CEU: Evaluation Concepts of the Shoulder - 210

Hey, this is Sandy. And Randy? And we're here on AT Corner. Being an Athi trainer comes with ups and downs, and we're here to showcase it all. Join us as we share our world in sports medicine. Welcome back to another episode of AT Corner. For this week's episode, we have an episode dedicated to the shoulder evaluation process. This is a request and I think Carly said it best. Carly T says. Could you guys do an episode on the shoulder for Orthoclass?

We are learning it. I want to be great at it because I know it is everyone's least favorite, so I want to make it my favorite. That's the Spirit. Yeah, I thought that was a pretty good attitude because honestly, shoulder could be rough. It can be rough, but I feel like there's only so much that could be going on with the shoulder that if I feel like if you break it down into like, well, it's either an impingement. Everything's impingement, that's what it feels.

Like, but it just depends on the structure that's impinged too, which we'll kind of talk about when we talked about those special tests in general. With such a mobile joint, it's hard. Yeah, there's a lot that can go wrong. So this is a CEU episode. So what that means is if you're listening to this right as it comes out, it is actually free. Thank you so much to Clinically Pressed and athletic training chat. Afterward, check the show notes to determine how to get your

certificate. There is a link directly to the clinically Pressed website so you can sign up for the course. You can get your certificate by doing your course evaluation and quiz, and it's pretty straightforward. And then you could check out some of our SC US. So what are we talking about in this episode, Randy?

Yeah. So we're going to discuss the various metrics used to evaluate just the quality and just like the accuracy of special tests, we'll examine the evidence of of special tests for just some of the common shoulder pathologies and we'll just kind of discuss the application of just special tests in the clinic. Sweet to get started, why don't we talk about just special tests for the common shoulder pathologies? Yeah. So I feel like with the shoulder, I feel like we've all

kind of heard this, that the special tests are just kind of crap. Like there's, there's already a ton of them. Like I think labrum like there's like probably 100 or so, like there's some insane amount. So like obviously we're not going to do all of them. So you have to be able to kind of. Pick you don't do 100 on your athletes. Just for one pathology, no, but some of the conditions we'll cover are like impingement, which in the shoulder it seems

to be like everything. It's always impingement, labrum and then a rotator cuff. So going into impingement, I feel like most of the common tests that were kind of looked at were nears, the Hawkins, Kennedy and then painful arc. So nears, that's the one, right? We're bringing their arm up like passively bringing them a remote. In internal rotation. Yeah. So that one had a sensitivity of like 72%. So sensitivity remember is the snout.

So it's actually being able to like rule out a condition. So if you have a negative and a sensitivity like you feel basically like 72% confident that that's going to not that they don't have that condition, just the drawback to sensitivity is it does allow for false positives. So that's kind of the concern. That's why like you can't, it's hard to judge a test just on that. But again, if, if that's all you have, I mean, you got to make a the best decision, you have to right.

The specificity of nears was 60%. So again, specificity is the spin, right? So being able to actually rule in the condition. So if it's positive, you're thinking, oh, like I'm 60% confident that or like 60% confident that they have this condition. But again, that does allow, like just using spin does allow for that kind of false negative.

So another way that you can kind of dive a little bit deeper into kind of choosing your task as as opposed to just comparing percentages is actually using likelihood ratios.

So for nears, the positive likelihood ratio was 1.8. So a positive likelihood ratio is basically what's the chance that if you have a positive test that they have the condition. And the nice thing with these ratios is it's really not hard to determine. So if like an article doesn't like put it in, it's literally just taking the sensitivity and then dividing it by 1 minus specificity, right?

So to give you a barometer of well, what these are just numbers to me at this point, like what's good, what's bad? Anything over one point O is a good test, so. 1.8 is good for impingement. Yes, but the closer to 10 the better. Oh OK, that changes it. Yeah. So it's a big range, right? So 1.8, it's all right. I mean it basically just says this test isn't trash. OK, I'll take it.

And then for the negative likelihood ratio, again, this is now saying what's the chance if it's negative that they actually don't have this condition? And it's pretty much just the reverse. It's 1 minus sensitivity divided by specificity. Anything less than one is is good, but if you are closer to 0, that's better. OK. And what's for nears and? Nears is 0.46. OK, so all right, not bad.

