0:04 This is Brent of the Brookbush 0:06 Institute, and in this video we're going over 0:07 the Neer Impingement Test, a special or 0:10 orthopedic test used during our shoulder 0:12 examination. I'm going to have my friend, 0:14 Melissa, come out. She's going to help me 0:15 demonstrate. This isn't a 0:18 particularly complicated test. I'm going 0:20 to take Melissa through passive shoulder 0:22 flexion in the scapular plane with her 0:25 humorous internally rotated, and then I'm 0:27 going to add a little over-pressure to 0:29 see if I can provoke symptoms. 0:31 I'm going 0:32 to grab Melissa just underneath the 0:35 elbow with an underhanded grip. I'm 0:37 going to use this hand to stabilize her 0:39 scapula and thorax, because as I 0:41 push up this way, I don't want a bunch of 0:43 scapular elevation. That's not great. 0:46 As I go into over-pressure, I don't 0:49 want to just push her off the table 0:50 Last I checked, if you push 0:52 somebody over the table, they don't come 0:53 back, and then you're not fixing anything. 0:56 We want to make sure she stays on the 0:58 table and that she's stabilized. I'm going to go 1:00 ahead and turn her arm in this way, take 1:03 her through all the flexion she has in 1:05 the scapular plane, and then like I said, 1:08 I'm going to add a little bit of over- 1:09 pressure. I'll take her just past that 1:11 normal end range. Here's the key, 1:13 "Are those the symptoms you were talking 1:15 about?" If those are the symptoms that she 1:18 was talking about, then I have a positive 1:21 Neer Test and a good indication that 1:24 impingement is what is bothering Melissa. 1:26 Keep in mind that if she had pain 1:31 but those was not her symptoms, I need to 1:36 continue doing my testing to figure out 1:39 where her pain is coming from. 1:41 Although she may or may not have 1:43 shoulder impingement, that's not what she 1:45 came in complaining about. I need to fix what 1:47 she's complaining about first. Maybe we 1:49 can address this at a later date. 1:51 What's the intent of the Neer Test? 1:54 The intent of the Neer Test is to 1:55 provoke symptoms in inflamed tissues. 1:59 With an impingement syndrome, we're 2:01 assuming that these inflamed 2:03 tissues are being caused by pinching 2:06 between the humeral head and what we can 2:09 call the roof of the shoulder, which is 2:11 the inferior surface of the acromion 2:13 and the coracoacromial ligament. 2:15 Under there, we have things like your 2:17 supraspinatus and infraspinatus tendon, 2:18 the biceps tendon, the long head 2:21 of your biceps tendon, we have your 2:23 subacromial bursa, and we 2:25 even have the superior portion of the 2:27 capsule itself for the shoulder. All those 2:31 things could be getting inflamed, because 2:35 Melissa's shoulder isn't working right. 2:36 Let's say she has some sort of arthrokinematic 2:38 dyskinesis that is causing 2:41 these tissues to get compressed or 2:43 rubbed more than they can handle during 2:47 functional activities. Maybe she's a 2:49 volleyball player and just continually 2:51 reaching overhead with poor shoulder 2:53 mechanics is causing all of this stuff 2:55 to get irritated. In the Neer Test, I've 2:58 taken the greater tubercle and moved it 3:01 into a position where I can smash it 3:04 against the roof of the shoulder here, 3:07 that subacromial space. If I get her 3:10 symptoms, I should have a pretty good 3:13 indicator that that's what's bothering 3:16 her. Why is this such a commonly used 3:19 test? I think this is a commonly used 3:22 test, because it looks very much like the 3:25 Maitland joint exams that we've 3:27 all done- that active motion with 3:30 over-pressure. "Melissa, can you raise 3:31 your arm up? Good. Does that hurt? 3:34 Does that hurt? No, all right. Clear. Good. Let 3:38 me have you go out into abduction all 3:39 the way up. Does that hurt? Good. 3:42 Does that hurt? If I do this, 3:48 though, 3:50 does that hurt? Yes." Maybe we're 3:54 getting a little bit more sensitivity 3:57 out of the fact that we're internally 4:00 rotating the humorous and she's doing this 4:03 in the scapular plane. Maybe that's a 4:04 more provocative test. The truth of the 4:07 matter is that the Neer Test isn't a 4:10 great test by itself. Why am I 4:13 teaching this to you? It's important 4:15 that you know this test. This is a very 4:16 