0:04 This is Brent, President of the Brookbush 0:06 Institute, and we're going over the 0:08 Supine Impingement Test, one of our 0:10 special orthopaedic tests used during 0:13 shoulder examination. I'm going to have my 0:14 friend, Melissa, come out. She's going to 0:17 help me demonstrate. Now, this is the 0:19 supine test, so I'm going to have her lay 0:20 down on her back. This is not a 0:24 complicated test. Although, if you're 0:26 reading the instructions for the first 0:28 time or listening to me tell you the 0:29 instructions for the first time, there is 0:31 a little trick at the end that may catch 0:35 you if you're not paying attention. So, 0:36 what we want to start with is taking 0:39 Melissa's elbow and wrist and we're 0:40 going to take her arm all the way into 0:43 flexion with the arm externally rotated, 0:46 just past neutral. As I get her all the 0:50 way down to flexion, I'm going to push 0:53 her into abduction, which is closer to 0:56 her ear, and then I'm going to internally 1:00 rotate. As I internally rotate, I can ask 1:04 her, "Does that replicate your symptoms?" 1:07 She said, "No," so that would be a 1:11 negative, or a sign that maybe she 1:14 doesn't have impingement syndrome. Now, I 1:17 told you there was one thing during that 1:19 little set of instructions that might 1:21 mess you up, and that's the fact that as 1:23 we get all the way into flexion, our 1:25 directions for external and internal 1:27 rotation get reversed. So, rolling out 1:30 down here would be external rotation, 1:32 rolling out up here would be internal 1:36 rotation. If I- that's all internal 1:38 rotation. So, watch how I perform this 1:41 test again. All the way into flexion with 1:45 the thumb kind of going in the direction 1:47 that we're going, and then as I get her 1:50 up here, I push her into a little bit of 1:52 abduction, really taking her all the way 1:54 to that end range. And then to internally 1:56 rotate, I have to turn her back this way. 2:00 And, of course, I ask that question, "Is 2:03 that what you were complaining about?" 2:04 Okay. 2:06 I'm going to show you guys on the other 2:08 side, just in case that gives you a 2:09 little better view. So, I take her wrist 2:12 and elbow all the way into flexion. If I 2:17 push her closer to her ear, that would be 2:20 abduction. Really take her all the way 2:22 into her end range. And then I'm going to 2:24 roll back this way into internal 2:28 rotation and ask that question, "Does that 2:31 replicate the pain you were talking 2:33 about?" Okay, and it doesn't replicate the 2:36 pain, so at this point this is a negative 2:38 test. Now, what's the intent of this test, 2:42 right, is to try to provoke those 2:45 impingement symptoms. You can kind of 2:49 think about the anatomy here. As I take 2:52 her all the way into her end range, and then at 2:54 end range internally rotate her shoulder, 2:56 I'm probably taking those tubercles, 2:59 the greater and lesser tubercle of 3:00 the humerus, and just running it across 3:02 the underside of the acromion shelf. And, 3:06 of course, that has the potential to 3:08 irritate tissues that 3:13 are already inflamed. This test does have 3:17 a higher sensitivity rating than our 3:21 Neer Test, which we've talked about 3:23 before. It's a pretty bad test. Neer is an 3:26 important test for you to know, because 3:27 it's going to be part of our impingement 3:30 cluster that I'll teach later. But this test, 3:32 if we're going to do one test for 3:34 impingement, this would be a better selection. 3:37 Keep in mind, if I'm doing one of 3:40 these tests, I'm never going to take a 3:42 test like this at face value. Just 3:46 because she said this doesn't 3:48 replicate her symptoms, it doesn't quite 3:49 mean she doesn't have impingement syndrome 3:52 yet. There could be another test that I 3:55 get a positive on, for example, Hawkins 3:58 Kennedy or the Neer, which we already 4:02 talked about. Also keep in mind that the 4:04 specificity of all of our impingement 4:07 tests overall is pretty low. We 4:09 talked a little bit about that in the 4:10 Neer Test, which was that 4:14 soon as something goes wrong with the 4:15 shoulder, we get some inflammation, we 4:18 decrease that subacromial space a bit, it 4:21 probably irritates tissues, then pushing 4:23 somebody to end range, regardless of 4:25 whether it's a labral tear, whether it's 4:28 a rotator cuff tear, whether it's biceps 4:31 tendinitis, supraspinatus tenditis, it 4:35 almost doesn't matter at this point. This 4:37 is going to hurt. Right? So, we have very 4:40 low specificity on these tests. Now, if 4:43 she came in and she complained about 4:46 anterior shoulder pain with a gradual 4:49 onset, so I'm not thinking acute things 4:51 like tears and ruptures and labral stuff, 4:54 and then I did my movement assessment and 4:58 she had some upper body signs. 