So do you ever use these? I think it's nice to use them if you're like torn between tests and you're trying to think, well, which one should I do? There's so many. Like when. You're when you're putting together your shoulder routine, Yeah. Right, if you're starting to put, or maybe you're learning a new test, right, then what you learned in school, you can now evaluate it to what it how it is and evaluate it to all the other special tests that you do. And maybe you're like, wow, this

one's really better. Like maybe I should start trying to work this one in or practice it and get used to it. I think something to remember is because we don't work in 100%, it's so much better to have a slew of tests instead of just one and done. Yeah, for sure. And you know what? With a lot of shoulder stuff, it was about a combination of tests. I mean, that makes sense. Yeah, 'cause individually these

tests are kind of poopy. So I think especially for a lot of the shoulder pathologies, it was combining tests. OK, so then going into the Hawkins Kennedy, right? Your sensitivity is 79%, specificity is 59% and that gave us a positive likelihood ratio of 1.92 and a negative likelihood ratio of 0.35. So it's. Kind of similar to yours, Pretty. Similar. Not much better. OK. Just kind of there. These ones both test the same impingement.

See, that's the thing that like, I feel like such a limitation when we're talking about like impingement, like when you're trying to look at these studies, because there's some that looked at impingement, but then there's some that looked at like rotator cuff tendonopathy, which could happen with impingement, right? So it really depends on how the study determined what they were testing and just work like basically semantics.

That's what's so hard like in literature, because there's so much out there, but it's hard to compare them. Yeah, especially like again when you're talking about impingement because almost anything in the shoulder can be impinged, right. And I think too, like a lot of these conditions like, well, if you have a torn labrum like more than likely doing something on like a Nears or Hawkins Kennedy, that might hurt maybe. You just have a painful shoulder, like right?

Yeah. So I think that's what also makes it really hard to talk about shoulder special tests. Then you had painful ARC. So that's just basically their arm coming up into flexion. And at what areas do they have the pain is? Is that that's at scaption right? I. Think it's in scaption. And I think it's like the positive is if they have pain, I think between 60 and 120, OK, sensitivity was 53%, specificity was 76%. So getting a little bit better on being able to actually

probably roll in this condition. So that gave us that positive likelihood ratio of 2.2. So a little bit better than the other ones, but the negative likelihood ratio was 0.61. So again, like if it's positive, right, you feel a little more confident maybe than the other ones to say, hey, maybe that's impingement. But again, I feel like, man, if I had a torn labrum and I did that, that would probably hurt

too. Yeah, I mean, it makes sense if you start to think about like what is going on though. Like if you if you think about like where the humerus is translating when you like lift your arm. Like I can see why painful art could be better than some of these like passive tests for. Sure.

Yeah, for sure. But for impingement, there was actually a great flow chart in the British Journal of Sports Medicine that kind of helped guide which structure or what could be the cause of like the impingement. It was, it was a pretty dope kind of flow chart that kind of looked at, OK, if this test was, was positive, right, it kind of you kind of would lean into like, OK, maybe, maybe this kind of condition, it could be causing it. So it kind of helps dictate treatment.

I thought that was actually very functional. There were no like metrics on it. Like they didn't necessarily test like, oh, how good is it actually at determining all that? But I, I thought it was a pretty good one to help kind of guide what could be impinged and how do you kind of necessarily treat that? Can you kind of like overview

it? Yeah. So basically if if someone had like those impingement symptoms, so I just like that shoulder pain or it hurts when I bring my arm up to here and like stuff like that, right. They had certain positive tests like a folk or an empty can or if they had a positive nears, which is interesting because they also had it to where if if the pains like anterior or posterior, right, that kind of change your direction on the

flow chart. If Hawkins Kennedy was also positive or if they had apprehension, right? You go to that next step, right? And now it's like testing the stability part. So like our relocation test, if that makes that better or if it's negative, then you kind of go down to the next one and then start doing more of your like scapular special tests, like what is it the scapular assistance test? So actually bringing your scapula into upward rotation and seeing if that takes care of the

symptoms. So it's all just stuff that's able to like kind of gear towards, OK, yes, you have impingement symptoms, but like what's the structure slash? How do I treat it? It's really cool that they put together like that map that kind of leads you to, I mean, that's how I learned shoulder was we just kind of did sections.

So like if like let, I don't want to say let it guide your treatment 'cause I know when I'm working with a lot of students now, I feel like they're so focused on finding out what it is instead of what it isn't. Yeah. And especially with the shoulder, you want to rule out what it is not so you can kind of narrow down what you're thinking, especially since a lot of the things you're going to be doing similar treatments. Yeah. So it's not necessarily you don't need to know exactly the

exact pinpoint thing. I mean, even I was talking to some of our team docs and they're like honestly shoulders like clinically you can only tell so much. Like then you send it to MRI. So like, if, if something really bad is going on in the shoulder and like you will know and they're not going to be able to be functional and then you're just going to refer that out. And that's beyond our scope.

