anterior shoulder instability test

28/02/2021

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Test is positive with pain or apprehension demonstrated by Positive test indicates the anterior instability decided by the amount of anterior translation which is accessible comparing with the normal side. [2], Negative likelihood ratio (-LR) = 0.57[4], The anterior drawer test (when pain does not prevent it from being performed) is helpful for diagnosing traumatic anterior instability. Step3. Shoulder Anterior Drawer Test Translation suggests anterior instability (90%) Shoulder Posterior Drawer Test Inferior translation (Shoulder sulcus sign) Patient stands Pull both arms downward Sulcus will form if ligament laxity on The program will vary in length for each individual depending on the seven rehabilitation factors. The glenohumeral ligaments: The superior glenohumeral ligament functions primarily to resist inferior translation and external rotation of the humeral head in the adducted arm. A positive apprehension test occurs if the patient either looks apprehensive or resists further movement. Step6. In cases of bony Bankart lesions, recurrent instability can cause erosive or attritional loss of the glenoid rim causing progressive instability. Decrease pain, inflammation, and muscular spasms, Retard muscular atrophy/establish voluntary muscle activity, Range of motion: Pendulums, rope and pulley, active-assisted ROM (F, IR, ER), Strengthening/proprioception: Isometrics (flexion, abduction, extension, IR, ER, performed with arm at side), Rhythmic stabilisation: ER/IR/F/E in scapular plane, weight shifts (standing hands on table), proprioception training drills (active joint reproduction: F/ IR/ER), Nearly full to full passive ROM (ER may still be limited), Good MMT of IR, ER, flexion and abduction, Baseline proprioception and dynamic stability, Progress ROM activities at 90° abduction to tolerance (pain free), Emphasis ER and scapular strengthening: Abduction to 90°, side lying ER to 45°, push-ups onto table, biceps curls, triceps pushdowns, prone rowing. [4][5] The consequences of an initial anterior glenohumeral dislocation in patients over forty years of age are quite different than in the younger population, primarily due to the increased incidence of rotator cuff tears and associated neurovascular injuries. That is usually the journal article where the information was first stated. When refering to evidence in academic writing, you should always try to reference the primary (original) source. The current options for treating an episode of shoulder instability includes either operative or non-operative management. A patient with anterior instability will be Anterior Release Test: A New Test for Occult Shoulder Instability. Modified axillary roentgenogram a useful adjunct in the diagnosis of recurrent instability of the shoulder. Apprehension indicates a positive test, as pain can also be elicited with primary impingement. It is important to refrain from pushing into external rotation or horizontal abduction with anterior instability. Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment. According to the review and meta-analysis from Hegedus et al. Lo IK, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A. Pavlov H, Warren RF, Weiss Jr CB, Dines DM. If further investigation is needed Didiee and West Point views can be considered. Improve neuromuscular control of shoulder complex: Rhythmic stabilisation drills at inner, mid, and outer ROM, proprioceptive, scapulothoracic/glenohumeral musculature, PNF, weight shifts hand on ball, wall stabilisation drills. Anterior Shoulder Instability is a pathologic state characterized by abnormal translation of the humeral head on or over the glenoid, leading to frank anterior dislocation, functional impairments, or pain. Glenohumeral bone loss and anterior instability. Milgrom C, Milgrom Y, Radeva-Petrova D, Jaber S, Beyth S, Finestone AS. Sixty-three patients had a negative test and 62 of these had an intact biceps tendon-superior labrum complex; the remaining patient had a type II superior labral anterior and posterior lesion. Medscape; 2011. These three tests are performed to assess glenohumeral joint anterior instability. Dislocations, which are significantly more common in men, represent about 4% of all high school sports injuries, with shoulder dislocations accounting for over 50% of all dislocations. The click may indicate a labral tear or slippage of the humeral head over the glenoid rim. Test is positive with pain or apprehension demonstrated by patient. This results in symptoms including pain, discomfort, to as 1 Abduct the patient shoulder between the 80 and 120 degree, Forward flexed up to 20 degree, laterally rotated up to 30 degree. Shoulder Apprehension Test | Anterior Shoulder Instability 陽性判定脱臼感や不安感や疼痛を訴えた場合に陽性となります. Study design: Retrospective review of prospectively collected data. [3], Research suggests that incidence of recurrent shoulder dislocation is significantly higher in younger patients. Available from: Web MD. Procedure for modified anterior drawer test for shoulder joint: With the patient in supine lying, place the patient’s affected shoulder just over the edge of the examination table (2). An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder instability. 