All right, so now let's move
on to the next structure,
let's take a look at the biceps tendon.
You can face forward again.
There's two tests that we use
to assess the biceps tendon.
We're going to do the
Yergason's and the Speed's test.
The Yergason's test is also
called the resisted supination test.
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.
So in this case, the resisted supination
test, I'm going to look like we're shaking hands.
And then what I want you to do,
Shayla, is direct your palm face up
and I'm going to resist you.
So she's trying to make her palm go face up.
I'm preventing it.
So she's trying to supinate
and I'm not letting her.
That is activating her biceps tendon,
specifically the long head of the biceps tendon.
I can feel it taut up here
where it's inserting in.
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.
And then the next test is the Speed's test.
It's very speedy, very easy to do.
You just basically have a straight elbow.
And I want you to try and lift up your arm,
basically flexing your arm against resistance
and keep your elbow flat or straight.
So that, too, is the Speed's
test for the biceps tendon.
And we're not looking for
pain in some vague place.
It should really be just there in the anterior
place and that we were talking about before.
Next up, let's take a look at the AC joint.
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.
So this next test really
relies upon that same concept.
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.
And that's called, conveniently,
the crossed body adduction test.
It's a very useful test to assess
for arthritis of the AC joints.
Sometimes you can even have rheumatoid
arthritis or other rheumatologic involvement
of the acromioclavicular joints.
Tenderness over that spot
can be helpful sometimes, but
only if the patient really
localizes their pain to that area.
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.
This is a great model because
I can take the muscles off.
And by doing that, I've exposed this gray
structure here called the glenoid labrum.
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.
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.
That being said, since it's not
bone, it can tear, it's cartilaginous.
And when it tears, that
labrum is called a labral tear.
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.
This is the top of the labrum shown
here, and an anterior to posterior tear
would be the most common location for that.
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.
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.
And that test is called the
passive compression test.
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.
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.
So I'm going to take this humeral head.
I'm going to externally rotate.
I'm applying a little bit of pressure
just back here on the scapula.
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.
And I'm looking to see if there's
any popping or reproduction of pain,
anything at all like that
while in this position.
In this case, it's nice and smooth.
I can feel like a ball bearing the
ball, moving around the socket
without any evidence of any popping at all.
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.
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.
And in particular, I'm just going to hone
in on the foraminal compression test,
which we've also demonstrated
in the neuromuscular section.
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.
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.
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.
So that was the passive compression test.
And I'm going to show you now
the apprehension-relocation test.
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.
So that person is going to
have glenohumeral instability.
Well, it turns out there's other things that
can also cause glenohumeral instability.
Sometimes it's simply congenital.
People are just, quote, loose jointed.
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..
And so this test is designed to
assess for glenohumeral instability.
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.
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.
You don't want to pop out of its socket,
but you want to get to the point where
it feels uncomfortable.
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.
So that's the apprehension test.
And the real important part of this
test is the relocation part of the test.
When I push down on her proximal
humerus, I'm essentially relocating her humerus.
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".
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.