April 10, 2025 • 32 mins
Discuss the various metrics used to evaluate the quality of special tests, examine the evidence of special tests for common shoulder pathologies, discuss applications of these tests in the clinic
Timestamps
(2:18) Special tests for common shoulder pathologies
(3:17) What is Sensitivity and Specificity?
(4:24) What are likelihood ratios?
(13:44) Labrum special tests
(19:43) Rotator cuff special tests
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-Sandy & Randy
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
Hey, this is Sandy. And Randy?
And we're here on AT Corner. Being an Athi trainer comes with
ups and downs, and we're here toshowcase it all.
Join us as we share our world insports medicine.
Welcome back to another episode of AT Corner.
For this week's episode, we havean episode dedicated to the
(00:24):
shoulder evaluation process. This is a request and I think
Carly said it best. Carly T says.
Could you guys do an episode on the shoulder for Orthoclass?
We are learning it. I want to be great at it because
I know it is everyone's least favorite, so I want to make it
my favorite. That's the Spirit.
Yeah, I thought that was a pretty good attitude because
honestly, shoulder could be rough.
(00:49):
It can be rough, but I feel likethere's only so much that could
be going on with the shoulder that if I feel like if you break
it down into like, well, it's either an impingement.
Everything's impingement, that'swhat it feels.
Like, but it just depends on thestructure that's impinged too,
which we'll kind of talk about when we talked about those
(01:09):
special tests in general. With such a mobile joint, it's
hard. Yeah, there's a lot that can go
wrong. So this is a CEU episode.
So what that means is if you're listening to this right as it
comes out, it is actually free. Thank you so much to Clinically
Pressed and athletic training chat.
Afterward, check the show notes to determine how to get your
(01:30):
certificate. There is a link directly to the
clinically Pressed website so you can sign up for the course.
You can get your certificate by doing your course evaluation and
quiz, and it's pretty straightforward.
And then you could check out some of our SC US.
So what are we talking about in this episode, Randy?
Yeah. So we're going to discuss the
(01:51):
various metrics used to evaluatejust the quality and just like
the accuracy of special tests, we'll examine the evidence of of
special tests for just some of the common shoulder pathologies
and we'll just kind of discuss the application of just special
tests in the clinic. Sweet to get started, why don't
(02:12):
we talk about just special testsfor the common shoulder
pathologies? Yeah.
So I feel like with the shoulder, I feel like we've all
kind of heard this, that the special tests are just kind of
crap. Like there's, there's already a
ton of them. Like I think labrum like there's
like probably 100 or so, like there's some insane amount.
(02:32):
So like obviously we're not going to do all of them.
So you have to be able to kind of.
Pick you don't do 100 on your athletes.
Just for one pathology, no, but some of the conditions we'll
cover are like impingement, which in the shoulder it seems
to be like everything. It's always impingement, labrum
and then a rotator cuff. So going into impingement, I
(02:54):
feel like most of the common tests that were kind of looked
at were nears, the Hawkins, Kennedy and then painful arc.
So nears, that's the one, right?We're bringing their arm up like
passively bringing them a remote.
In internal rotation. Yeah.
So that one had a sensitivity oflike 72%.
(03:16):
So sensitivity remember is the snout.
So it's actually being able to like rule out a condition.
So if you have a negative and a sensitivity like you feel
basically like 72% confident that that's going to not that
they don't have that condition, just the drawback to sensitivity
is it does allow for false positives.
(03:38):
So that's kind of the concern. That's why like you can't, it's
hard to judge a test just on that.
But again, if, if that's all youhave, I mean, you got to make a
the best decision, you have to right.
The specificity of nears was 60%.
So again, specificity is the spin, right?
(03:58):
So being able to actually rule in the condition.
So if it's positive, you're thinking, oh, like I'm 60%
confident that or like 60% confident that they have this
condition. But again, that does allow, like
just using spin does allow for that kind of false negative.
So another way that you can kindof dive a little bit deeper into
(04:19):
kind of choosing your task as asopposed to just comparing
percentages is actually using likelihood ratios.
So for nears, the positive likelihood ratio was 1.8.
So a positive likelihood ratio is basically what's the chance
that if you have a positive testthat they have the condition.
(04:39):
And the nice thing with these ratios is it's really not hard
to determine. So if like an article doesn't
like put it in, it's literally just taking the sensitivity and
then dividing it by 1 minus specificity, right?
So to give you a barometer of well, what these are just
numbers to me at this point, like what's good, what's bad?
