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