This is Brent of the Brookbush
Institute, and in this video we're going over
the Neer Impingement Test, a special or
orthopedic test used during our shoulder
examination. I'm going to have my friend,
Melissa, come out. She's going to help me
demonstrate. This isn't a
particularly complicated test. I'm going
to take Melissa through passive shoulder
flexion in the scapular plane with her
humorous internally rotated, and then I'm
going to add a little over-pressure to
see if I can provoke symptoms.
I'm going
to grab Melissa just underneath the
elbow with an underhanded grip. I'm
going to use this hand to stabilize her
scapula and thorax, because as I
push up this way, I don't want a bunch of
scapular elevation. That's not great.
As I go into over-pressure, I don't
want to just push her off the table
Last I checked, if you push
somebody over the table, they don't come
back, and then you're not fixing anything.
We want to make sure she stays on the
table and that she's stabilized. I'm going to go
ahead and turn her arm in this way, take
her through all the flexion she has in
the scapular plane, and then like I said,
I'm going to add a little bit of over-
pressure. I'll take her just past that
normal end range. Here's the key,
"Are those the symptoms you were talking
about?" If those are the symptoms that she
was talking about, then I have a positive
Neer Test and a good indication that
impingement is what is bothering Melissa.
Keep in mind that if she had pain
but those was not her symptoms, I need to
continue doing my testing to figure out
where her pain is coming from.
Although she may or may not have
shoulder impingement, that's not what she
came in complaining about. I need to fix what
she's complaining about first. Maybe we
can address this at a later date.
What's the intent of the Neer Test?
The intent of the Neer Test is to
provoke symptoms in inflamed tissues.
With an impingement syndrome, we're
assuming that these inflamed
tissues are being caused by pinching
between the humeral head and what we can
call the roof of the shoulder, which is
the inferior surface of the acromion
and the coracoacromial ligament.
Under there, we have things like your
supraspinatus and infraspinatus tendon,
the biceps tendon, the long head
of your biceps tendon, we have your
subacromial bursa, and we
even have the superior portion of the
capsule itself for the shoulder. All those
things could be getting inflamed, because
Melissa's shoulder isn't working right.
Let's say she has some sort of arthrokinematic
dyskinesis that is causing
these tissues to get compressed or
rubbed more than they can handle during
functional activities. Maybe she's a
volleyball player and just continually
reaching overhead with poor shoulder
mechanics is causing all of this stuff
to get irritated. In the Neer Test, I've
taken the greater tubercle and moved it
into a position where I can smash it
against the roof of the shoulder here,
that subacromial space. If I get her
symptoms, I should have a pretty good
indicator that that's what's bothering
her. Why is this such a commonly used
test? I think this is a commonly used
test, because it looks very much like the
Maitland joint exams that we've
all done- that active motion with
over-pressure. "Melissa, can you raise
your arm up? Good. Does that hurt?
Does that hurt? No, all right. Clear. Good. Let
me have you go out into abduction all
the way up. Does that hurt? Good.
Does that hurt? If I do this,
though,
does that hurt? Yes." Maybe we're
getting a little bit more sensitivity
out of the fact that we're internally
rotating the humorous and she's doing this
in the scapular plane. Maybe that's a
more provocative test. The truth of the
matter is that the Neer Test isn't a
great test by itself. Why am I
teaching this to you? It's important
that you know this test. This is a very
commonly used test, and you're going to
see things like a positive Neer on
various paperwork that heads your way.
Maybe a doctor notes positive Neer Test
and you need to understand what that is.
What is happening now, because of
research, when we talk about things like
sensitivity and specificity, is we're
realizing a lot of these orthopedic
tests or special tests
aren't great, so we'll cluster them.
The Neer Test is part of many of those
clusters. I think part of the problem
with all of our impingement tests is the
fact that they're usually okay too good
on the sensitivity part,
but the specificity is really bad. I
think what you guys will find as you
practice is that just about every
dysfunction of the shoulder starts
leading to some impingement syndrome
signs, and that should kind of
make sense to us. If you have
a labral tear, your shoulder's not going
to move well. If it doesn't move well,
things are going to get rubbed and then
pinched, and it's going to start getting
inflamed. Something like bashing your
humeral head into the underside of your
shoulder is going to hurt. We don't
have a very specific test, because if
somebody has a labral tear, maybe rotator
cuff tear, maybe posterior capsule impingement
versus internal- it all kind of
gets mashed together in these tests.
How do I use these tests? I'm going
to go ahead and start with her
subjective examination. That's going to
help a lot. Did this come on
gradually or was it acute trauma? If it's
acute trauma, impingement might not be my
first hypothesis.
If she has signs of upper body
dysfunction in my movement assessment,
like in my overhead squat assessment her
arms fall forward and she has scapular
elevation, and she said that this came on
gradually during her subjective
assessment. Okay. I'm starting to
think towards impingement. So, where does
Neer come in? I'm probably
going to do Neer in a cluster of tests,
which we're going to go over as we break
down each one of these tests
individually. Most importantly, is this
the test that gets me to her symptoms? If
it does, this becomes a great quick test
for me to do pre- post-assessment both as
she's coming in from session to session,
as well as maybe I'm going to try a new
intervention and I want to see if it has
any affect on her shoulder. I can quickly
do this test. Let's say I have her
come in, "How do you feel? Pain?
Yes." I do posterior deltoid release. "How
does this feel? Any better? Yes." Oh, good.
That's one more intervention that I know
is going to be effective, or maybe it's even
something I could add to her home
exercise program. That's where
tests like this become super, super
helpful. The other thing you might think
of, which is a little outside of the
box, is as we show you different
special tests, you'll see that this one
is very flexion related. If I'm
missing a bunch of flexion and flexion
causes her pain, I might start thinking
about, "Well, what's restricting flexion? Is
there a movement impairment that I can
draw from this test? The
muscles that happen to restrict end range
flexion are also my internal rotators.
We know a lot of us sit like this, so
maybe I need to look at releasing things
like my subscapularis, my latissimus
dorsi, my teres major, my pectoralis
major, and maybe do a little stretching and
lengthening of those structures to see
if I can get a little extensibility back
and bring everything back down
to normal. Here's one more
review of what the Neer Test looks like.
Grab just below the elbow, internally
rotate, go through the scapular plane with
over-pressure, and then ask, "Does that replicate the
symptoms you were talking about?" If she
says yes, then I have a positive Neer and
one more indicator in a cluster of signs-
this is just one clue- that we might have
impingement syndrome. I hope you guys
enjoyed this video. I'll talk with you soon.
you