Dynamic Shoulder Evaluation: Testing What Drives Shoulder Pain

If you observe, let's just say with someone with a positive empty can test, you can look at that and say, well, why are they shrugging and looking up during this test? Well, can you look down? Does that feel any better? Yeah, it goes away now. Huh, that's weird. That doesn't make any sense at all, you know? And so other examinations is, with that being said, with an empty can test or full can test, maybe it's positive there, but maybe you can tell them, can you do the opposite of shrugging for me? Just sink your shoulder down or crush my finger under your armpit. Now let's do it again. Hey, it went away.

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey, everybody. I'm Sebastian Gonzales, your host for the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time to the show. Welcome. You're in an extra special month. This is month of December, the second week of December now. And actually, I don't curate content very often, but this month I did. And this is an intended to give back to all the great listeners that have had comment to me over the show.

The show's history has been about a couple years. And so, I've been trying to do my very best to relay my gratitude for everybody really listening, following along, and encouraging me to continue the show going. Randomly, throughout the last six months, I've been getting some amazing comments on messages from Instagram that have been really meaningful to me. Now, if it's your first time to the show, just know that this podcast is intended to improve the communication between doctor and patient and help us as clinicians to improve our clinical outcome by improving communication as well as making what was expected of the patient to do or what is happening with them or explaining their problem, making it relatable.

Because we have a very different communication and language than they do, and patients, it's nice if you meet us partway too. And so, I like to think of this like we're all going to a bar and we're having a beer, and so you decided to get a beer and what is your beer? You know, you got a hard cider. You got whatever that apple hard cider is. I don't know why you got it, but you thought, man, I'm going to be so chill right today. And you're looking around, you're like, I wonder if everyone sees me seeing this cider. Yeah, they're seeing you, but they're not really envious of you. And you're a, let's see, you're going to be a plumber today, okay?

And so, we're two clinicians. We got better beers, but for some reason, you got that cider. I don't know why. But we're all hanging out and just chatting and we're having a common communication. So, that's the goal here. If you have not been through the archives of the podcast already, please do so. There's some amazing content back there and stuff that I continually refer people back to even now. All Things Hamstrings is a great one. Dermal Traction Method with, I think we did through Philip Snell, was great. And I also had Stuart McGill on there back in the 60s or so. And so, there's a lot of content.

We're up into the 160s, 170s right now. So, please do go back there and binge listen to them because it would be a very big shame if you guys did not get access to that all that old stuff and just started anew here. So, just go through and look and see what stands out to you. Now, also too, before we start the show, I'd like to share a little bit of a short story about myself just so everyone can understand what it is to, something about me and my life so you guys can be relatable and hopefully like me or I can be relatable and hopefully you guys like me because I think everyone should like their host and if they don't like your host then they don't listen to the show.

And so, let me get in that short story real quickly here and we'll get into the format today which actually is about going into a shoulder examination, a dynamic shoulder examination. So, this is going to be clinical goal for you guys and I think you're really going to love it. So, let's get into that short story and we'll start right into the show. So, there was this one time that I went to Cancun and went to a resort where, obviously like all the resorts, like you get there and they want to tell you about all their amenities. And so, immediately when you jump off the cab or the shuttle service, the next person grabs your bag and wheels your bag all the way over into the front desk.

The front desk checks you in, they ask you for a bottle of water, you want some champagne and blah, blah, blah. And then they hand you off into the last person who is kind of the resort amenities person. And so, this guy's name was Justin. He was probably, if you can imagine, he's probably like an 18, 19-year-old kid, well-spoken. He had a Mexican accent or a Spanish accent because we were in Mexico, obviously. Very well-spoken. And so, his goal was to get me to come to a morning talk, like at breakfast. And so, they wanted you to get to the point where they're like, hey, we'll offer you two-night stay, three-night stay, something like that.

If you go, just listen to what we have to say and blah, blah, blah, right? And so, after about like five, ten minutes of doing this and traveling that whole way, like I wanted to just go to the room, right, and just have a beer, get some food, chill by the water. It was a red-eye flight, by the way. So, I really, I didn't sleep during it. So, I just wanted to go. And so, he's like, hey, do you want to go to this morning thing? And I said, yeah, sure. And he's like, sir. And he looks at me with puppy dog Justin eyes and he says, sir, you gave me your word. You'll come to this breakfast meeting?

And he slowed it down like that. He kind of looked like Enrique Iglesias at that point, you know, just about to cry like when he's looking at you. And so, I thought, damn it, damn it, Justin. Yes, you know. And so, I went to the room and thought, okay, am I going to break my word? You know, and so, after having a whole day of having like beers and all that kind of stuff, I'm like, so I got to the hotel room and it was around like eight, nine o'clock at night. And I thought, I don't want to go to that thing. Like, everything on my mind was like Justin was on my mind. Like, I gave Justin my word.

Like, I got to go to this thing, but I don't want to go to this thing. And it's at seven o'clock. I don't want to wake up that early. I don't want to go to this thing. And so, the only thing I could think of, and this is the only time I've ever done this, was I called the front desk and I said, hey, is Justin there? And, you know, Justin left for the day. I said, can you leave a message for Justin that this is Sebastian and I'm sorry. I know I gave him my word, but I will not be able to make it in the morning. And I was like ashamed to walk through the reception area and see Justin again because I gave him my word.

So, if you ever go to Cancun, just make sure that they pin you into that type of thing. Don't give me a word. Just say, I'll do what I can. And so, the next time I went, I just told him straight out like, look, here's what happened last time. And I'm going to tell you right now, I'm not going to want to get that early. So, I'll call you in the morning. But that's when Justin, with his puppy dog eyes, almost got me to go to something I didn't want to go to because he called me out of my word. Damn it. All right. Let's get to the content. Now, if you listened to last week's show, you heard that there was a dynamic hip examination.

And the dynamic aspect, I guess we can call it also to differentiating. And I'm starting to learn as I'm writing these documents and kind of getting an idea how to present the ideas to you guys, that my communication is also cleaning up too. I'm not going to pretend to make these things perfect because honestly, after I wrote them the first time, I wrote them again. And actually, going into the shoulder examination, one that we're going to talk about today, I kind of realized, holy shit, I need to improve my shoulder examination. And so, it really challenged me to go back through some of my old notes, which you will get access to as well, that I put together because actually, I failed the chiropractic diplomate DACBSP course for the upper extremity first time through.

