0:04 This is Brent of the Brookbush Institute, and in 0:06 this video we're going to go over two special, 0:08 or orthopedic tests for the shoulder 0:10 that are indicative of either 0:12 impingement or rotator cuff damage. I'm 0:14 going to have my friend, Melissa, come out. 0:16 She's going to help me demonstrate these 0:18 tests. The reason we've paired these 0:19 tests is I think you're going to find 0:21 they look very similar to the Kendall 0:24 manual muscle tests we've gone over in 0:26 previous videos. The first one is 0:28 actually called the Internal Rotation 0:31 Resisted Strength Test. I'm going to have 0:33 Melissa go ahead and bring her shoulder 0:36 into 90 degrees, her elbow in 90 0:38 degrees of flexion, and her wrist is 0:39 going to be in neutral. I'm going to 0:41 brace her elbow a little bit here. I'm 0:43 going to go ahead and put my hand behind 0:45 her hand and have her press back into my 0:49 hand to externally rotate the shoulder. 0:51 I'm not going to try to overpower her. I'm 0:53 just going to match her strength. Press 0:54 as hard as you can, Come on, come on. 0:57 Alight, you don't have to actually egg 0:58 people on, but you do want to take mental 1:00 note of how strong she is in external 1:03 rotation. Now, I'm going to do the same in 1:06 internal rotation. Alright, go ahead and 1:08 press into my hand. Good. Good. And what I 1:12 want to note is: Are they about equal? If 1:16 internal rotation is weaker than 1:20 external rotation, that is indicative of 1:23 either a rotator cuff problem or 1:26 impingement. Of course, the other sign 1:29 that we always go back to is- go ahead 1:31 and press in- "Does this replicate the 1:34 symptoms you were talking about?" Always 1:36 remember to ask that question. So, 1:38 pain and/or weakness in internal 1:43 rotation when compared to external 1:45 rotation is a positive result for that 1:48 test. Now, the other test we're going to 1:50 do looks exactly like the manual muscle 1:53 test for external rotation. I'm going to go ahead and 1:56 brace her elbow hit a little bit here. I 1:58 want to make sure I show her what I'm 1:59 doing, what we want her to do. So, "Go ahead 2:01 and turn your hand out this way." Because 2:04 what you'll find is if you guys go, "Just 2:06 press out," people tend to do that old 2:08 school like deltoid machine thing. We 2:13 want to test external 2:14 rotation here. So, "Go ahead and externally 2:17 rotate. Does that hurt? Does that provoke 2:21 the symptoms you're talking about?" 2:23 So, if it's pain or if I know some 2:26 real significant weakness she may be- "Go 2:29 ahead press out"- if she just gives way under 2:32 a little bit of pressure, that's a 2:34 positive sign for this test. Alright, 2:37 guys, so, we have two tests here. We have 2:39 the Internal Rotation Resisted Strength 2:42 Test, and then we have the Infraspinatus, 2:45 or External Rotation Resistance Test. 2:49 Both of these tests can be used for 2:52 either rotator cuffs or impingement. We 2:56 do have to keep in mind that these 2:58 probably should be used within testing 3:00 clusters, because what I'm about to tell 3:02 you is going to be a little confusing. 3:04 These tests actually have higher 3:06 specificity than some of the other tests 3:09 we've already talked about, like the Neer, 3:11 or the Hawkins Kennedy, or the Yocum, or 3:13 even the Supine Impingement Test. 3:16 These tests tend to be more specific 3:19 than sensitive, which makes absolutely no 3:23 sense to me. We have tests that- 3:26 obviously, if they're testing for 3:29 impingement, why are we rotating and 3:32 testing the strength of our rotator cuff? 3:34 So, this is already bringing in more 3:36 diagnosis, making it a more specific test. 3:39 Ah, fun with research. Guys, if you weren't 3:42 confused about specificity and 3:44 sensitivity before, you probably are now. 3:48 That's okay, because sometimes it 3:50 doesn't work out mathematically as it 3:53 should. Let's start thinking through this 3:56 logically though. Obviously, moving, 4:01 resisting, resistance- using our strength 4:05 in this position- for somebody with 4:06 shoulder impingement is not going to 4:08 feel very good. We already have 4:11 some external rotation and some 4:13 abduction that's probably already 4:15 starting to compress on some of those 4:16 subacromial tissues. In this position, 4:20 external rotation, if somebody has pain 4:24 in this position, they're probably pretty 4:29 far along 4:30 in that impingement syndrome. They're 4:33 probably really, really inflamed. Also, 4:37 keep in mind that if we have a rotator 4:39 cuff tear- let's say we have a 4:41 subscapularis tear- is this going 4:44 to hurt? Yeah, yeah that's going to hurt a 4:46 lot. If we have a supraspinatus or an 4:50 infraspinatus tear, is this going to 4:52 hurt? Sure. So, how do we differentiate 4:56 between impingement and rotator cuff tear? 4:58 Well, we're going to have to think about 5:00 our subjective examination, realizing 5:03 that ruptures and tears are usually 5:06 acute. They usually happen with some sort 5:08 of incident that happened rapidly. 