6th edition. Step2. Methods We performed … The anterior apprehension test, or crank test, is also used to evaluate shoulder instability. The glenohumeral joint (multi-axial spheroidal joint) is one of the largest and most complex joints in the body. Anterior glenohumeral instability secondary to a traumatic shoulder dislocation is a common problem that plagues both athletes and non-athletes of all age groups. Elsevier. Anterior instability - unlike other shoulder pathologies - can very well be diagnosed by clinical testing. This test can be performed with the patient in sitting or in supine. Abduct arm to 90 degrees with elbow flexed to 90 degrees and then passively and slowly externally rotate the shoulder. [1] It is an injury to the glenohumeral joint (GHJ) where the humerus is displaced from its normal position in the center of the glenoid fossa and the joint surfaces no longer touch each other. Information regarding all treatment prior to presentation should be ascertained, including any period of immobilisation or physiotherapy and previous surgical interventions. The presence and quantity of previous shoulder subluxations or dislocations is also important to note. Often Clinical orthopaedics and related research. These tests are highly specific and strongly predictive of traumatic anterior glenohumeral instability. One hundred shoulders were examined preoperatively by the same examiner. Recurrent anterior Diagnosis of occult instability by physical examination remains challenging. Medscape. Anterior shoulder instability is defined as soft-tissue or bony insult of the shoulder that causes the humeral head to sublux or dislocate from the glenoid fossa. However, instability also may present as subluxation, a condition in which the joint symptomatically translates but does not completely dislocate. Humeral avulsion of the glenohumeral ligaments is also a cause of anterior shoulder instability. Examiner position: Stand facing the patient’s affected side. Anterior Drawer Anterior shoulder instability among youth athletes accounts for nearly a quarter of all shoulder injuries. Apprehension is a better criterion than pain for a … Adding contrast and performing a CT arthrogram of the shoulder can also provide some insight into the status of the labrum, rotator cuff and ligamentous complex. The patient’s arm should be relaxed. Signs and symptoms for anterior shoulder instability: Symptoms related to recurrent anterior instability:[7], Diagnosis of anterior shoulder instability is through a thorough history, radiology and three specific tests carried out in this order: apprehension, relocation and surprise (release) test. CT may be useful to demonstrate and quantify bony abnormalities including glenoid bone loss or fractures, glenoid version and humeral head abnormalities. Any associated symptoms including neurologic deficits and functional limitations should also be assessed . Patient position: Supine lying. Evaluation and management of recurrent anterior shoulder instability. Patients with shoulder instability were assessed and our patients were selected on the basis of certain criteria. The patient’s arm is pulled anteriorly to apply a gliding force to the glenohumeral joint. Age, activity level, sports participation, and hand dominance should be noted, as well instability in any other joints, especially the contralateral shoulder. Anterior Glenohumeral Instability. The Didiee view is obtained with the patient prone and the hand is placed on the ipsilateral iliac crest with the x-ray beam directed laterally at 45° to the floor. Clinical assessment of three common tests for traumatic anterior shoulder instability. Anterior shoulder instability is defined as soft-tissue or bony insult of the shoulder that causes the humeral head to sublux or dislocate from the glenoid fossa. Loss of 20% of the glenoid rim has been shown to cause significant recurrent instability and usually requires surgical correction of the bony deficiency. The GHJ is formed where the humeral head fits into the glenoid fossa, an irregular oval shape, which is an extension of the scapula, like a ball and socket, although only 25% of the humeral head makes contact with the glenoid fossa at any time. Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. The anterior or posterior supporting structures of the shoulder can also be disrupted following an anterior dislocation. The primary function of the anterior band is to resist anteroinferior translation. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. Age of the patient at the first dislocation is a key prognostic indicator. Apprehension test: (supine) anterior instability. During the early rehabilitation program, caution must be applied in placing the capsule under stress until dynamic joint stability is restored. Purpose of Test: To assess for anterior instability of the glenohumeral joint capsule. David J. Magee. Anterior Shoulder Instability is the Most common type of shoulder instability. Based on surgical findings, the shoulders were classified as anterior instability or … Lizzio VA, Meta F, Fidai M, Makhni EC. Anterior shoulder instability is the most common type of shoulder instability. The inferior glenohumeral ligament is composed of two bands, anterior and posterior, and the intervening capsule. For example, the anterior apprehension test for anterior shoulder instability is fairly accurate for the patient with traumatic anterior instability, but its usefulness is less clear in the throwing athlete who does not have true anterior shoulder instability have been described4,8-10, with the apprehension test and the relocation test being the most com-mon6,7. shoulder locked in an internally rotated position common in undiagnosed posterior dislocations pain on flexion, adduction and internal rotation for posterior instability provocative tests - performed in the setting of chronic posterior If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. In the younger population, anterior capsuloligamentous structures most commonly fail, whereas in older patients with pre-existing degenerative weakening of the rotator cuff, the posterior structures are more likely to fail. In the acute setting, the hemarthrosis resulting from the dislocation serves as an intra-articular contrast medium. RESULTS: A total of 564 patients who underwent surgical