Additional Structures Testing

by Stephen Holt, MD, MS

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    00:00 All right, so now let's move on to the next structure, let's take a look at the biceps tendon.

    00:04 You can face forward again.

    00:05 There's two tests that we use to assess the biceps tendon.

    00:08 We're going to do the Yergason's and the Speed's test.

    00:11 The Yergason's test is also called the resisted supination test.

    00:15 It's always good to avoid eponyms if you can, because it's easy to remember a test if it's got some meaning to it.

    00:20 So in this case, the resisted supination test, I'm going to look like we're shaking hands.

    00:26 And then what I want you to do, Shayla, is direct your palm face up and I'm going to resist you.

    00:31 So she's trying to make her palm go face up.

    00:34 I'm preventing it.

    00:35 So she's trying to supinate and I'm not letting her.

    00:37 That is activating her biceps tendon, specifically the long head of the biceps tendon.

    00:41 I can feel it taut up here where it's inserting in.

    00:45 And so if that reproduced pain, specifically anterior pain in that area, that would suggest issues with her, the long head of her biceps tendon or bicipital tendinopathy.

    00:56 And then the next test is the Speed's test.

    00:58 It's very speedy, very easy to do.

    01:00 You just basically have a straight elbow.

    01:02 And I want you to try and lift up your arm, basically flexing your arm against resistance and keep your elbow flat or straight.

    01:07 So that, too, is the Speed's test for the biceps tendon.

    01:10 And we're not looking for pain in some vague place.

    01:13 It should really be just there in the anterior place and that we were talking about before.

    01:18 Next up, let's take a look at the AC joint.

    01:20 I've already talked about how patients who have significant AC joint disease are not going to like to have their arm all the way up there because you are crunching that acromioclavicular joint together.

    01:30 So this next test really relies upon that same concept.

    01:34 If I have her bring her arm all the way across her body, so fully adducting the shoulder, that's going to reproduce pain on the top here on her AC joint.

    01:44 And that's called, conveniently, the crossed body adduction test.

    01:49 It's a very useful test to assess for arthritis of the AC joints.

    01:54 Sometimes you can even have rheumatoid arthritis or other rheumatologic involvement of the acromioclavicular joints.

    02:00 Tenderness over that spot can be helpful sometimes, but only if the patient really localizes their pain to that area.

    02:07 So now I'm going to talk briefly about a SLAP lesion and to do this, I'm going to show you a quick visual on my model here.

    02:15 This is a great model because I can take the muscles off.

    02:18 And by doing that, I've exposed this gray structure here called the glenoid labrum.

    02:23 The glenoid labrum is essentially a way to provide a little bit of extra stability around the glenohumeral joint because normally, if not for this labrum, the glenoid fossa, the bony little part of the scapula, it's like about as small as a golf tee, it's not really going to provide any stability.

    02:42 So this cartilaginous labrum provides, still maintains the mobility because it's cartilage, not much different than my earlobe, but provides some extra support in the cup that my humeral head is sitting in.

    02:55 That being said, since it's not bone, it can tear, it's cartilaginous.

    02:59 And when it tears, that labrum is called a labral tear.

    03:04 But the most common type of labral tear is called the SLAP lesion, which means a superior labral tear from anterior to posterior, S-L-A-P And that just happens to be the most common one.

    03:16 This is the top of the labrum shown here, and an anterior to posterior tear would be the most common location for that.

    03:24 So there are at least a dozen different tests, maybe two dozen to assess a labral tear and only an orthopedic surgeon would even have to know half of those tests.

    03:35 I'm just going to focus in on one particular one, which I found to be particularly sensitive and specific and has good likelihood ratios associated with it.

    03:43 And that test is called the passive compression test.

    03:46 Remember, a passive test is one where I'm doing the work, not the patient and it's a compression test, because I'm essentially driving the humeral head into the glenoid fossa.

    03:55 In some ways, this test is a lot like a McMurray that we were doing to assess for a meniscial injury in the knee because we're essentially trying to drive one joint or one part of one bone into another bone and to see if there's a tear or defect in the cartilage that we would, that would get a popping sensation from by moving it around.

    04:14 So I'm going to take this humeral head.

