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This is Brent of the Brookbush Institute, and
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in this video we're going over the
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Michener et al. impingement testing cluster. I'm excited to bring you guys
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these videos, because finally it brings together all of the special test videos
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as we would actually use them in clinic. I'm going to have my friend Alyssa come
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out she's going to help me demonstrate this testing cluster. Now the Michener et
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al. cluster uses the Neer test, the Hawkins-Kennedy test, something that
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looks like the infraspinatus test which is basically an external rotation
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strength test, we're going to do the empty can test, and then we're going to
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do the painful arch test. If she gets a positive on three or more of these tests
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that's a good indication that she has impingement syndrome. Alright that's a
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stronger diagnosis for impingement syndrome than any one of those tests
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alone. Alright so let's go ahead and go through these tests. So Neer, I'm gonna
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take her into internal rotation all the way through, all the flexion she has in
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the scapular plane. Notice I'm stabilizing her scapula so she doesn't
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go into a bunch of elevation. At her end range i'm going to give her a little
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over pressure and ask her does that hurt? Is that your symptoms? No pain, that's not
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the symptoms she was talking about. Alright so that's negative, next we're
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going to go through the Hawkins-Kennedy, so this hand goes in the same position, I
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want to keep that scapula from going into upward rotation because this is a
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shoulder test, and then I can use my palm to stabilize your torso so I don't push
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her off the table. I'm going to go ahead and take that lumbrical grip over her elbow,
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90 degrees of horizontal adduction, 90 degrees of flexion and I'm going to
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twist. How does that feel? Hey that hurts a little bit, okay so we have a positive
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Hawkins-Kennedy, now we're going to do that external rotation test. Now this is
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one I demonstrate. I don't want her to try and use her deltoids to push
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out against me. So I want you to turn your arm so that you're
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pushing out with like, more like your wrist, okay. Alright go ahead and push out,
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and she's strong, it's all those big muscles she's got, so she's nice and
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strong there. So that's negative for that test. Next we're going to do the empty
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can test. So she's going to start in abduction this way, I want you to go
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ahead and resist me, I'm going to note how strong she is in this position,
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and she is super strong, I can do a push off of this position, all right. Then I'm
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going to have her turn her thumbs down and I'm going to put her in the scapular plane,
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which was 30 degrees of horizontal adduction. I'm going to have her go ahead
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and try to resist again, and note if she has any marked weakness in this position
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or this provokes her symptoms or pain on the symptomatic side, so once again we're
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negative for this test. And then the last test you're going to do, go ahead and
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stand up, is the painful arch test. So what I want you to do is I need you to tell
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me when the pain starts, when it's at its worst and when it goes away, as you
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slowly move your arm all the way up as high as you can. I want you to go
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sideways with it though like this, okay ready ? Go, okay no pain.
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Oh okay, so we have no pain on painful architects, that's a negative to that
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test. You can go ahead and sit down. So we had negative to everything but the
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Hawkins-Kennedy. So pretty good indication that you don't have
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impingement syndrome, or if you do have some start of impingement syndrome
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because of the Hawkins-Kennedy thing it's not very bad. The idea behind these
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testing clusters is that would be strong diagnostic criteria that we need to look
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for something else that is causing her problems. Now let's set up a little
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patient scenario and test your acting skills. Alright we're going
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to say Alyssa is a swimmer, which I'm not even sure if you are a swimmer but
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if you are great. Alyssa is a swimmer and three months ago she started having a
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little pain while she was swimming. It progressively got worse and now you're
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seeing me, because you noticed that even when she tries to like push open a heavy
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door she gets anterior shoulder pain. So we had that kind of chronic onset, she
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can't remember a single instance that hurt her shoulder, it's just been getting
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progressively worse over time. So we have a pretty good subjective analysis that
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leads us to believe that impingement syndrome might be your problem. So we're
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going to do this Michener et al. cluster. You ready? We're going to do it
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again, you got the scenario in your head? Yeah. Alright so first first thing we're
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going to do is the Neer test, internal rotation stabilize the scapula, all the
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way through all available flexion in the scapular plane, a little bit of
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overpressure. How do you feel? No pain. No pain, okay so she has no pain there. Next
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I'm gonna take her into Hawkins -Kennedy and you guys saw that she was positive
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before this, so yeah this is definitely positive. Is this the symptoms you
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feel when you're swimming? It is, ok good. Let's try the external rotation test
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here, so she's going to go ahead and push out, good.
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how about that? That hurts a little bit. That hurts a little bit, all right so so
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far we have positives on the Hawkins-Kennedy, we have positive on the external
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rotation test for pain, and even I notice like she's a little weak here and you
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guys will see that a lot with people who have pain in this position, is it's not
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it's not that they can't push out against you they won't be able to
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maintain, and if we were to compare sides this side would probably be a little
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weaker. Alright the next test that we're going to do is the empty can test,
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so I'm going to have you go ahead and pull out like this. Alright I'm going
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to note her strength in this position, good. She's a little weak in that position but
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let's compare it to this one, alright good and she's even weaker in this
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position. How does this feel? Alright it feels really hard, yeah it doesn't feel
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good. So we have a positive empty can test, we even notice she was
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a little weak on the full can test there, and then go ahead and stand up for me. Alright now
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once again with this painful arc test I need you to tell me when the pain starts,
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when it's at its absolute worst, and then when it starts to go away. As you take
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your arm all the way through your total range of motion out to the side here.
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It's starting right now, this is the worst.
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Okay, okay good go ahead and sit, all right so we now have positives for the
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Hawkins-Kennedy, the external rotator strength test, we have a positive for the
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empty can test, and it was positive for the painful arch test. Four out of five on
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the Michener et al cluster is more than three out of five. So i would say
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you're positive for impingement syndrome. Now just like the Park et al.
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cluster we talked about in an earlier video, despite the fact that these
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clusters are better diagnostic tools than any one of these tests, in fact I've
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talked in some of the other videos where I explain each one of these tests, some
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of these tests are pretty bad individually, even though they're better
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together, the diagnosis of impingement is a fairly poor indicator of what we
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should do with our intervention, and it's not a very good indicator of prognosis.
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So although this is going to add to your hypothesis and you might be able to be a
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little bit more secure and saying that it's impinging syndrome using these
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testing clusters, make sure that you follow up this testing with perhaps
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other clusters to rule out some things like rotator cuff tears, or labral tears.
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We want to make sure that there's not some other little something that's
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contributing to your pain, and then we're going to have to follow this up with a
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movement assessment, something like the overhead squat, goniometry,
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manual muscle testing. Something that's going to give us an indication of
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interventions that we can do to improve our movement, and hopefully improve our
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symptoms over time. I hope you guys enjoyed this video. I hope you guys will
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write down these testing clusters, start using them. If I were you I would put it
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in some sort of Excel spreadsheet, or make a table and make some templates for
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yourself so that you can start just checking boxes and get this into your
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memory. I think if you guys start using them on a regular basis whether it be
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the Park et al. which we use here, or the Michener et al. cluster it doesn't
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take very long to get very efficient at using these tests in combination, and
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it really doesn't take that much more time than using one test alone. I'll talk
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with you guys soon.