treatment for anterior shoulder instability from November 2012 to June 2017 were Step2. Also see related pages for shoulder instability, shoulder subluxation and shoulder dislocation. Posterior shoulder instability (PSI), although less common than anterior instability, is becoming an increasingly recognised pathology irrespective of the underlying cause. Patients under 20 years with shoulder dislocations have a 90% chance of recurrence, whilst patients older than 40 years only have a 10% recurrence rate, but are more prone to rotator cuff injuries. If pain restricts the patient's ability to tolerate an axillary lateral view, a Velpeau view may be obtained in a semi-reclined, seated position. Elsevier. Furthermore the exam was focused on the presence of scapular dyskinesia and posterior shoulder pain. The stabilising hand is placed on the scapula so that the fingers and thumb secure the scapula at the spine of the scapula and the coracoid. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. A conservative rehabilitation program needs to be patient specific, based on the type and degree of shoulder instability present and the desired level of return to function. Continued progression of resistive exercises, Normal muscle strength, dynamic stability and neuromuscular control, Continue isotonic strengthening (progress resistance): Full ROM strengthening, bench press in restricted ROM, flat and incline chest press, Advanced neuromuscular control drills: Ball flips on table, push-ups on ball with rhythmic stabilisations, manual scapular neuromuscular control drills, initiate perturbation activities, Endurance training: Timed bouts of exercises (30-60s), increase number of repetitions, multiple bouts throughout day, Initiate plyometric training: 2 hand-drills (chest pass throw, side to side throw, overhead soccer throw) and progress to 1 hand-drills (wall dribbles, 90/90 baseball throws), Maintain optimal level of strength/power/endurance, Progressively increase activity level to prepare patient/athlete for full functional return to activity/sport, Progress isotonic strengthening exercises, Gentle joint mobilisations (Grade I and II) for neuromodulation of pain, Refrain from activities and motion in extremes of ROM, ROM exercises: Pendulum, rope and pulley, Strengthening exercises: Isometric, flexion, abduction, extension, Regain and improve muscular strength of glenohumeral and scapular muscles, Improve neuromuscular control of shoulder complex, Initiate isotonic strengthening: IR/ER (sideling dumbbell), abduction to 90°, Initiate eccentric exercises at 0° abduction, IR/ER. References: Lo I, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A. VIDEO ( Kibler et al, AJSM, 2009 ) - Speed's Test - resisted flexion with straight arm forward 90 degrees and externally rotated. Anterior traumatic shoulder instability can be deﬁned as excessive anterior translation of the humeral head on the glenoid fossa caused primarily by a traumatic event. Anterior instability Supine apprehension test—patient is positioned supine and the shoulder is placed into 90 abduction and maximum external rotation. Occult shoulder instability is recognized as a significant contributor to shoulder dysfunction in throwing athletes. Step3. 1997;339:105-8. Background To evaluate the clinical relevance of the painful anterior apprehension test in shoulder instability. 2004 Mar;32(2):301-7 PDF | On Apr 5, 2019, Matthew Varacallo and others published Anterior Shoulder Instability | Find, read and cite all the research you need on ResearchGate Anterior traumatic shoulder instability can be deﬁned as excessive anterior translation of the humeral head on the glenoid fossa caused primarily by a traumatic event. Relocation test: anterior instability. https://www.physio-pedia.com/index.php?title=Anterior_Drawer_Test_Of_The_Shoulder&oldid=265998, Humeral head can be dislocated but spontaneously resolved, Humeral head does not spontaneously reduce. The anterior apprehension test, or crank test, is also used to evaluate shoulder instability. The term ‘shoulder instability’ is used to refer to the inability to maintain the humeral head in the glenoid fossa. If all three, two of the three or the surprise test alone were +ve the Sensitivity was 67% and the Specificity was 98%. The surrounding capsule may also add some stability with the coracohumeral and glenohumeral ligaments reinforcing the capsule. The recurrence rate for a shoulder dislocation in the young athlete is betw… Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability. Glenoid defect associated with anterior shoulder instability: results of open Bankart repair. The patient is in a supine position, with the shoulder in 90° of abduction and maximal lateral rotation. Defining posterior shoulder instability (PSI) is therefore difficult, not only defining it within this continuum but differentiating it from other shoulder pathologies. Wilson SR, Price DD. A rehabilitation programme can consist of a combination of any of the following: Strengthening exercises, dynamic stabilisation drills, neuromuscular training, proprioception drills, scapular muscle strengthening and a graded return to the desired activities. Background: Although there are many studies describing tests for shoulder instability, there are few assessing the validity of these tests in diagnosing anterior shoulder instability. Picture of the shoulder. Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. The final test is the release test, where the posteriorly directed force applied in the relocation test is removed. Stabilize the patient scapula with the therapist opposite hand by pushing the spine of the scapula with index and middle finer. Sign up to receive the latest Physiopedia news, The content on or accessible through Physiopedia is for informational purposes only.

