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This is Brent of the Brookbush
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Institute, and in this video we're going over
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the Neer Impingement Test, a special or
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orthopedic test used during our shoulder
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examination. I'm going to have my friend,
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Melissa, come out. She's going to help me
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demonstrate. This isn't a
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particularly complicated test. I'm going
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to take Melissa through passive shoulder
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flexion in the scapular plane with her
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humorous internally rotated, and then I'm
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going to add a little over-pressure to
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see if I can provoke symptoms.
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I'm going
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to grab Melissa just underneath the
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elbow with an underhanded grip. I'm
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going to use this hand to stabilize her
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scapula and thorax, because as I
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push up this way, I don't want a bunch of
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scapular elevation. That's not great.
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As I go into over-pressure, I don't
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want to just push her off the table
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Last I checked, if you push
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somebody over the table, they don't come
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back, and then you're not fixing anything.
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We want to make sure she stays on the
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table and that she's stabilized. I'm going to go
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ahead and turn her arm in this way, take
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her through all the flexion she has in
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the scapular plane, and then like I said,
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I'm going to add a little bit of over-
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pressure. I'll take her just past that
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normal end range. Here's the key,
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"Are those the symptoms you were talking
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about?" If those are the symptoms that she
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was talking about, then I have a positive
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Neer Test and a good indication that
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impingement is what is bothering Melissa.
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Keep in mind that if she had pain
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but those was not her symptoms, I need to
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continue doing my testing to figure out
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where her pain is coming from.
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Although she may or may not have
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shoulder impingement, that's not what she
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came in complaining about. I need to fix what
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she's complaining about first. Maybe we
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can address this at a later date.
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What's the intent of the Neer Test?
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The intent of the Neer Test is to
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provoke symptoms in inflamed tissues.
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With an impingement syndrome, we're
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assuming that these inflamed
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tissues are being caused by pinching
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between the humeral head and what we can
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call the roof of the shoulder, which is
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the inferior surface of the acromion
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and the coracoacromial ligament.
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Under there, we have things like your
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supraspinatus and infraspinatus tendon,
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the biceps tendon, the long head
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of your biceps tendon, we have your
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subacromial bursa, and we
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even have the superior portion of the
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capsule itself for the shoulder. All those
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things could be getting inflamed, because
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Melissa's shoulder isn't working right.
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Let's say she has some sort of arthrokinematic
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dyskinesis that is causing
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these tissues to get compressed or
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rubbed more than they can handle during
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functional activities. Maybe she's a
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volleyball player and just continually
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reaching overhead with poor shoulder
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mechanics is causing all of this stuff
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to get irritated. In the Neer Test, I've
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taken the greater tubercle and moved it
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into a position where I can smash it
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against the roof of the shoulder here,
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that subacromial space. If I get her
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symptoms, I should have a pretty good
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indicator that that's what's bothering
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her. Why is this such a commonly used
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test? I think this is a commonly used
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test, because it looks very much like the
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Maitland joint exams that we've
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all done- that active motion with
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over-pressure. "Melissa, can you raise
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your arm up? Good. Does that hurt?
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Does that hurt? No, all right. Clear. Good. Let
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me have you go out into abduction all
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the way up. Does that hurt? Good.
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Does that hurt? If I do this,
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does that hurt? Yes." Maybe we're
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getting a little bit more sensitivity
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out of the fact that we're internally
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rotating the humorous and she's doing this
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in the scapular plane. Maybe that's a
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more provocative test. The truth of the
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matter is that the Neer Test isn't a
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great test by itself. Why am I
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teaching this to you? It's important
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that you know this test. This is a very
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commonly used test, and you're going to
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see things like a positive Neer on
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various paperwork that heads your way.
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Maybe a doctor notes positive Neer Test
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and you need to understand what that is.
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What is happening now, because of
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research, when we talk about things like
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sensitivity and specificity, is we're
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realizing a lot of these orthopedic
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tests or special tests
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aren't great, so we'll cluster them.
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The Neer Test is part of many of those
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clusters. I think part of the problem
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with all of our impingement tests is the
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fact that they're usually okay too good
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on the sensitivity part,
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but the specificity is really bad. I
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think what you guys will find as you
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practice is that just about every
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dysfunction of the shoulder starts
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leading to some impingement syndrome
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signs, and that should kind of
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make sense to us. If you have
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a labral tear, your shoulder's not going
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to move well. If it doesn't move well,
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things are going to get rubbed and then
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pinched, and it's going to start getting
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inflamed. Something like bashing your
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humeral head into the underside of your
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shoulder is going to hurt. We don't
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have a very specific test, because if
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somebody has a labral tear, maybe rotator
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cuff tear, maybe posterior capsule impingement
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versus internal- it all kind of
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gets mashed together in these tests.
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How do I use these tests? I'm going
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to go ahead and start with her
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subjective examination. That's going to
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help a lot. Did this come on
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gradually or was it acute trauma? If it's
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acute trauma, impingement might not be my
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first hypothesis.
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If she has signs of upper body
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dysfunction in my movement assessment,
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like in my overhead squat assessment her
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arms fall forward and she has scapular
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elevation, and she said that this came on
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gradually during her subjective
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assessment. Okay. I'm starting to
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think towards impingement. So, where does
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Neer come in? I'm probably
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going to do Neer in a cluster of tests,
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which we're going to go over as we break
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down each one of these tests
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individually. Most importantly, is this
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the test that gets me to her symptoms? If
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it does, this becomes a great quick test
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for me to do pre- post-assessment both as
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she's coming in from session to session,
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as well as maybe I'm going to try a new
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intervention and I want to see if it has
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any affect on her shoulder. I can quickly
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do this test. Let's say I have her
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come in, "How do you feel? Pain?
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Yes." I do posterior deltoid release. "How
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does this feel? Any better? Yes." Oh, good.
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That's one more intervention that I know
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is going to be effective, or maybe it's even
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something I could add to her home
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exercise program. That's where
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tests like this become super, super
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helpful. The other thing you might think
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of, which is a little outside of the
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box, is as we show you different
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special tests, you'll see that this one
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is very flexion related. If I'm
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missing a bunch of flexion and flexion
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causes her pain, I might start thinking
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about, "Well, what's restricting flexion? Is
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there a movement impairment that I can
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draw from this test? The
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muscles that happen to restrict end range
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flexion are also my internal rotators.
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We know a lot of us sit like this, so
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maybe I need to look at releasing things
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like my subscapularis, my latissimus
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dorsi, my teres major, my pectoralis
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major, and maybe do a little stretching and
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lengthening of those structures to see
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if I can get a little extensibility back
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and bring everything back down
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to normal. Here's one more
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review of what the Neer Test looks like.
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Grab just below the elbow, internally
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rotate, go through the scapular plane with
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over-pressure, and then ask, "Does that replicate the
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symptoms you were talking about?" If she
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says yes, then I have a positive Neer and
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one more indicator in a cluster of signs-
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this is just one clue- that we might have
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impingement syndrome. I hope you guys
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enjoyed this video. I'll talk with you soon.