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This is Brent of the Brookbush Institute
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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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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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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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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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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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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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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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So she has a positive Hawkin's on the left side.
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I look forward to hearing from you guys soon.