5:11 They're usually not chronic- not that 5:13 they can't be. If this was a 5:15 gradual onset, I might be thinking more 5:18 towards impingement, whereas if this was a 5:20 sudden onset, I might be thinking more 5:22 towards rotator cuff, or maybe if they 5:24 had a history of rotator cuffs. And then, 5:26 of course, we have to start adding all of 5:28 our other test results to this. So, if 5:32 let's say I do some other rotator cuff 5:35 tests and they come back negative, but I 5:39 do a bunch of impingement tests and they 5:42 all come back positive, then these two 5:45 tests probably help us solidify our 5:50 impingement hypothesis, as opposed to 5:54 solidify a rotator cuff hypothesis. Now, 5:59 how would I use this? Of course, I would 6:02 use this within a testing cluster, and I 6:04 would be looking for the concordant 6:07 sign, which I keep talking to you guys 6:08 about. You want to find your quick tests. 6:11 We're all short on time. So, as you're 6:14 going through your tests and find the one that 6:16 immediately provokes their symptoms, man, 6:18 you want to make note of that, because 6:19 when they come to the next time, that's 6:21 the one you're going to go back to. You're 6:22 not going to go through your whole 6:23 battery of tests again. You're going to 6:25 go back to that one provocative test, and 6:28 then that's the one you're going to keep 6:30 going back to as you test different 6:32 interventions. So, maybe I want to release 6:35 a few things and then see how that works, 6:37 test my hypothesis. Maybe I then want 6:40 to activate a few things, test my 6:42 hypothesis. Maybe I want to try something a 6:45 little bit more outside of the box, 6:47 although I know us movement 6:49 professionals think in this way. Maybe I 6:51 want to try some thoracic spine 6:53 mobilization or manipulation, thinking 6:56 that maybe scapular dyskinesis is 6:58 contributing to shoulder instability and 7:00 see if that improves. Well, I now have- 7:04 let's say this is her concordant sign- 7:06 I now have a quick test that I can 7:08 keep coming back to after each 7:11 intervention. We are going to be talking 7:13 about those testing clusters in 7:15 future videos. Please stay tuned. Let me 7:18 give you guys a quick review here of 7:20 these two tests. I hope you guys will 7:23 keep watching. So, starting with the 7:26 Internal Rotation Resistance Test: I'm 7:30 going to go ahead and bring her arm up 7:32 to 90 degrees of abduction, elbow 90 7:35 degrees of flexion, and wrist neutral. The big 7:38 sign on this test is internal rotation 7:41 weaker than external rotation. That 7:43 should make sense to you guys from a 7:45 kinesiology standpoint. Your internal 7:47 rotators are much bigger and stronger. So, 7:50 if your internal rotation rotators are 7:52 testing weaker than your external 7:53 rotators, that's an issue. We go ahead and 7:55 test external rotation first. Alright, 7:58 that feels pretty strong. We test internal 8:01 rotation. That's also pretty strong, so that's a 8:05 negative test, unless it happened to- "Did 8:07 that provoke your symptoms?" Oh, it did 8:09 provoke her symptoms. Well, then that's a 8:11 positive, actually. That's still a 8:12 positive test. I want to remember 8:13 that for my future quick tests. Again, the 8:17 External Rotation Test looks exactly 8:19 like that Kendall MMT. I'm going to go 8:21 ahead and brace her elbow here a 8:23 little bit, hold her elbow and make sure she's 8:25 not doing the old-school deltoid 8:27 exercise here. Go ahead and press out 8:30 in external rotation. She's very, very 8:33 strong, so I'm not getting any indication 8:35 there. "Does that provoke your symptoms?" 8:37 Yes, oh, that provokes her symptoms, so we 8:40 have some some serious issues here 8:42 having to do with either impingement or 8:44 rotator cuff, and I need to continue 8:46 testing. Guys, I hope you will continue to 8:49 learn your assessments. If you're not 8:50 assessing, your guessing. Step up your 8:53 assessment game 8:54 and continue watching these videos 9:03