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22. Risk and Title: The risk in relation to any hire item(s) supplied pursuant to this Contract shall pass to the Hirer upon delivery, in accordance with the Hirer’s request or direction and shall remain with the Hirer until the hire item(s) are collected by the Provider. Title shall not transfer to the Hirer under any circumstances.

23. Where the Service is provided under a consumer transaction as defined by the Consumer Transaction (Restriction on Statements) order 1976, the statutory rights of the Hirer are not affected by these conditions.

24. It is specifically provided and agreed that any compensation &/or damages payment in respect of any claim or claims arising out of, or in connection with, the terms of this contract for any reason whatsoever and howsoever arising, shall not amount in the aggregate to more than the cost of the provision of the service by the Provider, or that part of the Service giving rise to such claim, and in any event not more than £1000; and Skipandwaste.com and any other person entitled to the benefit of this contract shall have no further liability to the Hirer. Except in respect of death or personal injury caused by the negligence of Skipandwaste.com or any other person entitled to the benefit of this contract, Skipandwaste.com or such party shall not be liable to the Hirer by reason of any representation, or any implied warranty, condition or other term, or any duty at common law, or under the expressed terms of this contract, for any consequential loss or damage (whether for loss of profit or otherwise), costs, expenses or other claims for consequential or incidental compensation whatsoever (and whether caused by the negligence of Skipandwaste.com or any other party entitled to the benefit of this contract, their employees, or agents, or otherwise) which arise out of, or in connection with the supply of the service, except as expressly provided in these conditions.

25. Skipandwaste.com shall not be liable to the Hirer or be deemed to be in breach of the contract by reason of any delay in performing, or any failure to perform, any of the provider’s, supplier’s, or co-ordinator’s obligations in relation to the service, if the delay or failure was due to force majeure.

26. Insolvency of Hirer:

a) This clause applies if:

i) The Hirer makes any voluntary arrangement with its creditors or becomes subject to an administration order or (being an individual or firm) becomes bankrupt or (being a company) goes into liquidation (otherwise than for the purposes of amalgamation or
reconstruction); or ii) an encumbrance takes possession, or a receiver is appointed, or any of the property or assets of the Hirer, or

iii) The Hirer ceases or threatens to cease; to carry on business; or

iv) Skipandwaste.com reasonably apprehends that any of the events mentioned above is about to occur in relation to the Hirer and notifies to the Hirer accordingly.

b) If this clause applies, then without prejudice to any other right or remedy available to Skipandwaste.com, Skipandwaste.com shall be entitled to cancel the contract or suspend any further deliveries under the Contract without any liability to the Hirer, and if the Services have been provided but not paid for, the price shall become immediately due and payable, not withstanding any previous agreement or arrangement to the contrary.

27. Refund Policy

27.1 Application for refunds must be sent directly to Skipandwaste.com, in writing, addressed to the Customer Service Manager.

28. Cancellation Policy – Cancellation of Hire. If the hirer chooses to cancel the hire, the following charges will be levied:

More than 4 days’ notice – 10% of total hire charge

1-3 days’ notice – 50% of total hire charge

Less than 24 hours’ notice – 100% of total hire charge

Please note cancellation charges apply on all orders once instruction to deliver has been taken.

Additional Terms & Conditions for Domestic Private Hire

The hirer is responsible for ensuring the position for hire item(s) delivery has a clear access. Blocked access due to abandoned vehicles or materials resulting in failed delivery/collection will incur standing time and or an aborted delivery charge (known generally as a wasted journey fee). The Hirer is responsible for theft or damage to hire item(s) whilst on hire & until hire item(s) is removed by the hire item(s) owner.

Skipandwaste.com cannot accept any liability for any costs incurred through damage to the hirer’s driveway or other property whilst delivering or collecting the hire item(s) off the public highway.

The hire item(s) vehicle is invited off the highways onto private property at the hirer’s own risk, and is a separate arrangement to be confirmed with the Provider. Please note that we draw your attention to the fact that tarmac, block paved, and pattern-imprinted concrete driveways are at most risk.

The Hirer is also responsible for pointing out low lying cables, narrow entrance pillars, manhole covers, and any other potential risks or obstructions to Hire item(s) or the driver, prior to the hire item(s) delivery.
The local authority may require the lighting and coning of all on-road hire item(s) and, unless otherwise advised, it is necessary to obtain the necessary council consent with a road permit. Hirers should note that the fines for failure to light and cone a skip correctly vary according to the regulations set by the permit issuing authority. Hirers are advised to consult https://www.gov.uk/apply-skip-permit prior to completing the request of the hire item(s). Skipandwaste.com can assist in the facilitation of the provision of a valid permit. Please be advised that there will be an administration charge of £15 per permit/paperwork application.

