0:04 This is Brent of the Brookbush Institute 0:06 and in this video we're going over the 0:07 Hawkins Kennedy and Yocum's Tests. 0:11 These are tests for shoulder impingement, some 0:15 shoulder pain and dysfunction, during our 0:16 physical exam for individuals who are 0:19 complaining of shoulder pain. I'm going 0:21 to have my friend Melissa come out, she's 0:22 going to help me demonstrate. The 0:25 Hawkins Kennedy is basically forced 0:27 internal rotation at 90 degrees of 0:29 flexion. 0:30 The way we're going to make that 0:32 happen is, I'm going to have Melissa 0:34 start at 90 degrees of flexion, I'm going 0:37 to lumbrical grip, or lobster 0:40 grip, her humerus and forearm like so. 0:45 I'm on her forearm, 0:47 but it's as close to her elbow as I can be. 0:48 That gives me control 0:50 of elbow flexion and extension, as well 0:53 as internal and external rotation. I then 0:55 have this hand to stabilize the scapula 0:59 so that this doesn't become a scapular 1:02 upward rotation test. Then 1:04 I'm going to put that palm down, like I 1:06 have in a few other videos, so that I 1:08 have control of her thorax. 1:10 I don't want to push her off of the table. We know that's 1:12 a bad thing! If you push somebody off a table, 1:14 they're not coming back and you're not going 1:15 to fix anything. You might 1:17 break something else actually, now that 1:18 I think about that! 1:19 You're going 1:20 to stabilize the scapula, and get this nice 1:23 grip. Notice, my elbows are nice and 1:24 high, so everything's in line for me. I 1:27 can compress a little bit, which is going 1:28 to help my control. I can then look at 1:30 Melissa's face, so I can see when I do this 1:33 test if she gets a little grimace. That's 1:35 going to help me decide whether 1:37 that was a positive test. I'm going to 1:39 force her into internal rotation, 1:42 somewhat vigorously, and I'm going to ask 1:45 her, "was that the symptom you were 1:47 talking about?". 1:47 -No. 1:48 That would be a 1:50 negative Hawkins Kennedy. 1:52 Keep in mind, I've seen different 1:54 things on the speed of this test. I think 1:57 the best thing to do is use your heads 1:59 when it comes to how fast you do this, and 2:02 consider, what was their subjective examination like? 2:04 Is Melissa a pitcher, who is only 2:07 complaining about shoulder pain when 2:09 she's throwing as fast as she possibly 2:13 can? Or, is she somebody who just walked in 2:15 and said, "look I had a fall about three weeks 2:18 ago, my shoulders gotten progressively 2:19 worse, and now if I push open a door, 2:23 I can feel a lot of pain". Obviously, 2:26 for the latter, just doing this might be 2:30 enough. If we're talking about a pitcher 2:33 whose only feeling pain during high- 2:35 level activity, I might have to be a 2:37 little bit more vigorous to 2:40 get that positive sign. I might take note 2:44 of that to ensure when 2:47 I come back to this, or maybe another 2:49 therapist follows up, they 2:51 don't go, "oh they're fine". We 2:55 want to make sure that we replicate what 2:58 they're doing in their lives. 2:59 Now, I'm just going to 3:00 show you guys a couple other views, 3:01 because I know this is a little bit 3:03 difficult to see if I face you. You 3:07 can see this hand, palm down, 3:11 arm high, so I can control her thorax, and elbow 3:14 high with lobster grip. If I come back this 3:19 way, it's same thing. You can see here, 3:22 here, and, I could even come down here with my 3:25 forearm, and stabilize her thoracic spine 3:28 if I got the table up a little higher. 3:30 I'm here, my elbow is nice 3:34 and high, I internally rotate, then, "was that the 3:37 symptoms you were talking about?". 