♪Bob and Brad, ♪
the two most famous physical therapists on the internet.♪
- Hi folks, I'm Bob Schrupp physical therapist.
- Brad Heineck, physical therapist.
- We are the most famous physical therapist on the internet.
- In our opinion, of course.
- Very modest too.
We're gonna talk about today, Brad,
according to you, is you shoulder pain coming
from nerve, joint, or muscle?
We got 10 tests.
- Right, yeah.
We had some viewers ask this question
and it's a great question.
And we're gonna go through and show you.
Why don't you have a seat right here, Bob.
- By the way, as I'm moving forward here, Brad
I saw a couple new people out there.
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- There you go, Bob.
Okay, so someone comes into the clinic, Bob,
they say they got pain in the shoulder.
So as therapists, we're now thinking, is it a shoulder
problem? It could be a joint problem,
it could be a muscle problem.
Exactly what we've been asked.
So how do we go about working this out?
I don't know about you Bob, but I always go
to the neck first.
- Right.
- Like clear the neck.
- Exactly.
- And one of the first things I'll do,
is ask about where does it hurt and what makes it worse
and what makes it better?
And the location, if the person is telling me, well
I got pain in my shoulder, but it kinda radiates down,
and sometimes it goes down into my hands and my fingers.
And it feels cold,
sometimes it tingles, it's numb at times.
I jot that down.
Right there, I'm thinking it's probably a nerve problem
and it's probably
- You're leaning more towards nerve
than at that point by far.
- Right. I don't know where that nerve is being
- When it's that far down ,right?
- Yeah.
- Not a hundred percent sure,
but it could be, and it could be from the shoulder,
it could be from the neck.
- Right.
- Okay, the next thing I like to do is I'll say, sit up nice
and tall.
Now, if you're at home, you wanna do this with yourself
or someone else you can, but you need to be gentle.
I'm gonna put gentle pressure straight down on the head.
Does that hurt, Bob?
Does that change anything?
- Yeah, that hurt.
That brought on some pain right here
and sent a little pain down my arm.
- So right away, that's a positive sign.
I'm thinking, well..
- Neck is involved.
- We definitely got some neck involvement.
I also may do bring your teeth together gently
in a gentle distraction, I'll pull up like this.
- That feels better.
- Yeah, oftentimes, usually that doesn't hurt
but sometimes people will say, oh, that feels better.
Makes my shoulder feel better.
And all I did was put some traction on a neck.
It's pretty clear that we've got some neck going on.
Still may have a shoulder problem, but we still got,
you know, could have both.
Okay? Now then the other thing,
let's say, this is no pain, no pain.
There's another one Bob likes to do it,
what do we call that one?
- Turn back and you go,
you just turn this way and go back like that
- And then put a little pressure.
Yeah.
- Yeah, and that's really compressing that side up
and you can do it on the other side too.
You can turn, go back, and press down.
- I'm not bearing on it.
I'm pressing down gently.
- And that, again, creates pain down the arm,
again leaning towards the fact
that it probably is a nerve coming from your neck
- Right? Well, don't you turn around once, Bob.
There was one thing I learned in a Mackenzie neck program.
Oh the way, I'm sorry.
I'm gonna have you turn a little bit here.
If someone generally has pain in the shoulder, but most
of it is back in this area, I'm thinking it's probably
from here, but it may not be.
Pain from the shoulder joint usually refers this direction.
Not this way, but it can, so you can't get these rules.
I'm just saying.
- But as a majority I'm leaning more towards neck again.
If I see it back here.
- Right, right.
See how we kind of look at things,
and this is from experience from, you know,
the courses we've been to.
It all comes together.
You can, you wanna turn around, Bob?
- It could even be upper, upper thoracic area.
- You bet.
Yep. Things referring in that direction.
That's the tricky part about pain.
- Yeah.
- The source of the pain and where you feel it
are two different things in a lot of cases.
- Right, and you're gonna do range of motion too, Brad?
- If all those are negative, I'll say
you know, can you look down?
As far as you can look straight ahead, bring your right ear
to your right shoulder.
Bring your left ear to your left shoulder.
Okay, sit up nice and tall.
Keep your shoulders still, look over to your right,
as far as you can, like you're trying to see a car coming
behind you when you're driving.
Then the other direction.
I'm looking for range of motion,
everything looks normal so far.
Now do a chin tuck.
There you go.
And now do that chin tuck, lean back into your chair
and look up at the ceiling, look behind you,
open your eyes up, Bob, I gotta see your eyes.
There we go.
And if he can do all that normal range, no pain
all these other things we did were negative.
I'm feeling pretty comfortable
- That it may not be neck.
You know the thing is, if I go
like this, I'm this far, you know, generally
what you're gonna start seeing is a real lack of motion.
- Yeah.
- And that makes you start thinking, yeah,
the neck's involved.
- Right. I mean, I've had a number of people,
this is not uncommon.
I'll say, can you look backwards?
Go ahead and start looking back.
And they start the feel and they'll say
I feel pain right here.
And it's like, the head goes back,
We got pain here.
It's a referral pain, likely a referral pain
from the neck because the nerves from the neck go
to down here and all the way to the fingertips.
- Yeah. It definitely means that the neck is involved and
and there's sometimes we have both neck and shoulder.