And so, it was a shoulder case. And I was really irritated by the examination process because they didn't have any results for supine testing or face-up testing, at least not in the ones that I did. And so, I was kind of irritated by that because there were just no findings. And I guess a real patient would have some type of finding or some type of pain. They just didn't have it because it was a standardized test. And so, after I failed that, I went back through, before I went back the next following year, and I wrote this massive like kind of manuscript, just pissed off manuscript, where I wrote down all these sensitivities and specificities of these tests that I did and correlated them to certain pathologies, especially in a cluster format, meaning that if I was looking at subacromial impingement, here's the three to four tests that I would do.

And if it was positive with most of those and negative with these labor ones, then I'm probably looking at a subacromial impingement or a pinching of the shoulder. And so, I was just burnt up by it. And also, I included some management stuff in there, too. And so, when you guys are looking for these references that I'm making for these show notes, or they're in the show notes, and so there's going to be an opportunity to put your email in. And you're going to go straight to the podcast. Or, sorry, scroll down and go to the podcast notes, and you're going to be taken to a page of my website. Now, it's going to say, do you want the emails, the videos, and the documents, okay?

I'm not going to spam you guys on this, but honestly, I run a practice. I'm a busy guy. And so, I'm not going to email these out individually and make it so I got to do it four times for everybody. Because in the month of December, we're going to do four different giveaways, which everybody's going to get access to the document that I'm talking about. In this case, the shoulder also has an affiliated document, which is my personal chicken scratch that is not proofread, which is the one that I just mentioned. I semi-proofread it because I was just ready to send that thing into the testing board.

By the way, Diplomate Course, it was a good course. I was just irritated that I failed that one part because I didn't want to do it again, and you can audit it later. And so, I was just ready to audit it. I was going to send that thing right in. So, you're going to get access to all this stuff, but I'm not going to be able to email it directly and send links to people. And so, do me a favor. Go through and put your email in there. You're going to get hit first, okay? If you went in last week, you don't need to do it again, and you're just automatically going to get the shoulder one, and you're automatically going to get the one next week, which is tension, clues, and cues, and they're automatically going to get the one, which is a lumbar spine case study, which is my girlfriend, who we did a podcast in two weeks.

It's going to release the talks about her experience and the reason why I actually referred her to somebody else. And so, we recorded that entire thing via video, and so I think you guys will get good value from it. Patients will even love that one, too. And you also have access to all of the testing that I'm talking about with the shoulder and the hip and so on. So, again, I will not be able to do these things one-on-one, so please go through the emails and just let them happen. If you did it in real time with the hip, you're going to get each one on the same day the podcast releases. If you decided to start the emails today, you're going to get hip first, and then you're going to get shoulder next week.

That's just the way it's going to happen. Now, on to the shoulder examination. Again, dynamic or differentiating, because I believe we can collect a lot more valuable information in addition to the stuff that we have in our standard orthopedic examinations and range of motion testing. The problem is that I think that we learn our standard testing as, because it is a standard test, all right? And if you notice that a lot of orthopedics testing is passive, you know? Obviously, sometimes we're testing passive structures. Other times we're testing, you know, to see if there's muscular tears in the cuff or whatever.

But also, too, there's other compensated components that I think that people demonstrate. And if you observe, let's just say with someone with a positive empty can test, you can look at that and say, well, why are they shrugging and looking up during this test? Well, can you look down? Does that feel any better? Yeah, it goes away now. Huh, that's weird. That doesn't make any sense at all, you know? And so other examinations is, with that being said, with an empty can test or full can test, maybe it's positive there, but maybe you can tell them, can you do the opposite of shrugging for me? Just sink your shoulder down or crush my finger under your armpit?

Now, let's do it again. Hey, it went away. Aptly scratch test, maybe. And I use all these tests. And whenever the person has a blatant symptom with it and I see an observational thing that changes with them, position, posture, just something that I maybe want to test the theory of to see if it's contributing to their problem. Then I'll see if we can dynamically test it or differentiate it. And so maybe with the aptly scratch test, they're slumped over when they do it. And I tell them to sit up and they do it again. And they're like, oh, it went away. And that's an example of how maybe thoracic extension or lack of cervical protraction or protraction would, maybe those are contributing factors to the test because those kind of drive together.

And you just have them perk up in their seat and you can show them how posture is related to their shoulder function. In that case, maybe they're an active care type of case versus a little bit more passive care. Passive care might have a little bit of a component in there, but you already demonstrated that you can decrease their symptoms with ADLs by doing or activities of the day of living by just doing, by just having them sit up. Okay. Active compression test or O'Brien's test. Maybe it's positive, but then the patient is instructed to press maybe their opposite hand into their thigh, cueing like a hard brace into the abdominal area, which can maybe solidify the central point or your central stabilization point or proximal stabilization before distal mobility or distal function.

And so maybe the test becomes negative at that point. And so these are all like, to me, they're like, huh, that's interesting. And that's very useful information to me because I feel like at that, in that case, maybe their labrum has, maybe it has an opportunity to help self-resolve a little bit if it's not too far into the higher grades of a labral tear. Maybe this person needs to see that they actually have control over their problem and that they can actually decrease their symptoms when they go home through their activities of daily living and they don't need to spiral out of control. And I have met people that kind of spiral a little bit and they mentally go down the drain because they feel like they're not in control.

And so I think when we make these realizations accessible to them, I think we do them a very good service in regards to just a mental part of the outcome. And I know there is a biopsychosocial effect on people. Obviously, there's a mechanical-based part that we're talking about today. But I think that, you know, when it's needed, when you see the person very frustrated about their problem, I think these little things can be very helpful in letting them see that there is light at the end of the tunnel. Now, in testing, I usually like to, I mean, obviously, I do all these tests because I want to see and gather information.

We're clustering data. We're clustering information to figure out what is the most probable working diagnosis, meaning that if I have five tests which indicate subacromial impingement, one test which shows the labral pathology, and we see one more that shows an AC joint, and those are maybe I'm going to treat it like a subacromial impingement or that's my working diagnosis. On the other hand, I see that their shoulder problems are provoked with cervical protraction, right, or finger movement on neurodynamic testing. If you've taken shack locks, of course, you'll know what I'm talking about. These things are like, huh, well, shoulder muscles don't go that far.

