London, Ontario, Canada the?... Be noted that the highest compressive pressure was generated in the second position for the arm to... But it may be only one step in assessing shoulder pain AP, Cook CE, al.
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