3:38 -Yes. 3:39 She's positive on her right side, 3:42 negative on her left side. 3:45 We do have one 3:46 problem with this exam, I don't 3:49 know if you've already seen it, but I 3:51 happen to have large hands which makes 3:53 this an easy test for me to do. I'm 3:55 usually a bit larger than my patients, so 3:59 this lobster grip for me, this lumbrical 4:03 grip is actually what it's called, is 4:04 easy. If we flip this around, and Melissa 4:09 was my therapist, I'm not so sure she'd 4:12 have as easy of a time controlling my arms 4:15 with this grip, or if she was an even 4:17 smaller practitioner, on an even larger 4:20 client. Let's say you're a female ATC 4:23 working on the football team at your 4:27 college program, 4:29 this is going to be a tough one to pull 4:30 off. I have seen this test performed 4:34 this way, holding an elbow and holding a 4:37 wrist, just be careful if you're going to 4:39 do internal rotation this way that 4:42 you're watching the AC joint 4:46 and it's not elevating as you go. If I 4:49 do that on this side, we don't want to 4:51 see this. We want to make sure that 4:53 that internal rotation is right in line 4:56 with where you started. You're going to 5:00 have to learn how to use this elbow to 5:02 do that, and also keep in the back of 5:04 your mind that that may decrease the 5:07 sensitivity of this test. What seems 5:11 to be a spin-off of the Hawkins Kennedy, 5:13 with a little less documentation on 5:17 standard directions, a little less in the 5:20 research department, in fact, I really 5:22 couldn't find any research determining 5:24 specificity and sensitivity for, 5:26 is the Yocum exam. It's 5:30 basically a spin-off of the Hawkins 5:32 Kennedy. 5:32 You're going to put one hand on 5:35 the opposite shoulder, then raise the 5:39 elbow. You can see here, where it's 5:42 still flexion and internal rotation, 5:44 they've just stabilized the hand, almost 5:48 making it closed-chain. I think 5:51 it may have started as an attempt to 5:54 test yourself. 5:58 If you have people do this they're going 6:00 to compensate. There's too much open, 6:02 there are too many ways to work 6:03 around whatever your painful range is. 6:07 With this, I've even seen it attempted to 6:12 be sensitised a little bit by having 6:13 somebody push into this shoulder, so now 6:16 you have horizontal adduction, flexion 6:18 with internal rotation, which from an 6:21 impingement standpoint, is definitely 6:24 going to be a little bit more 6:25 provocative. I have seen it done 6:28 self-administered this way. I've seen it 6:30 done where the therapist passively lifts 6:33 into elbow flexion. Again, not so much 6:38 research on this. That's something for you to 6:41 think about. It may be something that can be 6:43 used in more of a group setting, as a 6:46 clearing or screen. It also might be 6:49 something that, once again, my smaller 6:51 practitioners, can do on much larger 6:54 patients. 6:55 What is the intent of this 6:58 test? Let's talk about anatomy here really 7:00 quickly. With all of these impingement 7:03 tests, we're trying to clamp down on the 7:06 subacromial space. 7:09 Basically, think of how impingement means 7:12 pinching. That's what it means, so 7:15 we're trying to pinch down on things 7:18 like the long head of 7:21 the biceps tendon. We're trying to brush 7:23 up against the acromioclavicular 7:25 ligament. We're trying to pinch down on 7:27 the subacromial bursa. 7:30 We're trying to irritate the 7:33 superior capsule, which has been inflamed 7:36 in part of this person's condition. 7:40 If I take her arm up this way, ideally, in a 7:43 person who had good shoulder function, 7:46 when we did internal rotation, they'd 7:50 have superior roll, and inferior glide. 7:53 But, if I'm stabilizing and holding 7:56 everything down, and I push them into 7:58 internal rotation, chances are we're 8:00 going to have superior roll, which is 8:02 going to take that humeral head and just 8:04 roll it right up into the inferior part 8:07 of the acromion, as well as that 8:12 acromioclavicular ligament. So, just like 8:14 all of our shoulder impingement tests, we're smashing the subacromial 8:18 space. If we smash the subacromial space 8:21 and we get pain, that's actually abnormal. 8:24 If these tissues were not already 8:26 inflamed, if they were not already 8:28 irritated, something like that shouldn't 8:32 hurt. It may not be comfortable, but it 8:34 shouldn't hurt or provoke 8:36 symptoms. Where does this fall when it 8:40 comes to specificity/sensitivity? How am 8:43 I going to use this? This test is 8:45 definitely more sensitive than the near 8:49 test. Like we talked about, the Neer test 8:51 isn't the greatest test out there. 