(04:59):
Anything over one point O is a good test, so. 1.8 is good for
impingement. Yes, but the closer to 10 the
better. Oh OK, that changes it.
Yeah. So it's a big range, right?
So 1.8, it's all right. I mean it basically just says
this test isn't trash. OK, I'll take it.
(05:21):
And then for the negative likelihood ratio, again, this is
now saying what's the chance if it's negative that they actually
don't have this condition? And it's pretty much just the
reverse. It's 1 minus sensitivity divided
by specificity. Anything less than one is is
good, but if you are closer to 0, that's better.
(05:41):
OK. And what's for nears and?
Nears is 0.46. OK, so all right, not bad.
So do you ever use these? I think it's nice to use them if
you're like torn between tests and you're trying to think,
well, which one should I do? There's so many.
Like when. You're when you're putting
(06:01):
together your shoulder routine, Yeah.
Right, if you're starting to put, or maybe you're learning a
new test, right, then what you learned in school, you can now
evaluate it to what it how it isand evaluate it to all the other
special tests that you do. And maybe you're like, wow, this
one's really better. Like maybe I should start trying
(06:22):
to work this one in or practice it and get used to it.
I think something to remember isbecause we don't work in 100%,
it's so much better to have a slew of tests instead of just
one and done. Yeah, for sure.
And you know what? With a lot of shoulder stuff, it
was about a combination of tests.
(06:43):
I mean, that makes sense. Yeah, 'cause individually these
tests are kind of poopy. So I think especially for a lot
of the shoulder pathologies, it was combining tests.
OK, so then going into the Hawkins Kennedy, right?
Your sensitivity is 79%, specificity is 59% and that gave
(07:03):
us a positive likelihood ratio of 1.92 and a negative
likelihood ratio of 0.35. So it's.
Kind of similar to yours, Pretty.
Similar. Not much better.
OK. Just kind of there.
These ones both test the same impingement.
See, that's the thing that like,I feel like such a limitation
when we're talking about like impingement, like when you're
trying to look at these studies,because there's some that looked
(07:25):
at impingement, but then there'ssome that looked at like rotator
cuff tendonopathy, which could happen with impingement, right?
So it really depends on how the study determined what they were
testing and just work like basically semantics.
That's what's so hard like in literature, because there's so
much out there, but it's hard tocompare them.
Yeah, especially like again whenyou're talking about impingement
(07:47):
because almost anything in the shoulder can be impinged, right.
And I think too, like a lot of these conditions like, well, if
you have a torn labrum like morethan likely doing something on
like a Nears or Hawkins Kennedy,that might hurt maybe.
You just have a painful shoulder, like right?
Yeah. So I think that's what also
makes it really hard to talk about shoulder special tests.
(08:09):
Then you had painful ARC. So that's just basically their
arm coming up into flexion. And at what areas do they have
the pain is? Is that that's at scaption
right? I.
Think it's in scaption. And I think it's like the
positive is if they have pain, Ithink between 60 and 120, OK,
sensitivity was 53%, specificitywas 76%.
(08:32):
So getting a little bit better on being able to actually
probably roll in this condition.So that gave us that positive
likelihood ratio of 2.2. So a little bit better than the
other ones, but the negative likelihood ratio was 0.61.
So again, like if it's positive,right, you feel a little more
confident maybe than the other ones to say, hey, maybe that's
(08:53):
impingement. But again, I feel like, man, if
I had a torn labrum and I did that, that would probably hurt
too. Yeah, I mean, it makes sense if
you start to think about like what is going on though.
Like if you if you think about like where the humerus is
translating when you like lift your arm.
Like I can see why painful art could be better than some of
(09:16):
these like passive tests for. Sure.
Yeah, for sure. But for impingement, there was
actually a great flow chart in the British Journal of Sports
Medicine that kind of helped guide which structure or what
could be the cause of like the impingement.
It was, it was a pretty dope kind of flow chart that kind of
(09:37):
looked at, OK, if this test was,was positive, right, it kind of
you kind of would lean into like, OK, maybe, maybe this kind
of condition, it could be causing it.
So it kind of helps dictate treatment.
I thought that was actually veryfunctional.
There were no like metrics on it.
Like they didn't necessarily test like, oh, how good is it
actually at determining all that?
(09:59):
But I, I thought it was a prettygood one to help kind of guide
what could be impinged and how do you kind of necessarily treat
that? Can you kind of like overview
it? Yeah.