    04:16 I'm going to externally rotate.

    04:17 I'm applying a little bit of pressure just back here on the scapula.

    04:20 But mostly at this level, I'm pushing her humeral head into the glenoid fossa and I'm just going to basically move it around like this.

    04:29 And I'm looking to see if there's any popping or reproduction of pain, anything at all like that while in this position.

    04:37 In this case, it's nice and smooth.

    04:39 I can feel like a ball bearing the ball, moving around the socket without any evidence of any popping at all.

    04:46 And the last part of our section on the shoulder exam is just to fully exclude that there isn't a cervical neck problem since that can so often mimic shoulder pain because such patients are going to have axial referred pain to the posterior shoulder and around the scapula area.

    05:02 So, again, any time you have a joint problem, it's good to assess the joint above and below, save the elbow for another exam today, but the neck exam is worth doing.

    05:12 And in particular, I'm just going to hone in on the foraminal compression test, which we've also demonstrated in the neuromuscular section.

    05:19 But just to do it again here, I would tilt the head back, tilt it to the side and apply a downward force just until you see the patient's shoulder buckle.

    05:28 If the patient has some facet joint arthritis in the right cervical vertebrae, then that may reproduce the patient's posterior shoulder pain and then you've got your diagnosis.

    05:40 All right, so having just reviewed one test for a labral tear, there's one other related test, or at least a test for related pathology.

    05:49 So that was the passive compression test.

    05:51 And I'm going to show you now the apprehension-relocation test.

    05:55 When somebody has a SLAP lesion, a labral tear, that necessarily means that the joint is now more unstable, that cartilaginous rim around in the glenoid fossa is no longer functioning correctly.

    06:07 So that person is going to have glenohumeral instability.

    06:10 Well, it turns out there's other things that can also cause glenohumeral instability.

    06:14 Sometimes it's simply congenital.

    06:15 People are just, quote, loose jointed.

    06:17 And you can imagine that a person who's loose jointed may be more susceptible to injury if they are a freestyle swimmer, if they have a lot of overhead throwing in baseball, etc..

    06:27 And so this test is designed to assess for glenohumeral instability.

    06:32 So what we're going to do is I'm going to put your arm abducted out to here and then we're going to externally rotate it.

    06:38 And what I would do with the patient is I would say, I want you to tell me if it feels like your shoulder is about to pop out of its socket.

    06:43 You don't want to pop out of its socket, but you want to get to the point where it feels uncomfortable.

    06:48 So I would say, does that feel uncomfortable? The patient would use their other hand and say, "Stop, doctor" "I feel apprehension about you continuing" They wouldn't actually use that word, but that's where the test comes from.

    06:59 So that's the apprehension test.

    07:02 And the real important part of this test is the relocation part of the test.

    07:06 When I push down on her proximal humerus, I'm essentially relocating her humerus.

    07:13 So if I do this and she says, "I don't like that, that feels uncomfortable, I feel like my shoulder is going to come out".

    07:18 if I then do this and I say, "Okay, how does that feel?" If that sensation disappears by me relocating the humerus, that would be a positive apprehension-relocation test in support of glenohumeral instability.

    About the Lecture

    The lecture Additional Structures Testing by Stephen Holt, MD, MS is from the course Examination of the Upper Extremities.

    Included Quiz Questions

    1. Bicipital tendinopathy
    2. Rotator cuff tendinitis
    3. A tear of the glenoid labrum
    4. Acromioclavicular joint arthritis
    5. Cervical spine facet joint arthritis
    1. Acromioclavicular joint arthritis
    2. Rotator cuff tendinitis
    3. Bicipital tendinopathy
    4. Cervical spine facet joint arthritis
    5. A tear of the glenoid labrum
    1. A tear of the glenoid labrum
    2. Rotator cuff tendinitis
    3. Cervical spine facet joint arthritis
    4. Bicipital tendinopathy
    5. Acromioclavicular joint arthritis
    1. Cervical spine facet joint arthritis
    2. Acromioclavicular joint arthritis
    3. Rotator cuff tendinitis
    4. Bicipital tendinopathy
    5. A tear of the glenoid labrum

    Author of lecture Additional Structures Testing

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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