8:53 However, 8:54 it's less sensitive than the supine 8:58 impingement test. So, why am i showing it 9:01 to you? The Hawkins Kennedy shows 9:04 up in these clusters that we're going to 9:07 use to get high sensitivity and 9:09 specificity, whereas the supine 9:11 impingement test does not. Now, we do have 9:14 to mention that the specificity of the 9:17 Hawkins Kennedy, and presumably the 9:20 Yocum, is very low, like all of our 9:24 impingement tests. You can 9:26 imagine the specificity is low because, 9:29 if you have shoulder dysfunction, whether 9:32 it's a labral tear, biceps 9:34 tendinitis, subacromial 9:37 bursitis, 9:39 or capsulitis, this is not going to feel 9:45 good. So, this test ends up 9:47 capturing a lot of things, and not being 9:51 very specific to impingement by itself. 9:54 In fact, there's been research on the 9:56 Hawkins Kennedy about how sensitive it is 9:59 to rotator cuff tears, and how sensitive it is 10:01 to superior labral tears. You've got to 10:05 keep this in mind as you're 10:07 building up your hypothesis going 10:10 through your assessment; if Melissa 10:13 came in and her subjective was, once 10:16 again, gradual onset, maybe only pain 10:21 during really high-end physical activity. 10:25 If I've done my movement assessment with her, and my 10:28 overhead squat assessment, and she had 10:31 scapular elevation and I see a little bit of 10:33 kyphotic posture - notice 10:36 she's a little internally rotated. She 10:39 sits like this a lot, because when 10:41 she's not pitching... as we totally make up 10:44 a college career for you... when she's not 10:46 pitching, she's sitting there studying. 10:48 These things are 10:50 starting to build a case for impingement. 10:52 Gradual onset pain, only at the highest 10:54 level of activity, maybe a little 10:56 soreness after high-end activity. I'm 10:59 starting to see some postural 11:00 dysfunction that makes her movement not 11:02 great. I'm starting to work towards my 11:04 clusters here. Maybe I did the 11:07 Neer, and got a positive, and add the 11:09 Hawkins Kennedy, and got a positive, and 11:11 then I did a few more tests for 11:14 impingement and they all came back 11:15 positive. Then, on top of it, when I 11:20 tried to test for some other stuff - 11:22 labral tears, rotator cuff tears, those 11:26 all came back negative. So now, even 11:29 though I had low specificity on this 11:31 test, I'm starting to gain some 11:34 specificity due to negatives on other 11:36 tests. Now I'm starting to 11:38 build this strong case of impingement. 11:43 This is her concordant sign, and it's 11:47 getting better with treatment for 11:50 impingement syndrome. Now I pretty much 11:53 know I'm on the right track. Always 11:56 keep in mind this test and the concordant 11:59 sign. This, as the test that you're going 12:03 to use pre and post, is what you're 12:05 always looking for. No matter what test 12:07 you're going through or how many tests you 12:08 use, always put a little asterisk by the 12:12 one test that you can keep coming back 12:14 to after every intervention if you want 12:17 to see if that's going to specifically 12:19 help the individual. Of course, keep 12:22 in mind, since all of these tests 12:24 for shoulder impingement have low 12:25 specificity, if you do some treatments 12:28 and you're not effective, and you're a 12:31 confident experienced therapist, it 12:33 might be time to refer out. 12:36 There's low specificity here. 12:38 Even though everything might 12:40 point to shoulder impingement, maybe she 12:43 did have a rotator cuff tear, and 12:46 me continuing to crank on this rotator 12:49 cuff tear without further diagnostic 12:50 imaging to tell me, "you should 12:53 probably back off of this or that" 12:56 is not a great idea. I might need to 12:58 send her back to her physician to get some 13:00 imaging. Or, maybe this is an impingement that's 13:02 out of control, 13:03 and we need anti-inflammatories, or a 13:06 shot or something like that. 13:08 I hope you guys have learned a lot from this video. 13:10 I hope you now understand the Hawkins 13:12 Kennedy. 13:15 Once again, 90 degrees shoulder 13:15 flexion with internal rotation, 13:17 stabilized on both sides with the scapula. I've got 13:20 her arm here, and then I'm going to 13:22 crank down and ask, "was that the symptoms you're 13:24 talking about?". 13:25 -Yes. 13:26 Good. 13:26 So she has a positive Hawkin's on the left side. 13:28 I look forward to hearing from you guys soon. 13:30 13:38