That doesn't make any sense. And these are very strong data points to say that we need, we have to address maybe a neurological component or a discogenic type of component or segmental component with these people. So cluster that information up and just realize that we've got to treat neurocentrically first, I think, because the muscles, although they can be predominant driving factors in people's problems, a lot of times they're just protectors. I call them pawns in the game, you know. If you're trying to save the queen and the king, you throw pawns in front as much as you can in the form of muscle spasms or altered movement to protect them, all right?

The nervous system, if you traumatize a nerve beyond its capacity to repair, then you can't move, all right? And if you tear a muscle, at least it heals back for the most part, unless it's a full rupture. And so those are the pawns in the way. So when we go into testing of these things, I like to do all that stuff to cluster information. And I will go over some of the tests here, but again, there is the correlated document. But I think it's important to pick also an outcome measure that is meaningful to the patient. Meaningful. Meaning, hey, why did you come in? You know, I can't raise my arm anymore because I like to feed the birds in the bird's nest outside, and that is the light, shining light of my day, you know?

And so, great, can you show me what that looks like? Cool, does that hurt? Yeah, it does. All right, we're going to do that in a little bit after we do some interventions just to see if it works or not. And if it goes very well, I'm looking for a 30% to 50% change or 30% to more% change within just a couple minutes if we do the correct intervention for your problem. If I choose the wrong intervention or the wrong first aid for your problem, it won't change. And I'm not offended at all if actually it doesn't change at all, okay? So I want you to be honest with me in that. It just helps make my job easier to help you find a solution to your problem.

I'm not married to any of these ideas, but I'm just testing. We're gathering information to see what you've got to do at home because you can actually do a lot of the homework at home, which is going to be more meaningful and a bigger volume of quote-unquote medication than it is if I do only one thing with you today and you don't do anything at home. Are you willing to do the stuff? Yeah, cool. All right, so let's just see what that movement looks like. And so we look at it and just observe. What are they doing? There's a whole categorization of observational tests I like to do, but obviously this one that they're picking is probably the most meaningful to me and them.

Also, other things that they might pick or if they're having trouble finding something that is meaningful to them, ask them what they can't do or what's the reason why they came in. Because some people say, oh, it hurts all the time. Okay, well, what makes it feel better? Nothing. What makes it feel worse after every single time you do it that made you feel like today you're like, I need to come in and come in and see somebody? Well, you know, as you see, I'm not wearing a shirt. I can't put on shirts. Oh, yeah, you are not wearing a shirt. Okay, that's pretty important. Let's get you to, let's use that as an outcome.

All right, I got a shirt over here. I'll give you one. Why don't we try to put that shirt on? So they might need coaching in with it. Might be something like combing their hair, getting out of a car, turning a car, sexy time. It could be a lot of things. All right? Figure out why they're there. And if you dig to the bottom of that, then you'll oftentimes, you'll unroot the meaningful thing to them, which is the real reason why they came in. And actually, if you solve that problem for them, they'll become your super fan. Like, they'll love you because they couldn't figure it out on their own. And someone else that they went to maybe couldn't figure it out for them either.

By the way, I should, I'm going to do probably a whole podcast on this later on in the month of January. But I've been listening, I listen to my own podcast. And so I feel like, so over the course of the years, I've tried to do a really good job of being honest with you guys and saying that I don't know everything. I'm not, I don't pretend to know everything. But at the same time, I think if you listen to some of these podcasts in just small, small increments, I sound like a know-it-all. I don't want you guys to think that of me at all. And I don't know it all. I know what's worked for me clinically, but I'm going to try to do a better job of not saying things like, I can do better than them or something, you know, because I think it comes down to what I realize I can do.

I know my limitations and I'm not better than a lot of people at working on fingers and wrists and elbows, but I'm really damn good at hips and backs. I just know I am. And I probably before I say that I'm quote unquote better than somebody, I just need to go and figure out what they're doing or what most of the people are doing. So I want to make sure that I'm honest with you guys about that. I need to, I need to do a better job of that because I sound like an arrogant asshole. I feel like when I hear myself saying on the podcast, although I know what I mean by it, and I just know that I mean that I feel confident in doing it.

And some of the people who have come in have been frustrated about their outcomes at other places. And I can't assume that the care is bad. I just can't, I can also can't assume that the person did their work. But what I could do is maybe a better job of managing that person and getting them to do what needs to be done or I need to, or I know I can get, if I've examined this person, I know I can get the outcome that I'm looking for. If I can't, then I'll jump ship. And I don't want to be that guy who sees people for three months for three times a week just because I think I can get them there.

But I know, I know deep down inside what I'm looking for as patient outcome, as I mentioned with this, the meaningful thing. I'm looking for a 30% change in the same day, whether it sticks or not, is whether they do their homework or not. And we can't control that always. We can always have a big boy, big girl conversation. But I need to make sure that I'm a little bit more clear with that with everybody. So I apologize for all the past thoughts. Now, part of this examination, too, again, observational. I'm going to go through, in the video, I go through mainly the examination I do for non-throwing athletes.

Getting into throwing athletes a little bit more in the weeds. And I think Guido Van Reis, again, covers it really well in Module 2 of Pro Car Online, which you will hear, there's a sponsorship partway through the middle of the show. I'm a creator of that, a partial creator of that. And Guido does a really good job of it because he's worked in baseball for many years. So I'm not going to pretend to do it better than him. And so most of mine, in my opinion, is for recreational or general population athletes. And I gather enough information to really begin their care. But if I'm looking at someone with higher function or a need for higher function, then usually I will investigate a little bit further in a different way.

So within the document I'm going to share with you, it's going to be, I'm going to show you the test that I use, or actually, again, I needed to revamp my testing a little bit. So the test that I will use, and I'm going to work on improving my flow much better over the next couple months. Because I'm really good with hip, as hopefully you saw in the video. It's seamless. I know where I'm going with it. I can come back and jump around and so on. With shoulder, I'm not as good with it. And I need to be, because the shoulder is basically the hip of the upper extremity. Hey, everyone. A little quick break before we get on to the remainder of the podcast.