In all cases delivery and collection times are given for guidance only and Skipandwaste.com accepts no liability for any costs incurred due to delays in delivery/collection; or failure to deliver on the preferred delivery date, or at the preferred time due to unforeseen circumstances. In all circumstances invoices exclude exceptional conditions such as force majeure.

In Addition to the above terms

1 INTERPRETATION

1.1 In these conditions the following words have the following meanings:
“Contract” means a contract which incorporates these conditions and made between the Customer and the Supplier for the hire of Hire Goods and/or the sale of Products;
“Customer” means the person, firm, company or other organisation hiring Hire Goods;
“Deposit” means any advance payment required by Skipandwaste.com in relation to the Hire Goods which is to be held as security by Skipandwaste.com;
“Force Majeure” means any event outside a party’s reasonable control including but not limited to acts of God, war, flood, fire, labour disputes, strikes, sub-contractors, lock-outs, riots, civil commotion, malicious damage, explosion, terrorism, governmental actions and any other similar events;
“Hire Goods” means any machine, article, tool, skip, ‘wheelie bin’ and/or device together with any accessories specified in a Contract, which are hired to the Customer;
“Hire Period” means the period commencing when the Customer holds the Hire Goods on hire (including Saturdays, Sundays and Bank Holidays) and ending upon the happening of any of the following events: the physical return of the Hire Goods by the Customer into the Provider’s possession; or the physical repossession or collection of Hire Goods by the Provider;
“Liability” means liability for any and all damages, claims, proceedings, actions, awards, expenses, costs and any other losses and/or liabilities;
“Products” means the products sold to the Customer by Skipandwaste.com; “Rental” means the Provider’s charging rate for the hire of the Hire Goods which is current from time to time during the Hire Period;
“Provider” means the appointed company arranged by Skipandwaste.com to fulfil the terms of the contract and will include its employees, servants, agents and/or duly authorised representatives;
“Services” means the services and/or work (if any) to be performed by Skipandwaste.com for the Customer in conjunction with the hire of Hire Goods including any delivery and/or collection service for the Hire Goods.

2 BASIS OF CONTRACT

2.1 Hire Goods are hired subject to them being available for hire to the Customer at the time required by the Customer. Skipandwaste.com will not be liable for any loss suffered by the Customer as a result of the Hire Goods being unavailable for hire where the Hire Goods are unavailable due to circumstances beyond Skipandwaste.com’s control.
2.2 Where hire of the Hire Goods is to a Customer who is an individual and the hire would be covered by the Consumer Credit Act 1974 the duration of the Hire Period shall not exceed 3 months, after which time the Contract shall be deemed to have automatically terminated.
2.3 Nothing in this Contract shall exclude or limit any statutory rights of the Customer which may not be excluded or limited due to the Customer acting as a consumer. For further information about your statutory rights contact your local authority Trading Standards Department or Citizen’s Advice Bureau.

3 PAYMENT

3.1 The amount of any Deposit, Rental and/or charges for any Services shall be as quoted to the Customer or otherwise as shown in Skipandwaste.com’s online quotation service. Where a Deposit is required for the Hire Goods it must be paid in advance of the Customer hiring the Hire Goods. Skipandwaste.com may also require an initial payment on account of the Rental in advance of the Customer hiring the Hire Goods.
3.2 The Customer shall pay the Rental, charges for any Services, monies for any Products and/or any other sums payable under the contract to Skipandwaste.com at the time and in the manner agreed. Skipandwaste.com’s prices are, unless otherwise stated, exclusive of any applicable VAT for which the Customer shall additionally be liable.
3.3 Payments by the Customer on time under the Contract are an essential condition of the Contract. Payment shall not be deemed to be made until Skipandwaste.com has received either cash or cleared funds in respect of the full amount outstanding.
3.4 Skipandwaste.com reserves the right to withhold payment for any requested hire item, until the appropriate certification and paperwork has been received by Skipandwaste.com. This is usually, but not limited to, Waste Transfer Note, Certification of Waste type and accurate weight thereof.