5:00 Maybe she had arms fall forward, elevation of 5:03 her scapula during that overhead squat 5:06 assessment, and when I put her hands down on 5:08 the overhead squat assessment with 5:09 modification, she collapsed forward. I'm 5:11 thinking, okay, gradual onset, upper body 5:14 mechanics don't look great, maybe we got 5:17 a positive test on this and a couple 5:19 other tests. Does this point to any 5:22 specific impairment? Well, as I'm going 5:24 through this, I'm not going to totally 5:25 turn off and only think about this test. 5:28 Did flexion feel normal? Did internal 5:31 rotation feel normal? Did external 5:32 rotation feel normal? Does this lead me 5:35 towards maybe wanting to do some goniometry 5:38 or something else that might give 5:40 me an indication of some movement 5:42 impairment that I could correct that's 5:44 going to help her symptoms. Of course, is 5:48 this her concordant sign? Is this 5:50 the test, which it wasn't in 5:53 this case because you told me no, could 5:57 I use this as a pre- post-test if this 5:59 Was the test that set off her symptoms? 6:01 We're always looking for those quick 6:04 test, guys. From a practice standpoint, you 6:07 need to find that thing that replicates 6:10 their pain, because that's going to be a 6:13 learning tool for you. Right? So, if I did 6:16 this- say yes this time- if I did this, did 6:20 this test, and asked, "Does this replicate your 6:22 symptoms?" 6:23 Yes. Well, good, now I have an easy test to 6:27 keep coming back to. Let's say I did that 6:29 at the beginning of a session and I go, 6:30 "Okay, here's what we're going to do. I'm 6:32 going to try releasing your 6:33 subscapularis. I'm going to try releasing 6:36 your pectoralis minor. And I'm going to 6:38 try a little posterior shoulder 6:40 mobilization, and we'll see if that helps your 6:43 shoulder out. Last time we did two of 6:45 those- subscapularis and pectoralis minor 6:46 release. This time I'm going to add that 6:48 mobilization. I want to see if it gets us 6:50 a little further." I do my manual 6:52 techniques and go, "Okay, does that feel 6:58 better?" Yes. If she says yes, then good, I 7:00 have one more box that I can check off, 7:03 one more intervention that I know worked. 7:05 If she said no, okay, we won't do that 7:10 intervention. That was not the 7:11 intervention we were looking for. It's 7:13 important that you have a quick test to 7:15 come back to if you're going to continue 7:16 refining your treatment program as you 7:19 go along. Now, of course, guys, keep in mind 7:22 that if this was a positive test and I 7:25 continue to do treatment and nothing is 7:28 working, that's a good sign that maybe 7:31 you have to refer out. As we said, these 7:35 tests have a very low specificity, all of 7:38 our impingement tests. So just because I 7:40 got pain, if I'm a confident therapist 7:42 and I've been doing this a while, and I 7:44 know or I kind of have a prognosis in my 7:47 head of how quickly things should work, 7:48 and after three, four, five, six sessions 7:50 I'm not really seeing change, a positive 7:54 impingement test just means I got pain 7:56 during shoulder flexion, and in this case 7:58 shoulder flexion with internal rotation. 7:59 It doesn't necessarily rule out structural 8:02 changes, like maybe a rotator cuff tear in 8:05 this case, maybe a subacromial bone spur, 8:09 maybe things have just gotten so 8:11 inflamed that we need some other medical 8:14 management such as some 8:19 anti-inflammatories or an injection. So, 8:21 there you guys have it. Here's a quick review of 8:24 this test: thumb up, hold elbow and wrist, go all 8:29 the way into shoulder flexion, push all 8:31 the way into abduction, closer to the ear, 8:34 and then you're going to roll that 8:36 humorous back towards you, and ask that 8:39 question, "Is that the symptoms you were 8:41 talking about?" Yes. We started off as 8:45 a no and now it's a yes, maybe it's 8:47 because this is not the first take 8:48 and I'm just starting to aggravate her 8:50 shoulder. I hope you guys learned a 8:52 lot in this video. I look forward to 8:53 hearing from you. 9:02 you