As always, this mid-session break is because I've got to make a little bit of a living. But also, too, I want to take a moment to really promote something I do care about a lot. And I am putting on a couple workshops this year. I've done enough promo over the last couple episodes. We probably kind of know the basics about it. But for first-time listeners, let's talk about it again. So I call the workshop putting it all together. And after teaching interns over the last couple years, I've gotten a lot of feedback about what works and what doesn't. And they said, if you just took all of these tools and methods and treatments that you kind of use and just cluster them into, here's the kind of order that you would use for a hip impingement case, that'd be really useful to us.

So I did that. I did that to create a nice training tool for my interns. But also, as I have people come in and shadow, they're like, hey, can I shadow you more? No, I drove myself crazy having four interns last year. And I will never do it again. So to kind of meet everyone where they're at, we're doing a student version, which is May 30th. That is a single day. There's limited spots. There's only 20. We're going to have a badass barbecue after. I will buy all the stuff for the barbecue. Unless you want to contribute a little bit, you can. And there's going to be a doctor one as well. Now, the docs might say, well, I'm not a student anymore.

I know. But I'd really suggest this for first, second, and third year students. Or, sorry, doctors, mainly because they might not be stuck in their way yet. And they're trying to figure out, how do I really get a really good outcome with some of these cases? And I want some, I want it. I want patience. That's probably what they're thinking. I want patience, right? And I want good testimonials. I'll show you how to get those, okay? This process has worked pretty well for me with shoulder, hips, low backs, necks. I'll show you what I'm doing with examination and key things I'll look for in history-taking process.

I'll show you these things that work. And I'll help guide you to the workshops of other people that will help you get more information as well. So, I do understand that everybody is on a budget with their extracurricular activities and their content education. I'll be honest with you. There's a lot of workshops that I wish I did not spend so much money on. And when people ask me, what workshop should I do? I'm like, look, this is going to sound real bad. But do this one, this one, as well as do mine. And they're like, well, those other two sound good, but why would I take yours? I'm like, I'm telling you, there's not a lot of workshops that will help you put logically the steps together.

I'm trying to do that with you guys. I'm trying to treat you even like my interns, okay? So, I will learn stuff from you as well. So, hopefully, if that sounds good to you and you want to get some CEUs for it, doctors, that's April 25th, 26th, 12 hours available. Students, May 30th. I hope that we all level up as a profession is my goal. And so, I'm looking to learn as well. But we're going to have a good old time. Make it fun. Everybody is just chill. There's no tests at the end. Just a good old time, okay? So, reach out to me on Instagram for that. That's performancehb. Or, better yet, email me, seb at p2sportscare.com.

Now, back into the show. So, the hip is to the back that the shoulder is to the neck. And so, I think I need to be much better at it if I'm expected to manage some cervical spine complaints and radiculopathies. And so, you'll see the tests as they kind of come up. And I'll mention a few of them and the reason why I picked them. Just a note, too, is that cervical spine examination and neurological workup are important and required if you're going to work with someone with upper quarter problems. I mentioned this through the document that I also linked to in the emails that are to come. Again, go onto my website, p2sportscare.com, for that.

There's a link in the show notes. And I talk about the theory of why. And a lot of times, I'd say well over 25, maybe 50% of the time, a lot of shoulder conditions, although they seem like they're going positive orthopedic tests regionally in the shoulder, a lot of them are nerve-based or disc-based, what I've seen. And the hip is just kind of, or sorry, the shoulder is just kind of stuck in the way. And so, before I get too distracted, personally, when I examine someone with a shoulder problem, I like to do the cervical areas first. And I usually tell people that, hey, I need to check these areas out as well as your nerves and pathological reflexes just to make sure that things are going well, okay.

I know they seem very unrelated to your problem. And I've had people, too, when I start flicking their fingers, come looking at Hoffman's sign or Hoffman's test, they say, are you looking at my finger? Why are you doing that, you know? And they're kind of, I think they're kind of concerned or judging. They're like, I came to the wrong guy. What a jerk, you know? And so, I just say, look, I understand these things aren't 100% related to your problem or it seems not to be. I'm collecting information. And so, just humor me, okay? Let me know if any of these bother you. Because some people, they can see them turning their neck and say you're doing rotational range of motion testing.

How does that feel? And you can see on their face, it's okay. It's normal for me, though. I came from my shoulder. And so, again, corral them back. I understand that. This is part of the test. This is part of the examination. I need to know this. How does it feel? Good. We're going to come back to that again because I think it might be part of your problem. So, orthopedics testing. Again, make sure that you're dynamically, you're differentiating, testing them when at all possible. I'll suggest a couple things right now which can be important for using those things as differentiators. And so, you can use neck cues, gravity cues, and shoulder blade or tension cues.

And so, some of the cues that I'll use, again, I'll describe it in the video, is if I'm looking for someone, say someone has some pain with, let's just say painful arc of the shoulder, instead of them doing it kind of like half-assed, I'll say make a huge rainbow. The biggest, widest rainbow you've ever seen in your life. And so, this will protract the shoulders a little bit and create some tension into the shoulder girdle and they might say, wow, that went away. That's interesting. You know? Also, too, you can have them sit against a wall so the shoulder blades are assisted through that test and have them do whatever test that was.

Maybe you do some of your empty can, full can O'Brien's in this position. They say, wow, that's better, too. Well, maybe the shoulder blade's a big part in this thing for you because the shoulder is basically, it's a ball and saucer joint and the glenoid or the saucer is actually an important part of it, okay? Another cue, again, a blade or tension cue is allow me to move your shoulder, allow me to move your shoulder in the test for you, okay? And I'm looking to see, or move the shoulder blade. And so, I'm looking to see a scapular assistance test. The range of motion they go through, is it provocative if I help them through that?

Lastly, is I see if tension is helpful. And so, I can have them face the door or door jam or spread their feet and push the wall over with the other hand and then move through that same test in a similar way with the free arm and they say, wow, that got better, too. And I've had quite a few people that don't understand this. And so, I say, look, sit on the table right there. Use your other hand because I don't want to bother your shoulder that's pissed. Push me over. Don't use your belly. If you can push me across the room or away from you while I'm leaning in, I'll give you a dollar if you can not use your belly and do that.