4 RISK AND TITLE OWNERSHIP AND INSURANCE

4.1 Risk in the Hire Goods and any Products will pass immediately to the Customer when they leave the physical possession or control of the Provider. Title will not transfer to the Customer in any case.
4.2 Risk in the Hire Goods will not pass back to the Provider from the Customer until the Hire Goods are back in the physical possession of the Provider. This shall apply even if the Provider has agreed to cease charging the Rental.
4.3 Ownership of the Hire Goods remains at all times with the Provider. The Customer has no right, title or interest in the Hire Goods except that they are hired to the Customer.
4.4 The Customer must not deal with the ownership or any interest in the Hire Goods. This includes but is not limited to selling, assigning, mortgaging, pledging, charging, securing, hiring, withholding, exerting any right to withhold, disposing of and/or lending.
4.5 The Provider may provide reasonably priced insurance in respect of the Hire Goods at additional cost to the Rental. Alternatively the Provider may require the Customer to insure the Hire Goods on such reasonable terms and for such reasonable risks as the Provider may specify. The proceeds of any such insurance shall be held by the Customer in trust for the Provider and be paid to the Provider on demand. The Customer must not compromise any claim in respect of the Hire Goods and/or any associated insurance without the Provider’s written consent.

5 DELIVERY, COLLECTION AND SERVICES

5.1 It is the responsibility of the Customer to collect the Hire Goods from the Provider and return them to the Provider at the end of the Hire Period. If the Provider agrees to deliver or collect the Hire Goods to and/or from the Customer it will do so at its standard delivery cost and such delivery and/or collection will form part of the Services.
5.2 Where the Provider provides Services the persons performing the Services are servants of the Customer and once the Customer instructs such person they are under the direction and control of the Customer. The Customer shall be solely responsible for any instruction, guidance and/or advice given by the Customer to any such person and for any damage which occurs as a result of such persons following the Customer’s instructions, guidance and/or advice except to the extent that the persons performing the Services are negligent.
5.3 The Customer will allow and/or procure sufficient access to and from the relevant site and procure sufficient unloading space, facilities, equipment and access to power supplies and utilities for the Provider’s employees, subcontractors and/or agents to allow them to carry out the Services. The Customer will ensure that the site where the Services are to be performed is, where necessary, cleared and prepared before the Services are due to commence.
5.4 If any Services are delayed, postponed and/or are cancelled due to the Customer failing to comply with its obligations the Customer will be liable to pay the Provider’s additional standard charges from time to time for such delay, postponement and/or cancellation except where the Customer is acting as a consumer and the delay is due to a Force Majeure event.

6 CARE OF HIRE GOODS

6.1 The Customer shall:-
6.1.1 not remove any labels from and/or interfere with the Hire Goods, their working mechanisms or any other parts of them and take reasonable care of the Hire Goods and only use them for their proper purpose in a safe and correct manner in accordance with any operating and/or safety instructions provided or supplied to the Customer;
6.1.2 Notify the Provider immediately after any breakdown, loss and/or damage to the Hire Goods;
6.1.3 Take adequate and proper measures to protect the Hire Goods from theft, damage and/or other risks;
6.1.4 Notify the Provider of any change of its address and upon the Provider’s request provide details of the location of the Hire Goods;
6.1.5 Permit the Provider at all reasonable times to inspect the Hire Goods including procuring access to any property where the Hire Goods are situated;
6.1.6 keep the Hire Goods at all times in its possession and control and not to remove the Hire Goods from the United Kingdom without the prior written consent of the Provider;
6.1.7 be responsible for the conduct and cost of any testing, examinations and/or checks in relation to the Hire Goods required by any legislation, best practice and/or operating instructions except to the extent that the Provider has agreed to provide them as part of any Services;
6.1.8 Not do, or omit to do, anything which will, or may be deemed to, invalidate any policy of insurance related to the Hire Goods, which is notified to the Customer;
6.1.9 not continue to use Hire Goods where they have been damaged and will notify Skipandwaste.com and the Provider immediately if the Hire Goods are involved in an accident resulting in damage to the Hire Goods, other property and/or injury to any person; and
6.1.10 where the Hire Goods require fuel, oil and/or electricity ensure that the proper type and/or voltage is used and that, where appropriate, the Hire Goods are properly installed by a qualified and competent person.
6.2 The Hire Goods must be returned by the Customer in good working order and condition (fair wear and tear excepted) and in a clean condition together with all insurance policies, licences, registration and other documents relating to the Hire Goods.

7 BREAKDOWN

7.1 The Provider will at its own cost carry out all routine maintenance and repairs to the Hire Goods during the Hire Period and all repairs which are required due to fair wear and tear and/or an inherent fault in the Hire Goods. The Customer will be responsible for the cost of all repairs necessary to Hire Goods during the Hire Period which arise otherwise than as a result of fair wear and tear, an inherent fault and/or the negligence of the Supplier while carrying out routine maintenance and/or repairs.
7.2 The Customer must not repair or attempt to repair the Hire Goods unless authorised to do so in writing by Skipandwaste.com or the Provider.