So I think those maps kind of like help guide you to like, OK, maybe I'm going to test this theory of impingement. So I'm going to do all my impingement tests and then maybe I'm going to OK, so impingement like not very likely. Let me let me go look at thoracic out listener or

something like that. And then we kind of go into like something else, but we we kind of like testing all of the same thing at once and then all of the same thing at once and then all the same thing at once for like different pathologies. So I kind of really like this idea of this map. Yeah, for. Sure, I think. I think it does at least give a little more like substance to

just an impingement diagnosis. You can like be able to kind of determine what might be causing the impingement or what structure. So it kind of helps give you an idea of treatment instead of just throwing the kitchen sink of those treatments, right? You can maybe tailor it a little bit more and hopefully save you a little time as well 30. Minute shoulder exams. Yeah, seriously. To that kind of moving from just impingement.

Now going a little more specific into the labrum. Now, labrum's also difficult because like you have like different types of labrum tears. It's not just a labrum tear, right? Because you have labrum tears, which could be like anterior, posterior, like inferior, like all that, but you can also have like a slap tear. All right? So that's also again, really hard when you're trying to look at like evaluations because you just say labrum, but then it's like, OK, well, which one,

right? Because you know, some are looking at slap, some are just looking at labrum, which did they put slap in there, right? So it can be really hard to kind of determine, again, semantics, but for slap tears specifically, the NATA did put out a position statement in 2018 that just examined like a good way to kind of evaluate slap tears. So we actually did a position statement episode on that one. So take a listen, right? We broke that down as well.

But just as a quick review here, individual tests for slap just don't really like perform that well. They again recommended just combining some tests, like really the best one for individually was kind of Jurgensen's, which is what I always learned it as a biceps subpluxation test. Yeah, me. Too, but it really. Pops up for slap a lot but that's I mean that it kind. Of makes sense like the yeah, the biceps, Yeah, all right, that's.

The Jurgensen's, if you're not familiar, that's where you're basically like like in a handshake grip and then you resist them going into external rotation and supination. And then you're also supposed to be bow painting the biceps tendon as well to see because again, you're trying to feel for the subluxation you just have. To be careful because you're not trying. To blow them up. No, I feel like they could blow you up.

Oh yeah. That's. True, I've gotten hurt doing during this test before so I'm also working with people like three times my weight. So probably need to position yourself really well for this test for sure. I also wonder what the difference is of having them stand sitting like the standard position versus laying down. Oh. I never thought that because. Sometimes I do this when they're laying down. Oh, OK. 'Cause I. Can get a better grip with them moving and it doesn't hurt my elbow.

It doesn't hurt me. But I don't know. I like, I haven't done the research. I haven't done the study to figure out if like positioning when I feel like it wouldn't affect it that much. Yeah, for sure. Except. That they're not usually not use not using their postural muscles like stay seated. But yeah, I feel. Like that'd be fine. That's kind of a cool way of doing it. I just. Added in like biceps load yurgisin.

No, that's good. I mean, that one has a specificity of 95, but then you're looking at a sensitivity of 12, so. So what does? That mean so. Basically what that's saying is if it's positive like oh man you you might feel pretty good about them having a slap tear but if it's negative it means. Nothing that definitely. Doesn't mean they don't have one. So that kind of led to that positive likelihood ratio of 2.49. So again, it's OK, right? But the negative likelihood

ratio was .91. That's not good. So again, that's why the combination of tests has been kind of advocated for. And again, the position statement kind of gave three, but the best one that they had was if they have a history of popping, clicking or catching. And then if they had a positive anterior slide, which that's the one where hand on your hip and then you basically load the joint and kind of like shift that like put like an anterior translation on. If that's positive, that would

indicate possibly a slap tear. I really. Like anterior slide, yeah. But it's a good, it's good in this in this combo, this one that just combination had a sensitivity of 40%, a specificity of 93%. So that kind of gives us the positive likelihood ratio of 60. That's the. Highest we've had so far so far. Right. And then a negative likelihood ratio of 0.6, right. So again, it's a little bit better than some of just the tests that we've talked about in

general. So that's a good way of just kind of looking at how you can kind of compare how tests performed compared to each other. What about labrum? So yeah, for labrum you I feel like there have been like a ton because like again. Hundreds. Yeah. Yeah, like. Crank jerk grind, like all the things that sound terrible for your shoulder, but the only one that I really kind of saw that was looked at was the crank

test. So that's basically putting their arm in like 90° of AB duction and basically taking them into like internal external rotation. I've seen this where they're sitting, so they're sitting upright and then you put them up into there and you're doing that. Or you can do it like supine, but the sensitivity of that was 57%, specificity 72%. So again, just kind of leads to just like all right, numbers like positive likelihood ratio 2.4, negative likelihood ratio

of .5, you know, I got. To say I have I do this test in every single one of my shoulder evals and I really don't think I've ever had a positive for this. It's not my favorite Labrum 1 as we talk about clinical application, like I'll I'll be able to talk a little more of what I like to do for labour and but yeah, that crank I'm like, yeah, like I. Do it to do it. Just to do it. But honestly, like, yeah, no, I've never felt like, I've never felt anything.