And they're like, yeah, I can't do that. Well, you got to use the rest of your body, okay? The body is one unit, all right? We can separate it based upon regional testing and conversation, but really things work together. Neck cues, you can double chin. You can look down. You can look up. You can put one ear on the opposite shoulder or on the same shoulder. Does the neck position have a correlation with what's going on? So, gravity cues or gravity changes. Do that position again, sitting, standing, lying down, or changing their posture. If these change things, again, consider it's painful to do a painful arc test while seated, but standing, it goes away.

Why is that? Well, standing naturally has a little bit more thoracic spine extension, and it stops a little bit of cervical protraction. It allows the shoulder blade to pack nicely onto the rib cage and move through that range of motion that allows the ball and saucer joint to be happy, okay? We can say beyond reasonable doubt that change of position should not really affect a joint that has a structural damage problem, okay? Understand that. If we have a structural damage problem, say a cuff is blown off, a labrum is torn to bits, these should not change it, in my opinion. I'm open to a conversation about this, but in my opinion, these should not have a big change.

Now, standing observational assessment, I don't always do this, and I know this is probably not great, but I'll be honest with you, I don't always do it, mainly because of speed of examination also, too. I don't tend to gown people, or it's kind of, I kind of, I put my hands on them, or I make sure their shirt is tight enough, or I have them take their jacket off, to where I can see someone with the shoulder blade is doing. But you can observe their movements with or without a shirt, okay? And so I can see the medial aspect and the inferior border of some people's scapulas if they're peaking and winging, all right?

And so the other side, I might see it flush. And so I do this oftentimes with even movement-based corrections or push-up planks or whatever I have them doing through their corrective exercise. And I can see it, and I can see that valley forming between their shoulder blades. And so I know with that being said, I can have them cue a little bit harder through that movement. And so I think it's your personal call and comfort zone if you want to have them with or without a shirt. And when it comes to lawsuits, I think it's really based upon, especially the sexual harassment-based ones, it's if the patient feels comfortable or not.

It's their perception against yours. And so just because of what I feel comfortable with, I don't always usually have someone go without a shirt or go into a sports bra. And it's kind of like when I personally go into the doctor's office, and if they make a gown up to take blood and sit on the exam table and there's stirrups there, it's kind of a position that it's kind of, it's authoritative and makes me feel uncomfortable. So I don't always like it. And so I don't like subjecting patients to that unless they really need to. Now, standing observation again, or observational tests while standing again.

And so positions or postures, just check out, is their cervical spine look a little wonky and is it an outlier? The thoracic spine, lumbar spine, do they have shoulder elevation on one side dominantly versus another? Do they have protraction winging? Are their arms not swinging when they're walking? These are all things that are good and note-worthy data points that you should just take observation of because they could be part of the puzzle later. Or they help you start patching things together. By the way, if you haven't clustered data before, it's important to realize don't jump to any assumptions just yet because you need to go through your other examinations and just see what else is presenting itself as useful information.

Okay, don't jump the gun, just collect. It's like Pokemon. Next is shoulder dislocation question. Have you ever dislocated it? If so, I might not test external rotation. That's just a general thing I like to ask. Standing shoulder range of motion. I usually like to cue it, I like the copy me slowly type of thing because they'll rush through it sometimes. And with flexion, I'll usually have them thumbs up, fingertips to the sky. And I'll do it with them most of the time. For abduction, adduction, I'll say go into a, act like you're going into a diving board. I'll start at the top and I want you to make a big old rainbow and then cover your zipper.

And I'll have them cover their zipper and then go further across because I want to make sure they're actually going well across midline and I'll just see what they got. Extension. Reach for your gun holsters, not on your belt buckle, but onto your side holsters, like on the vest version. And I'll show them. Internal, external rotation, I'll make a T, kind of like the NSYNC video. I think it's bye, bye, bye. And so I'll have them do it internal, external, that way just to see if there's general changes. All right. If I see there's something going on there, then I might isolate a single side and just have them do it and see if there's any shoulder movements, elevations, or cervical changes.

Even lateral translation in the cervical spine can mean some neural tension. And so I'm just generally observing. I might come back to these later, though. For seated observational testing, again, I like to do standing, then seated if I really can. Only make the patient move a handful of times if need be. Seated observational testing. I like range of motion, again, in the form of aptly scratched tests or touch the points. And so if you have them scratched, sometimes they'll reach and try to claw at it. So just touch that point. Copy me, copy me, copy me, copy me. Go through about six of them or so.

How does that feel? Great, cool. Also, too, we'll do seated rotational testing. I like to do this from some, it was a test that I learned through FMS or I think TPI. And so I have them go seated, I put my knees over their knees to make sure that I'm pinning their knees together and I say, don't move your knees. I'm going to be holding your knees together, but if I feel you fight me, I'm going to stop you. Put your arms over your, cross your arms over your shoulders or put a stick in the shoulder if they want to. Or underneath their hands, just to see general measurements. I'm looking for about 45 degrees both directions, but it's not uncommon for people to have a lot of shoulder blade movement versus T-spine movement.

And so make sure that you see the T-spine continually move and stop them. Have them do it slowly because you'll give them a chance to actually reach the terminal range, the appropriate terminal range or the accurate terminal range a little bit easier. And so just see if there's a general outlier in there. Rotation of the thoracic spline is really important for shoulder conditions or shoulder blade ones, even neck ones. And so rotation couples with extension. And so make sure that they do have extension. And you can do that via a wall squat test too. While you're facing the wall, don't touch your nose on the wall.

Squat down or you can hold a weight so they don't fall over like a potato sack. Potato sack squat against the wall, toes against the wall, and just see if they can get down there and keep their chest upright without hitting their nose against the wall. Sorry, that was off the cuff. That was not actually on the document. So common finds we're going to have here is the shoulder complex might elevate or depress a lot. We're looking for blatant wide offensive asymmetry that is not commonly found in sport. If you have a pitcher, you're going to have, and he's pitched for a long time, he's going to have more external rotation than internal rotation on the throwing side.

