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This is Brent, President of the Brookbush
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Institute, and we're going over the
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Supine Impingement Test, one of our
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special orthopaedic tests used during
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shoulder examination. I'm going to have my
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friend, Melissa, come out. She's going to
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help me demonstrate. Now, this is the
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supine test, so I'm going to have her lay
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down on her back. This is not a
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complicated test. Although, if you're
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reading the instructions for the first
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time or listening to me tell you the
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instructions for the first time, there is
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a little trick at the end that may catch
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you if you're not paying attention. So,
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what we want to start with is taking
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Melissa's elbow and wrist and we're
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going to take her arm all the way into
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flexion with the arm externally rotated,
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just past neutral. As I get her all the
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way down to flexion, I'm going to push
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her into abduction, which is closer to
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her ear, and then I'm going to internally
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rotate. As I internally rotate, I can ask
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her, "Does that replicate your symptoms?"
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She said, "No," so that would be a
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negative, or a sign that maybe she
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doesn't have impingement syndrome. Now, I
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told you there was one thing during that
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little set of instructions that might
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mess you up, and that's the fact that as
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we get all the way into flexion, our
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directions for external and internal
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rotation get reversed. So, rolling out
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down here would be external rotation,
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rolling out up here would be internal
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rotation. If I- that's all internal
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rotation. So, watch how I perform this
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test again. All the way into flexion with
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the thumb kind of going in the direction
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that we're going, and then as I get her
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up here, I push her into a little bit of
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abduction, really taking her all the way
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to that end range. And then to internally
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rotate, I have to turn her back this way.
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And, of course, I ask that question, "Is
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that what you were complaining about?"
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I'm going to show you guys on the other
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side, just in case that gives you a
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little better view. So, I take her wrist
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and elbow all the way into flexion. If I
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push her closer to her ear, that would be
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abduction. Really take her all the way
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into her end range. And then I'm going to
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roll back this way into internal
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rotation and ask that question, "Does that
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replicate the pain you were talking
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about?" Okay, and it doesn't replicate the
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pain, so at this point this is a negative
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test. Now, what's the intent of this test,
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right, is to try to provoke those
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impingement symptoms. You can kind of
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think about the anatomy here. As I take
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her all the way into her end range, and then at
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end range internally rotate her shoulder,
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I'm probably taking those tubercles,
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the greater and lesser tubercle of
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the humerus, and just running it across
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the underside of the acromion shelf. And,
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of course, that has the potential to
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irritate tissues that
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are already inflamed. This test does have
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a higher sensitivity rating than our
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Neer Test, which we've talked about
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before. It's a pretty bad test. Neer is an
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important test for you to know, because
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it's going to be part of our impingement
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cluster that I'll teach later. But this test,
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if we're going to do one test for
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impingement, this would be a better selection.
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Keep in mind, if I'm doing one of
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these tests, I'm never going to take a
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test like this at face value. Just
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because she said this doesn't
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replicate her symptoms, it doesn't quite
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mean she doesn't have impingement syndrome
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yet. There could be another test that I
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get a positive on, for example, Hawkins
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Kennedy or the Neer, which we already
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talked about. Also keep in mind that the
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specificity of all of our impingement
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tests overall is pretty low. We
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talked a little bit about that in the
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Neer Test, which was that
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soon as something goes wrong with the
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shoulder, we get some inflammation, we
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decrease that subacromial space a bit, it
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probably irritates tissues, then pushing
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somebody to end range, regardless of
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whether it's a labral tear, whether it's
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a rotator cuff tear, whether it's biceps
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tendinitis, supraspinatus tenditis, it
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almost doesn't matter at this point. This
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is going to hurt. Right? So, we have very
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low specificity on these tests. Now, if
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she came in and she complained about
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anterior shoulder pain with a gradual
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onset, so I'm not thinking acute things
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like tears and ruptures and labral stuff,
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and then I did my movement assessment and
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she had some upper body signs.
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Maybe she had arms fall forward, elevation of
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her scapula during that overhead squat
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assessment, and when I put her hands down on
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the overhead squat assessment with
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modification, she collapsed forward. I'm
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thinking, okay, gradual onset, upper body
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mechanics don't look great, maybe we got
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a positive test on this and a couple
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other tests. Does this point to any
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specific impairment? Well, as I'm going
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through this, I'm not going to totally
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turn off and only think about this test.
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Did flexion feel normal? Did internal
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rotation feel normal? Did external
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rotation feel normal? Does this lead me
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towards maybe wanting to do some goniometry
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or something else that might give
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me an indication of some movement
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impairment that I could correct that's
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going to help her symptoms. Of course, is
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this her concordant sign? Is this
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the test, which it wasn't in
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this case because you told me no, could
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I use this as a pre- post-test if this
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Was the test that set off her symptoms?
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We're always looking for those quick
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test, guys. From a practice standpoint, you
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need to find that thing that replicates
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their pain, because that's going to be a
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learning tool for you. Right? So, if I did
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this- say yes this time- if I did this, did
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this test, and asked, "Does this replicate your
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symptoms?"
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Yes. Well, good, now I have an easy test to
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keep coming back to. Let's say I did that
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at the beginning of a session and I go,
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"Okay, here's what we're going to do. I'm
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going to try releasing your
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subscapularis. I'm going to try releasing
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your pectoralis minor. And I'm going to
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try a little posterior shoulder
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mobilization, and we'll see if that helps your
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shoulder out. Last time we did two of
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those- subscapularis and pectoralis minor
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release. This time I'm going to add that
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mobilization. I want to see if it gets us
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a little further." I do my manual
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techniques and go, "Okay, does that feel
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better?" Yes. If she says yes, then good, I
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have one more box that I can check off,
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one more intervention that I know worked.
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If she said no, okay, we won't do that
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intervention. That was not the
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intervention we were looking for. It's
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important that you have a quick test to
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come back to if you're going to continue
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refining your treatment program as you
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go along. Now, of course, guys, keep in mind
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that if this was a positive test and I
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continue to do treatment and nothing is
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working, that's a good sign that maybe
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you have to refer out. As we said, these
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tests have a very low specificity, all of
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our impingement tests. So just because I
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got pain, if I'm a confident therapist
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and I've been doing this a while, and I
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know or I kind of have a prognosis in my
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head of how quickly things should work,
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and after three, four, five, six sessions
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I'm not really seeing change, a positive
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impingement test just means I got pain
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during shoulder flexion, and in this case
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shoulder flexion with internal rotation.
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It doesn't necessarily rule out structural
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changes, like maybe a rotator cuff tear in
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this case, maybe a subacromial bone spur,
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maybe things have just gotten so
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inflamed that we need some other medical
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management such as some
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anti-inflammatories or an injection. So,
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there you guys have it. Here's a quick review of
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this test: thumb up, hold elbow and wrist, go all
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the way into shoulder flexion, push all
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the way into abduction, closer to the ear,
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and then you're going to roll that
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humorous back towards you, and ask that
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question, "Is that the symptoms you were
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talking about?" Yes. We started off as
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a no and now it's a yes, maybe it's
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because this is not the first take
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and I'm just starting to aggravate her
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shoulder. I hope you guys learned a
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lot in this video. I look forward to
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hearing from you.