They've never complained. Like sometimes they'll be like, oh, like it's like maybe they don't want me to get in that full like internal extra rotation, but not like a

positive test for sure. So finally going into our rotator cuff and we kind, I kind of broke it down into just kind of different muscles. So supraspinatus if anything, I think the rotator cuff test actually performed the best out of all the pathologies like so we should be able to identify rotator cuff tear pretty good. We don't really see that many, no. But theoretically we should be able to. That was the one problem with like rotator cuff tears. It's like that tends to be like

older population ish. Then like maybe like again, traditional setting of like college athlete, high school athlete, but still something important to know. And maybe you can find some things with like rotator cuff strains. All right, so you had a job's test, which I was like, what the hell is that? That's empty can. I did not know it as jobs, so I did have to look that one up. I'm like, oh, all right, good to know. Yeah. So that's empty can. Sensitivity was 88% and then

specificity was 62%. So again, that's leading to 2.3 on positive likelihood ratio and 1.9 you feel like a lot. Of these have a higher sensitivity to rule things out, yeah. You, you feel a lot better about it. Oh well. Not that, not that, not that. Full can did better sensitivity of 70%, specificity of 81. OK, I'll take, I'll take. A specificity higher, yeah, for. Sure. And then again that led to a positive likelihood ratio 3.75, negative likelihood ratio of .37, right.

So that's pretty solid. What do you? Use full can for. Supraspinatus. So I like to do it for like testing supraspinatus strength. I feel like and integrity I have. I have three different programs that I've worked with for students and some of them have different full can pathologies. What? Do you mean? Like some like some people use full can and empty can for like impingement, some people use it for like bicep, some people use it for AC joint. Interesting.

Yeah. That's very interesting, right? She's always like. Yeah, I've always known as Super Spinatus. That's interesting. I could see that with like O'Brien's right too. Like O'Brien's like I think it was originally supposed to be for like slap tear but then like it does really good for AC joint. Yeah, yeah. Well, I mean it kind of makes sense you're crossover and then put it, you know putting pressure on it, it's going to

start jamming in the AC joint. And then finally for supraspinatus we have drop arm which sensitivity was 24% not great specificity 96%. Oh, here the. Positives here that rules in what? Which one's drop arm? That's the one where like they're had, they have their arm at 90° and then they slowly, they're supposed to slowly breathe their arm back down to

their side, not like. They don't start like at the top it. When I read about it, it literally just specifically said at 90 and down and a positive is like if their arm just like falls or they just can't control that motion. So positive likelihood ratio was 6.45, negative likelihood ratio .79. So that again, at least positive wise, hey, if you got a positive test, you're like so. Supraspinatus, we can count on the positives. Everything else, you're kind of yeah, if it's. Negative.

Well, that you're still in the weeds, right? Then moving into infraspinatus, Basically all these tests had an awful sensitivity, like they were bad, like we're talking like 12%. Yeah. So just because it's negative does not mean infraspinatus is not damaged. But if it's positive, infraspinatus is damaged. The best test that was kind of reported was external rotation lag at 0°. So that's the one where they're at 0° of AB duction.

They're an external rotation. You gently, like you basically push against them. You don't have. Any shoulder AB duction? No, this was truly at 0. Oh. Interesting. I do it with some reduction. That's how I normally do it. But yeah, this was at 0. You just basically push and then you let go and then if they start to lose it and they start to literally just start to drop into internal rotation, that would be the positive specificity was 98%.

Wow. And that that led to a likelihood ratio of 6 point O 6. So again, one of the higher tests we're we're. Climbing. Yeah, we're climbing. And then one that surprisingly there was a lot of research on is looking at subscap. And again, as with kind of most things, a combination of tests was recommended. They use the bear hug, which when I think bear hug, I'm literally thinking like, oh, you're wrapping your arms like both arms around.

Like no, it's not that intense. It's literally just there the test, the hand that the arm that you're testing touches like holds on to the opposite shoulder. So if I'm testing my right, I would hold my left shoulder and then basically you're trying to pull them away like you're trying to pull their elbow up and off like their shoulder. That's bear hug and then belly press them pushing into into their their abdomen. That had positive likelihood ratio of 18.29. I thought you could only go.