That would make sense, all right? As long as he has total range of motion that is not over 184, I think it is 185, then it's really not a big issue. It's a change of neutral point, all right? They have a change that happens to the bony structure that is a normal occurrence, especially as they're developing. And so don't fuss too much of that. If it's common for the sport, don't wreck the athlete to make them fit into your standard of normal movement. Cervical spine. Does it laterally glide or translate? Symptoms present in different positions or in transitions of positions. And make sure that you're looking at the shoulder to see or the shoulder blade to see if it's, quote, unquote, sick, winging, or tipping.

All right, and that's where you might have them take the shirt off if need be, just to make sure you gather that information. In regards to the next category, which is palpation, by the way, we have a couple categories I should have talked about in the beginning. We have observational testing, which is seated standing. We have palpation or range of motion. We have orthopedics testing. We have neurodynamic screening. We have optional advanced testing. These are the things that I kind of clustered things into. And so palpation testing or range of motion testing or resisted range of motion testing.

I know we did some general testing, but I clustered that into observational for now. You got to palpate for defects. And so defects of the especially supraspinatus or rotator cuff, it's a pretty big indicator of a problem. And so if you find a defect in there, I think that's going to be important. But also, too, when you kind of pry in there and touch all the areas of the front side of the shoulder, the top part, the clavicular space, the humeral head, the posterior aspect, you have a better idea of what the person's actual painful region is. I'm not saying the area that you touch is actually the pain generator, but you know where they're talking about.

And you can also feel around to see what the quality of the structure is. Is it stringy? Is there a defect? Is it boggy? And so these are all important parts. And you can probably get also into the shoulder blade area or the armpit to see if there's any areas that have outliers, weird things like swollen lymph nodes or things of that nature. You might need to refer them out for them. You can do palpation with movement as well and just to see if there's any clicking, popping, snapping, grinding when they do that type of movement or just see if you have a bony infill, too. I remember the first person that I had with, I would say, very severe arthritic findings of the shoulder girdle or, sorry, of the shoulder, the GH joint.

I'll never forget it. It feels like a skipping. It's like you're putting a rock onto another rock and it's like, I can go a little further and it's like, and it skips down to the next position that it actually feels like it's stuck in again. And so this was more of the quote unquote bone on bone that I would qualify as maybe I can't help this person. And so if you haven't felt it before, feel it. You can feel in ball and socket joints, you have those definitive skips. Those skips are interesting to feel the first time and you'll never forget it. Next, we have to make sure that you chest the AC joint to do some shear testing, usually in wrists and ankles, too.

Like the testing is like, in my opinion, it's kind of vague, but you just basically take two bony areas and you shear the joint between them to see if it's a pain generator. I'll do active range of motion. Again, like I kind of said earlier, I like to see or feel the shoulder blades. Resisted range of motion, I'll do part of it through myotomes of the cervical spine, which is done prior. But with a rotator cuff in particular, you've got to add interliction and rotation at the side. Or with throwers, you've got to do with abduction as well, 90 degrees. Orthopedic testing. Oh, by the way, if those resisted range of motions are painful, then maybe use that as an outcome measure later if the person doesn't really have a meaningful one.

All these tests you can use if you really need to, but again, the more meaningful outcome measure is probably better. Orthopedic testing, seated, I tend to do first. The ones that I pick for rotator cuff is full can, empty can, external lag sign, internal lag sign mainly. And obviously palpating for defect. So if we're looking at labrum, I'll usually do O'Brien's or O'Brien's slash active compression. Again, all these can have a dynamic aspect to them. In the document, they do have hyphens next to them where you can use dynamic tests for them because sometimes, even with external lag or empty can tests, it seems like a positive test, but they give out because of pain.

It's not because they don't have strength always. It's just that they have pain. Also, too, I know that I personally had a dead arm while throwing before. I've had this a couple times over the years of playing baseball, and I remember the last time when I was in center field, it was a couple years ago. And so it was, I had gotten to the point, I think it was about the fifth inning or so, and so right around my elbow, I could not physically hold my hand up. It was my throwing hand, so I didn't have to have a glove on it, but if I had a glove on it, I would not be able to hold it up. And in fact, I got up to bat the next time, and it was my backside hand, so I could still backhand the ball.

And so this was my right hand as a right-handed hitter. And so I couldn't hold the bat up if I put only the bat in that hand. It was just dead, all right? Sometimes people have it with the shoulder, too. It just feels dead. In my opinion, that is not a muscle tear, necessarily, because I can still use it, but you put a little load onto it, and it gives way. And so in that case, in my experience, a lot of times those are nerve-based problems. You don't just lose power immediately after, you know? And it's funny, too, actually, it was the last play of the game. I was able to throw someone at the plate, and so I committed, and I threw hard.

I used the rest of my body. My shoulder didn't hurt at all, but to actually warm up between innings, I couldn't throw the ball. But there are other aspects to these tests that would mean that there's other things that can cause positives in these tests. And so if you use differentiation in these tests, then I think you'll gather more information. Anyways, back to labrum. So I'll do O'Brien's and active compression test, also anterior slides test, and a couple of the tests when they go supine. Supine, I'll use a supine's crank. I'll do a biceps to load and a passive distraction test. Okay? I'll come to those in a little bit here.

Impingement. I, and this is probably wrong, I don't tend to go into the specific types of impingement. I just see if I'm looking at an impingement case, or if I'm looking at a cuff case. If they have a full blown-off cuff, I need to refer them out. All right? If I'm looking at a labrum case that is severely provoked, and maybe they had dislocations, or they're a chronic dislocator. Maybe an instability, I kind of got to refer them out because it's more of like a tubs type of thing. A traumatic type of dislocation, surgical intervention is a little bit more merited. And so I just want to see if they're a rehab case, honestly.

And I want to make sure that they should be in-house or not. And so with the labrums, or sorry, with the impingements, I do NEARS and Hawkins-Kennedy. And I notice that a lot of times the other tests are provocative, too. And so, but if I see, especially Hawkins-Kennedy, if that's positive, I see that that's going to be a really important one. Or internal rotation really bothers them. That's kind of what those two tests have in common, as well as elevation. For instability testing, I'll do a load and shift, a sulcus sign, and I'll go and flip them onto their back, doing a supine apprehension and relocation test, as well as a supine posterior apprehension test.