8 LOSS OR DAMAGE TO THE HIRE GOODS

8.1 If the Hire Goods are returned in damaged, unclean and/or defective state except where due to fair wear and tear and/or an inherent fault in the Hire Goods the Customer shall be liable to pay the Provider for the cost of any repair and/or cleaning required to return the Hire Goods to a condition fit for re-hire and to pay the Rental, in accordance with the provisions of clause 8.3, until such repairs and/or cleaning have been completed.
8.2 The Customer will pay to the Provider the replacement cost of any Hire Goods which are lost, stolen and/or damaged beyond economic repair during the Hire Period less the amount paid to the Provider under any policy of insurance taken out in accordance with these conditions.
8.3 The Customer shall pay the Rental for the Hire Goods up to and including the date it notifies Skipandwaste.com that the Hire Goods have been lost, stolen and/or damaged beyond economic repair. From that date until Skipandwaste.com has replaced such Hire Goods the Customer shall pay, as a genuine pre-estimate of lost rental profit, a sum as liquidated damages being equal to two thirds of the Rental that would have applied for such Hire Goods for that period. Skipandwaste.com shall use its reasonable commercial endeavours to purchase replacements for such Hire Goods as quickly as possible using the monies paid under clause 8.2 above.

9 TERMINATION BY NOTICE

9.1 If the Hire Period has a fixed duration, subject to the provisions of Section 10 neither the Customer nor Skipandwaste.com shall be entitled to terminate the Contract before the expiry of that fixed period unless agreed with the other party.
9.2 If the Hire Period does not have a fixed duration either of the Customer or Skipandwaste.com is entitled to terminate the Contract upon giving to the other party any agreed period of notice.
9.3 If no period of notice has been agreed or specified the Customer may terminate the Hire Period by the physical return of the Hire Goods to the Provider and Skipandwaste.com shall be entitled to terminate the hire of the Hire Goods by giving not less than 14 days’ notice to the Customer.

10 DEFAULT

10.1 If the Customer:-
10.1.1 Fails to make any payment to Skipandwaste.com when due without just cause;
10.1.2 breaches the terms of the Contract and, where the breach is capable of remedy, has not remedied the breach within 14 days of receiving notice requiring the breach to be remedied;
10.1.3 Persistently breaches the terms of the Contract;
10.1.4 provides incomplete, materially inaccurate or misleading facts and/or information in connection with the Contract;
10.1.5 pledges, charges or creates any form of security over any Hire Goods, or ceases or threatens to cease to carry on business, or proposes to compound with its creditors, applies for an interim moratorium in respect of claims and/or proceedings, any distress, execution or other legal process is levied on any property of the Customer, has a Bankruptcy Petition presented against it or the Customer takes or suffers any similar action in any jurisdiction;
10.1.6 being a company, enters into voluntary or compulsory liquidation, has a receiver, administrator or administrative receiver appointed over all or any of its assets, any attachment order is made against the Customer, any distress, execution or other legal process is levied on any property of the Customer or the Customer takes or suffers any similar action in any jurisdiction;
10.1.7 appears reasonably to Skipandwaste.com due to the Customer’s credit rating to be financially inadequate to meet its obligations under the Contract; and/or
10.1.8 appears reasonably to Skipandwaste.com to be about to suffer any of the above events; then Skipandwaste.com shall have the right, without prejudice to any other remedies, to exercise any or all of the rights set out in clause 10.2 below.

10.2 If any of the events set out in clause 10.1 above occurs in relation to the
Customer then:-
10.2.1 Except where the Customer is acting as a consumer, Skipandwaste.com may enter, without prior notice, any premises of the Customer (or premises of third parties with their consent) where Hire Goods owned by Skipandwaste.com may be and repossess any Hire Goods;
10.2.2 Skipandwaste.com may withhold the performance of any Services and cease any Services in progress under this and/or any other Contract with the Customer;
10.2.3 Skipandwaste.com may immediately cancel, terminate and/or suspend without Liability to the Customer the Contract and/or any other contract with the Customer; and/or
10.2.4 All monies owed by the Customer to Skipandwaste.com shall immediately become due and payable.

10.3 Any repossession of the Hire Goods shall not affect Skipandwaste.com’s right to recover from the Customer any monies due under the Contract and/or any damages in respect of any breach which occurred prior to repossession of the Hire Goods.

10.4 Upon termination of the Contract the Customer shall immediately:
10.4.1 return the Hire Goods to Skipandwaste.com and/or Skipandwaste.com’s nominated Provider; or make the Hire Goods available for collection by Skipandwaste.com’s nominated Provider as requested by the Provider; and
10.4.2 Pay to Skipandwaste.com all arrears for Rentals, Charges for any Services, monies for any Products and/or any other sums payable under the Contract.