Up to 10. Oh wait, closer to 10. Is better. Oh. Wow, yeah. And then a negative likelihood ratio of .2. So a lot of. Research on this one, yes. Seriously. So overall, just like that's just those are the numbers. So now I feel like clinically like we all have our own again, based on the test that we like, we do that we feel comfortable with. And I feel like a few of those I do, like I said, like I like to do full can, I'll do empty can. Do you do empty can? Uh huh.

Yeah, I'll do. It but I'm like, yeah. I don't really, I think I do it not necessarily for the positive negative like of ruling something in ruling something out. I think I do it as part of my eval to more just see their motion to like, oh, if I change this like, well, how does it change your test? You know, like it gives me a little bit more to the full can for me, I feel like. Empty. Can I feel more just like I'm trying to see, I'm trying to

identify impingement. I feel like, I feel like I'm not really testing, testing the integrity of super spinners. I feel like I'm just testing, like oh can I just elicit pain? I do a ton of impingement tests because I feel like, again, that's like a lot of what we see. Yeah. For. Sure, for sure. I think the one that is pretty variable is labrum. Like for me, like I really don't

use a ton of special tests. I really like just like joint translation for labrum because I feel like I can actually feel it shift out or maybe I can feel it catch. So I do a lot of translations for labrum and I've found some pretty good success doing that, like just being able to do, oh, do anterior translation, Antero inferior, like translation and actually see if I can catch certain areas.

And it has also helped me with like laxity and instability because like I'll feel it kind of shift out or I'll feel them guard like I actually feel their muscles like fire or like it gets like you can all of a sudden see their shoulder going with it. I'm like, bro, does that make you nervous? And then I think too, when we evaluate shoulder, right, another thing again, we're not just looking at the shoulder, right, evaluating the scapula as well, right? Understanding, like it take

impingement, right? The understanding of why could we be seeing impingement issues? Or maybe we just don't have good rhythm. And this is where a lot of like the scapular tests can come into play. So scapular assistance, so that tests like they're going into like I think it's like a reduction and flexion, shoulder flexion, the patient and you basically are helping upwardly rotate the scapula and if that takes away their pain, you're like, oh, it's because you don't do that very well.

So that's what we have to train. Yeah, that's what we have to work on. Or even like the scapula retraction test, which you have them in scaption and then you'd like test their strength. And if, if this test is positive, I could be weak. But if you were to put the scapula into retraction and then test it and all of a sudden they're strong, you're like, oh, well, that's the problem. Your scapula is not set. So your rotator cuff muscles aren't stabilizing the shoulder very well, right?

So those tests can give you a kind of an indicator of like, oh, we need to work on scap stuff too. And of course, visual inspection or I feel like we all kind of do this where we're watching and being like, oh, whoa, oh, you see a flare there? You see a wing, right? But what's interesting is like research has shown like it's, we're not really good at using that to say this is your diagnosis, like, oh, Scapula's doing that impingement, right?

But that doesn't mean it's not important, right? I still think it's important to kind of help understand, paired with their history, paired with their test that you've already done to say, oh, this is the structure that's damaged, to understand that, oh, this is a problem. This might be the contribution we need to fix this.

It's all pieces to the puzzle. And I think that's why like we were talking about earlier, like when I do empty can, it's not necessarily for a positive negative or like some of these things. It's not necessarily for trying to rule in or rule out. It's more like comprehensive in your in your evaluation for sure. For sure. Do you have an action? Item for this. I think at the end of the day, like pick the test that you're comfortable with.

I mean, don't pick like like do your best to pick like something that does have really strong stats with it. But at the end of the day, like they didn't do a study on you, right, on how your test performed. So I think it's important that you pick a test that you feel like you can execute comfortably and that you have really liked the results that you've seen if you ever have. The chance to watch Randy do his shoulder evaluation.

It is like beautiful, like artistry, like the way that the way that you move like your arm and the and your patient's arm is just like so smooth. Oh, thanks. Sometimes. That drives me nuts when they're not relaxed and then I have to. It slows down the flow. I'm like bro, relax. So this is a CEO episode like we

said before. So if you would like ACU certificate, make sure you Scroll down the show notes or episode description wherever you're listening to this or watching on YouTube or Spotify. We have the links below. We also have different episodes that you can listen to other than CU episodes. We have story episodes with stories from real life athletic trainers all over the world.

And we also have spotlight interviews where we bring on highlight topics from someone who is more of an expert in that area than we are. So with that, I think we're going to keep the fine print short today. Thank you for helping us. Showcase athlete training behind the tape Bye.