And these are the ones that I'll mainly use, again, for instability. I need to see if they need to be in-house or not with instability. If you're not familiar, there's Tubbs and Ambrys types of instabilities. I learned this at the Diplante program. It was a great piece of information. And it tells you a little bit more how to manage these instability cases, should they be in-house or not. And so this is actually an affiliated document that I wrote. And just go into the emails, and you'll see my brainstorming document. Scroll on down to instabilities. It covers it all in there. Labrums, again, I'll go through supine.

I'll go through supine crank, supine passive distraction test, and biceps load two. Now, I was looking actually for, I don't have all of them that I could. And so I was looking for clusters of tests. And I think clusters of tests are really nice, such as Laszlo's cluster for the SI joint. I found a cluster of two tests, a passive and active compression test for looking at slap tears. But I really wanted to find some for rotator cuffs, for instabilities, that kind of shows beyond reasonable doubt that that's what we're looking for. And we can say within, if three of these tests are positive of the five, then we are beyond reasonable doubt looking at this type of pathology.

And so I text Michael Fanning to see, he's an instructor over at SCU, smart guy, really smart guy. He's been on the podcast before. And so I asked you, do you have any clusters that you like? Because you're a diagnostic guru. And so he says he's got the Fanning cluster. And so I need to figure out what the Fanning cluster is. So Fanning, I want the cluster. And I'll patch it into my examination here. So I think that clustering tests would be nice. Obviously, there's not a bunch of information out there on all these clusters of tests. Or there are some that kind of fell short in research. So it's kind of like they'll talk about the cluster of tests, but the cluster of tests was really not extremely useful.

So if you guys have suggestions on clusters for certain pathologies of the shoulder, then I would really be open to hearing about it because I'm always looking to improve my testing as well. By the way, in the document as well, I've already put links to videos on YouTube that I didn't produce necessarily, but they're how to do these tests, as well as sensitivity and specificities, which is on some of those videos, as well as on the document, the correlated document. Now, neurodynamic testing or screens, I'm not legally allowed to show you. And I didn't include them in that document, but I mentioned them.

The place that I learned them is from Michael Shacklock's Neurodynamic book, as well as attending his course. I'd venture to say that using those tests really blew my mind about how many of these shoulder conditions and upper extremity conditions are actually have a nerve component or nerve percentage. And so when you clear that area out, a lot of times the water unmuddies and where we look at actually if there really still is a positive O'Brien's test, because sometimes there isn't. There might be tensioning the radial nerve, you know, and it just doesn't like it. And so you can do upper extremity tension tests or a neurodynamic test with biases to certain nerves, median, ulnar, and radial.

So again, Michael Shacklock covers his. Also, too, there is some versions of the test that you will learn in school. I don't love all the ones they teach in school because I think they're at least I haven't learned them. We didn't learn them when I was in school. And so but some of the schools or at least the students that I've seen exit school and show me the test. They're kind of reckless with the test, meaning they do it quickly. And so these these tension tests, again, it's irritating to have neural tension and it amps up exponentially. So they're quick. So make sure that when you when you do these tests and you practice them, just do them slow because it's it's it really will provoke somebody and it happens quickly.

So just go real slow and act like they're a hot, ridiculous case, please. And just see which there's a sequencing effect, which I think is really important that Michael covers in his course, as well as his book, which the book is a really good read for like 60, 70 bucks. I just Amazon it. I put a link in the book in my notes as well. I don't get any money for suggesting these courses, by the way. But I think the sequencing is important. So and what I've noticed from young docs coming out is that they don't always pay attention to the sequencing. It's more of the end position. Again, I'm not pretending to know to say I'm a no-doll.

I still need to improve on these tests a little bit every single time, too. But for the most part, the more you do it, the better you get and the slower you do it, the I think the more you're going to keep the patient's trust. Don Murphy actually covers some of it in his crisp book. He has some for the lower extremity as well as upper extremity. And so the crisp manual is a good overview of things. And I know some of you who have heard of crisp and have not read the book, you're missing out. All right. It is a very good comprehensive look at how to use different types of tools with cervical spine and lumbar spine cases.

Obviously, if we're talking about shoulder, shoulder won't be necessarily covered in there. But it's a good start with some of the cervical spine and lumbar spine testing and neurodynamic testing. Now, for advanced testing, I had to do this the other day with somebody who wasn't really a painful case. He just wanted to see where his deficiencies are. And so with people who are actually highly sensitive or they have a problem or symptoms, they might not want to do these and you might not have to do them either. And so these are people who we're looking to see if they really have little examination findings.

And we are looking to see if we can tease out a little bit more problems with them or outliers with them. And so sometimes these people will not have a problem unless they do something for a long period of time. An example would be I don't have shoulder pain until I hang from a pull-up bar on the fifth rep or for 30 seconds or more. So one of these tests that I chose is a bar hang. Simple, right? And I'm just looking to see if they can hit a minute-ish. All right? Also, too, I know I did this in kind of a bit of a podcast a while back. But I believe in the callus rule, okay? I know that when I look at a shoulder case and I talk to DMAC about this kind of jokingly, he's like, oh, that might be a good rule.

I kind of do. I do believe it. If you look at your hand right now and if you have calluses, you'll have calluses mainly on three fingers. You'll have the last three digits, okay? And so you might have some on the first digit or on the thumb if you swing a bat or a club. All right? So these last three digits, my theory is that there's that hardwired or software in there. There's that hardwired software in there that helps the body feel that, holy shit, there's something in the hand. I'm going to stiffen up that shoulder. And so if you think about it, if someone has calluses in their hand, they probably spend a little bit of time of challenging the rotator cuff and the shoulder girdle to stay on the body on the rib cage.

And so I think that is a good outcome measure to figure out if somebody is lagging in something. And so usually with somebody, even if I didn't look at their hands and say, you should surely be able to hang from a pull-up bar for a minute. And I know there's people who weigh different amounts who are listening, and I get it. It's not really a fair assumption for someone to hang from a pull-up bar with 300 pounds, who's 300 pounds versus 150 pounds. But you should be able to control your own body weight. And if your body weight is the outlier, then that might be the outlier. Okay? And in that case, they might just be an overall deconditioned person.