11 LIMITATIONS OF LIABILITY

11.1 All warranties, representations, terms, conditions and duties implied by law relating to fitness, quality and/or adequacy are excluded to the fullest extent permitted by law.
11.2 If Skipandwaste.com is found to be liable in respect of any loss or damage to the Customer’s property the extent of Skipandwaste.com’s Liability will be limited to the retail cost of replacement of the damaged property.
11.3 Any defective Hire Goods must be returned to Skipandwaste.com’s nominated Provider for inspection if requested by Skipandwaste.com’s nominated Provider, before Skipandwaste.com’s nominated Provider will have any Liability for defective Hire Goods.
11.4 Skipandwaste.com shall have no Liability to the Customer if, without just cause, any monies due in respect of the Hire Goods and/or the Services has not been paid in full by the due date for payment.
11.5 Skipandwaste.com shall have no Liability for additional damage, loss, liability, claims, costs or expenses caused, or contributed to, by the Customer’s continued use of defective Hire Goods and/or Services after a defect has become apparent, or suspected, or should reasonably have become apparent to the Customer.
11.6 The Customer shall give Skipandwaste.com a reasonable opportunity to remedy any matter for which Skipandwaste.com is liable, before the Customer incurs any costs and/or expenses in remedying the matter itself. If the Customer does not do so Skipandwaste.com shall have no Liability to the Customer in this regard.
11.7 Skipandwaste.com shall have no Liability to the Customer to the extent that the Customer is covered by any policy of insurance arranged as a result of the Contract and the Customer shall ensure that the Customer’s insurers waive any and all rights of subrogation they may have against Skipandwaste.com.
11.8 Skipandwaste.com shall have no Liability to the Customer for any:-
11.8.1 Consequential losses (including loss of profits and/or damage to goodwill and/or reputation);
11.8.2 Economic and/or other similar losses;
11.8.3 Special damages and indirect losses; and/or
11.8.4 Business interruption, loss of business, contracts and/or opportunity.

11.9 Skipandwaste.com’s total Liability to the Customer under and/or arising in relation to any Contract shall not exceed 5 times the amount of the Rental and charges for Services (if any) under that Contract or the sum of £1,000 whichever is the higher. To the extent that any Liability of Skipandwaste.com to the Customer would be met by any insurance of Skipandwaste.com, then the Liability of Skipandwaste.com shall be extended to the extent that such Liability is met by such insurance.

11.10 Each of the limitations and/or exclusions in this Contract shall be deemed to be repeated and apply as a separate provision for each of:
11.10.1 Liability for breach of contract;
11.10.2 Liability in tort (including negligence); and
11.10.3 Liability for breach of statutory and/or common law duty; except clause 11.9 above, which shall apply once only in respect of all the said types of Liability.

11.11 Nothing in this Contract shall exclude or limit the Liability of Skipandwaste.com for death or personal injury due to Skipandwaste.com’s negligence, nor exclude or limit any other type of Liability which it is not permitted to exclude or limit as a matter of law.

12 GENERAL

12.1 Upon termination of the Contract the provisions of clauses 3.2, 3.4, 3.5, 8.1, 8.2, 8.3 and Section 6 shall continue in full force and effect.

12.2 Each hire of an item of Hire Goods shall form a distinct Contract which shall be separate to any other Contract relating to other Hire Goods.

12.3 The Customer shall be liable for the acts and/or omissions of its employees, agents, servants and/or subcontractors as though they were its own acts and/or omissions under this Contract.

12.4 The Customer agrees to indemnify and keep indemnified Skipandwaste.com against any and all losses, lost profits, damages, claims, costs (including legal costs on a full indemnity basis), actions and any other losses and/or liabilities suffered by the Supplier and arising from or due to any breach of contract, any tortuous act and/or omission and/or any breach of statutory duty by the Customer.

12.5 No waiver by Skipandwaste.com of any breach of this Contract shall be considered as a waiver of any subsequent breach of the same provision, or any other provision. If any provision is held by any relevant competent authority to be part of the validity of the other provisions of this Contract and the remainder of the affected provision shall be unaffected and shall remain in full force and effect.

12.6 Skipandwaste.com shall have no Liability to the Customer for any delay and/or non-performance of a Contract to the extent that such delay is due to any Force Majeure events. If Skipandwaste.com is affected by any such event then time for performance shall be extended for a period equal to the period that such event or events delayed such performance.

12.7 All third party rights are excluded and no third parties shall have any rights to enforce the Contract.

This shall not apply to any finance company with whom Skipandwaste.com has an outstanding finance agreement relating to the Hire Goods. Such finance company shall, subject to Skipandwaste.com’s consent, have the right to enforce this Contract as if they were the Supplier. This Contract is governed by and interpreted in accordance with English law and the parties agree to submit to the non-exclusive jurisdiction of the English courts.

13 ADDITIONAL CONDITIONS

13.1 Skipandwaste.com may insert and present for payment any balance due and unpaid where the Customer has signed a blank or nil value debit or credit card voucher. The Supplier may also process interim payments by credit or debit card at any stage of the Contract.