That's a place where we're probably gonna start,
is treating the neck first and see what goes away.
- Exactly.
Now all four of those tests, plus a little bit more
took us about three minutes to go through.
But in the clinic, Bob and I have been doing this for years.
I can whip through that in less than a minute easily
unless there's a red flag, then I will stop and look
at it a little closer.
So everything goes clear in the neck,
let say we're gonna go to the, the shoulder joint now.
Okay.
One thing I learned from one of the great shoulder
people, therapists, in the United States, George Davies
a physical therapist.
I don't know if he's got his doctorate yet,
but he's got so much.
- I think he does now.
- Yeah. I think he does.
He may have his PhD.
He is, his mind is way up there in the therapy,
in the physical medicine world.
If someone has pain right there, and I'll have this a number
of times with shoulder patients.
Pain here, not so much here.
And they have problems reaching up and behind him, etc.
But they say pain right here.
That's oftentimes a referral pain from the shoulder joint.
Doesn't have to be
- So no pain here, no pain here, pain right there.
- Right. And there might be some pain there, particularly
if they're reaching up overhead or behind you.
But a lot of the thing they say it hurts right here.
And I'm thinking, ah, that indicates here,
not necessarily, but it indicates
- I'm glad you told me that Brad, cause again
I just had a patient that had this.
- Yeah, it's amazing how we, we keep learning as we grow.
- Right.
- Older, gray.
- Wiser.
- Wiser. Yeah.
Okay, and I'm gonna go through these next
tests pretty quick, Bob.
They're just general impingement tests for the shoulder
and one is the near because you bring the arm near
to the ear.
That's how I remember it.
One hand here and I'll push up here.
If this is positive, by the time I'm getting up to here
- Positive, he means it's painful.
- Painful, right?
That means there's probably an impingement,
something like a joint problem.
- The tendon is pinching.
- Yep. It's a joint problem
- Which is very common by the way.
It's probably one of the more common shoulder issues.
- Then the next one I'll go here,
elbow here, and I'll go across.
So the elbow is going right to this shoulder and it's again
we're doing some pinching up in here and if you can push
like I'm not pushing hard, but just a little squeeze.
Normally it shouldn't hurt.
Although on my shoulder it hurts a little bit
and I don't have a shoulder problem.
- Sometimes it can be your ACE,
your acromioclavicular joint too on that one.
- Right, Yep, there's a number of things, but it's but
- It's shoulder.
- It's a joint thing.
Yeah. Okay.
And then the Hawkins Kennedy, this is where the arm is here.
90 degree bend here.
I always hold the elbow right here
and we just go down like this and you know
all of these are gonna make the person's eyes open
up and say stop that kind of a thing.
If it's positive
- It shouldn't hurt a lot
you know, if it's a normal shoulder,
it shouldn't hurt at all.
- Right, if you got a healthy shoulder
all of those should feel like, oh little stretch
but you know, no big deal.
Okay. All of those tests are specific to the joint.
Okay? So we talked about the nerve pinching.
Oftentimes it's from the neck,
it can be from the shoulder.
A nerve being pinched as the nerve runs through this area.
The joint and now muscle.
How do we know if it's muscle or not?
One thing I do,
and I don't know if you do this, Bob, I'll simply palpate.
I'll start up here and I'll go into muscle belly.
I don't get around the joint, the bony parts
but just the muscle belly.
And I'll work back here.
I'll work in the front.
There's a lot of muscle in the anterior part
of the shoulder.
And I'll kind of get in there cause these muscles
especially on someone as massive as Bob.
He's got these big chest muscles and shoulder muscles.
- Well, one thing I do Brad, and I'm sure you do too,
is I'll actually check the other side first quite often
because they'll go,
Yeah, it really hurts.
And I'll go, does it hurt over here too?
Oh yeah it really hurts over there too.
I'll do one
- It's a really good point.
Check one side and then the other.
There's one tendon that I do like to check
and that's the long head
of the biceps and to do this, why don't you stand up, Bob.
Go like this with your Palm up.
There you go.
- That's my weak hand, well it doesn't matter.
- Do this one.
And I'll just say, hold your hand right there.
And I'm putting pressure making that muscle work.
Okay? And if that feels fine, why don't you turn sideways?
I'll go like this and I'll have
them turn their palm forward, elbow straight.
And then I'll slowly bring their hand back
and I'm stretching that tendon and a good stretch.
And if that gets a sharp pain up in here
that's a positive sign that it's a muscle or muscle tendon.
And it's getting up to the joint.
Some of these can overlap each other a little bit.
Anything else that you do for a muscle tendon, Bob?
- Well, I would definitely do the check for the
rotator cuff.
- Sure. The empty can, empty can yeah.
Looking at the shoulder.
- Usually about 20 degrees forward, put the hand
down the thumb down, bring it out about this far
and you're gonna push on.
If it just gives way you probably have a
a partial rotator cuff tear.
- Right.
- And that's the supraspinatus.
- Right. And so that's kind of the joint kind of the muscle.
There's a little cross over there as well.
But I think overall,
you know, I think we did a pretty good job.
- That was ten tests, Brad, I'm patting myself on the back.
- Yeah.
- And you too.
- Nice job.
- Yeah. Give me a little pat.
- All right, thanks for watching.