And I honestly don't know if, like, I know the power lifters, they're bigger guys. I don't know if they can hang on to a pull-up bar, but I'm sure their grip sync is probably pretty good. And I bet they could probably hang on a pull-up bar quite a long time. Anyways, I would shoot for about a minute or so. Next is a bottoms-up kettlebell carry. Roughly about 25 pounds or so. I know, again, I do not believe in saying everything kilo, so I'm going to say 25-ish pounds. If you have someone who is able to press a shit ton of weight overhead, 25-6-ish pounds should be pretty damn easy. All right? And I can personally do about 53 for a little bit of a carry.

And so I kind of assume someone who's of my stature should be able to do at least 35-44 pounds for about a 15-20-30 second period of time. And so if we have someone come in who's like a stellar high school basketball player or football player, and they're pretty damn strong in all their lifts, and they're a star player, they can't do 25 pounds or so. I'm kind of wondering what's going on here with that person. And so bottoms-up carry is a good reflection of core strength and grip strength. Actually, can they stay under the kettlebell? I always show people it's not a grip test, actually. It's not how hard they can hold on to the thing to make it not spin and fall over.

It's how well they can stay under it. And you can actually release some of the fingers into it and just kind of circle it with the thumb and index finger, and it'll stay there if you cradle the weight. And so I'm looking to see if we can actually hit about 30 seconds or so, roughly. Again, these are generic tests. If you guys have a better number for me, please let me know. Last is the sitting hand press-up test. Imagine getting out of a wheelchair or like a ring dip. A ring dip would probably work. You put someone in that position right there. And just generally see if they can hold it for about 15 to 20 seconds or so, and if they start to grade and they start to lose their ability to hold the spine up through the shoulder blades.

In this case, the shoulder blades are fixed. The spine is not, or the rest of the body is not. Push the shoulder. You should be able to keep a flush area right there. And you'll start to see as you start to load that area, they might just start to fall apart. And you'll see all those things start to present themselves that might be useful in your examination treatment. Now, I am not going to go much further in the podcast with mentioning these things. I think I'm going to be able to cover a fair amount of it in the video and in the document that you guys are going to get access to. I do suggest you get access to it.

By the way, if you put your email in there, I'm not going to try to spam you with a bunch of crap, okay? But here's the fact of the matter is that I really want to know who the podcast listenership is, and I really want to help give you guys the information that I've learned over time has been helpful to me. So hopefully it can help you. If you already know it, great, cool. Like you don't need it, all right? But I believe as the movement movement, we're always trying to get better. And so the easiest way to disseminate that information and to give you suggestions of workshops that I've learned to be helpful, the pros and cons of going, some books that I've read, as well as a workshop that I might hold, and some useful free information, the easiest way is via email, all right?

Email is still king. I swear, if I got to go onto Instagram and see that I have 7,000 followers, but only 300 people ever see the post, it frustrates me. And it frustrates me mainly because I think the information is useful, but the people that are intended to see it are not seeing it. And I don't spend a lot of time on Facebook, so that's the wrong place for me to actually push that out. And so I believe you guys can get organization of the information better if I can disseminate it in an organized fashion. And so please go through there. Again, you might be suggested to come to a couple things, such as there's the, I don't know, this podcast is going to reach in December.

Good. If you guys are looking to actually meet me in person and hang out and just bro down and just ask questions, I'm going to be at Sandy's and Huntington Beach right at the end of the pier on January 18th, 5 to 7. I'm going to have beer, food. You don't have to pay to come. Just hang out and bro down. Docs, trainers, orthopedic surgeons, coaches, all welcome to come. It's just people who think they want to. Similar minded people. Let's just say that. I want to make sure that everybody understands that it is a place to learn. It is a place to bro down and meet new people so we're not alone in this world, you know?

And I think that a lot of us go into our offices and gyms and we're just alone all the time and we're with our clients, actually. We're not alone, but we're not necessarily by other people who can help nurture a relationship and improve education. I've been fortunate to learn from a lot of people that I hang out with, but I would always love to meet more. And so if you guys have questions for me at all, clinical, business, that's the place to meet. But anyways, those are the type of things that I might suggest through the emails. And so please sign up there. You're going to get more information than you ever thought you'd want.

And hopefully you'll be able to apply them to your clinical practice. Now, this is going to be, again, right? We have one more podcast or two more podcasts of this towards the end of the year. The next one is going to be on tension clues and cues. And this is the reason I'm including this is because I had the opportunity to work with some amazing lifters who were surprised by the amount of tension that they did not have and how much tension improved their lifts and how it made their back feel better. And so I'm sharing this. I'll keep their privacy, but I'm intending it to be so that those types of people who want to lift at the gym, get their gains, do their booty work, whatever it might be, do it in a safe fashion.

And there's no way to lose your gains quicker than to have an injury. And so these tension cues really help them. And so I included a video as well as a podcast that's correlated so that hopefully more people can realize that these things can be helpful to them. You guys can use it as clinicians to help nurture that conversation that you're going to have with some of your patients as well because some of them are going to want to go back and lift again. All right? And the last podcast of the year is a very special one. It's already been recorded. My girlfriend actually had a back issue. She had an acute disc injury from no trauma a couple weeks back.

And so I managed her, and she has a good story to tell. And I actually sent her for a second opinion to another doc that I like and I trust. His name is Ben Ramos. He's also a partner in ProCyro Online. And I just wanted to make sure I wasn't missing anything. And so her case in particular, I'm hoping, is a good story of how I think a lot of us should be okay with being wrong. And I was okay with being wrong because for the greater good of her, I need to make sure I wasn't wrong or missing something. And so I wanted that second opinion. And whatever he suggested at that point, we're going to be willing to try.

She did. She feels better. Within the next day, she was able to put her own shoes on. And so, again, I recognize I don't know everything. And so I think all of us should be okay with doing that. And so her story is just a good example of where I was able to do that and for the greater good of the patient. So, as always, thank you for listening to the show. Share it with your fellow doctors if you think they're going to benefit from this in any way. I thank you for sharing it because, again, this is the only way the podcast is promoted is if you guys share it. There's no paid promotions. There's nothing really put on Facebook or Instagram really that is a large marketing campaign.

This is just a grassroots thing, all right? I do it because I get good feedback from you guys and I see that you guys enjoy it and I learn stuff. So, please share it on whatever media player you're listening to. And thanks for being part of the movement. Movement, you're the movers. I'll see you guys soon.