commonly used test, and you're going to 4:18 see things like a positive Neer on 4:21 various paperwork that heads your way. 4:24 Maybe a doctor notes positive Neer Test 4:27 and you need to understand what that is. 4:29 What is happening now, because of 4:32 research, when we talk about things like 4:33 sensitivity and specificity, is we're 4:35 realizing a lot of these orthopedic 4:37 tests or special tests 4:38 aren't great, so we'll cluster them. 4:41 The Neer Test is part of many of those 4:44 clusters. I think part of the problem 4:46 with all of our impingement tests is the 4:50 fact that they're usually okay too good 4:53 on the sensitivity part, 4:55 but the specificity is really bad. I 4:59 think what you guys will find as you 5:01 practice is that just about every 5:04 dysfunction of the shoulder starts 5:07 leading to some impingement syndrome 5:09 signs, and that should kind of 5:12 make sense to us. If you have 5:13 a labral tear, your shoulder's not going 5:15 to move well. If it doesn't move well, 5:17 things are going to get rubbed and then 5:19 pinched, and it's going to start getting 5:20 inflamed. Something like bashing your 5:24 humeral head into the underside of your 5:26 shoulder is going to hurt. We don't 5:30 have a very specific test, because if 5:32 somebody has a labral tear, maybe rotator 5:35 cuff tear, maybe posterior capsule impingement 5:38 versus internal- it all kind of 5:41 gets mashed together in these tests. 5:44 How do I use these tests? I'm going 5:48 to go ahead and start with her 5:49 subjective examination. That's going to 5:51 help a lot. Did this come on 5:53 gradually or was it acute trauma? If it's 5:55 acute trauma, impingement might not be my 5:59 first hypothesis. 6:01 If she has signs of upper body 6:04 dysfunction in my movement assessment, 6:06 like in my overhead squat assessment her 6:07 arms fall forward and she has scapular 6:09 elevation, and she said that this came on 6:11 gradually during her subjective 6:13 assessment. Okay. I'm starting to 6:17 think towards impingement. So, where does 6:19 Neer come in? I'm probably 6:22 going to do Neer in a cluster of tests, 6:25 which we're going to go over as we break 6:27 down each one of these tests 6:28 individually. Most importantly, is this 6:33 the test that gets me to her symptoms? If 6:36 it does, this becomes a great quick test 6:40 for me to do pre- post-assessment both as 6:45 she's coming in from session to session, 6:46 as well as maybe I'm going to try a new 6:49 intervention and I want to see if it has 6:51 any affect on her shoulder. I can quickly 6:53 do this test. Let's say I have her 6:56 come in, "How do you feel? Pain? 6:59 Yes." I do posterior deltoid release. "How 7:05 does this feel? Any better? Yes." Oh, good. 7:08 That's one more intervention that I know 7:10 is going to be effective, or maybe it's even 7:12 something I could add to her home 7:13 exercise program. That's where 7:16 tests like this become super, super 7:19 helpful. The other thing you might think 7:22 of, which is a little outside of the 7:24 box, is as we show you different 7:27 special tests, you'll see that this one 7:29 is very flexion related. If I'm 7:33 missing a bunch of flexion and flexion 7:38 causes her pain, I might start thinking 7:39 about, "Well, what's restricting flexion? Is 7:42 there a movement impairment that I can 7:44 draw from this test? The 7:46 muscles that happen to restrict end range 7:50 flexion are also my internal rotators. 7:53 We know a lot of us sit like this, so 7:55 maybe I need to look at releasing things 7:56 like my subscapularis, my latissimus 7:58 dorsi, my teres major, my pectoralis 8:01 major, and maybe do a little stretching and 8:04 lengthening of those structures to see 8:06 if I can get a little extensibility back 8:08 and bring everything back down 8:12 to normal. Here's one more 8:15 review of what the Neer Test looks like. 8:17 Grab just below the elbow, internally 8:22 rotate, go through the scapular plane with 8:27 over-pressure, and then ask, "Does that replicate the 8:31 symptoms you were talking about?" If she 8:34 says yes, then I have a positive Neer and 8:37 one more indicator in a cluster of signs- 8:41 this is just one clue- that we might have 8:44 impingement syndrome. I hope you guys 8:46 enjoyed this video. I'll talk with you soon. 8:47 8:56 you