So basically if if someone had like those impingement symptoms,
so I just like that shoulder pain or it hurts when I bring my
arm up to here and like stuff like that, right.
(10:20):
They had certain positive tests like a folk or an empty can or
if they had a positive nears, which is interesting because
they also had it to where if if the pains like anterior or
posterior, right, that kind of change your direction on the
flow chart. If Hawkins Kennedy was also
positive or if they had apprehension, right?
(10:41):
You go to that next step, right?And now it's like testing the
stability part. So like our relocation test, if
that makes that better or if it's negative, then you kind of
go down to the next one and thenstart doing more of your like
scapular special tests, like what is it the scapular
(11:04):
assistance test? So actually bringing your
scapula into upward rotation andseeing if that takes care of the
symptoms. So it's all just stuff that's
able to like kind of gear towards, OK, yes, you have
impingement symptoms, but like what's the structure slash?
How do I treat it? It's really cool that they put
together like that map that kindof leads you to, I mean, that's
(11:27):
how I learned shoulder was we just kind of did sections.
So like if like let, I don't want to say let it guide your
treatment 'cause I know when I'mworking with a lot of students
now, I feel like they're so focused on finding out what it
is instead of what it isn't. Yeah.
(11:49):
And especially with the shoulder, you want to rule out
what it is not so you can kind of narrow down what you're
thinking, especially since a lotof the things you're going to be
doing similar treatments. Yeah.
So it's not necessarily you don't need to know exactly the
exact pinpoint thing. I mean, even I was talking to
(12:13):
some of our team docs and they're like honestly shoulders
like clinically you can only tell so much.
Like then you send it to MRI. So like, if, if something really
bad is going on in the shoulder and like you will know and
they're not going to be able to be functional and then you're
just going to refer that out. And that's beyond our scope.
(12:35):
So I think those maps kind of like help guide you to like, OK,
maybe I'm going to test this theory of impingement.
So I'm going to do all my impingement tests and then maybe
I'm going to OK, so impingement like not very likely.
(12:55):
Let me let me go look at thoracic out listener or
something like that. And then we kind of go into like
something else, but we we kind of like testing all of the same
thing at once and then all of the same thing at once and then
all the same thing at once for like different pathologies.
So I kind of really like this idea of this map.
(13:15):
Yeah, for. Sure, I think.
I think it does at least give a little more like substance to
just an impingement diagnosis. You can like be able to kind of
determine what might be causing the impingement or what
structure. So it kind of helps give you an
idea of treatment instead of just throwing the kitchen sink
of those treatments, right? You can maybe tailor it a little
bit more and hopefully save you a little time as well 30.
(13:39):
Minute shoulder exams. Yeah, seriously.
To that kind of moving from justimpingement.
Now going a little more specificinto the labrum.
Now, labrum's also difficult because like you have like
different types of labrum tears.It's not just a labrum tear,
right? Because you have labrum tears,
which could be like anterior, posterior, like inferior, like
all that, but you can also have like a slap tear.
(14:02):
All right? So that's also again, really
hard when you're trying to look at like evaluations because you
just say labrum, but then it's like, OK, well, which one,
right? Because you know, some are
looking at slap, some are just looking at labrum, which did
they put slap in there, right? So it can be really hard to kind
of determine, again, semantics, but for slap tears specifically,
the NATA did put out a position statement in 2018 that just
(14:24):
examined like a good way to kindof evaluate slap tears.
So we actually did a position statement episode on that one.
So take a listen, right? We broke that down as well.
But just as a quick review here,individual tests for slap just
don't really like perform that well.
(14:45):
They again recommended just combining some tests, like
really the best one for individually was kind of
Jurgensen's, which is what I always learned it as a biceps
subpluxation test. Yeah, me.
Too, but it really. Pops up for slap a lot but
that's I mean that it kind. Of makes sense like the yeah,
(15:06):
the biceps, Yeah, all right, that's.
The Jurgensen's, if you're not familiar, that's where you're
basically like like in a handshake grip and then you
resist them going into external rotation and supination.
And then you're also supposed tobe bow painting the biceps
tendon as well to see because again, you're trying to feel for
the subluxation you just have. To be careful because you're not
(15:28):
trying. To blow them up.
No, I feel like they could blow you up.
Oh yeah. That's.
True, I've gotten hurt doing during this test before so I'm
also working with people like three times my weight.
So probably need to position yourself really well for this
test for sure. I also wonder what the
(15:51):
difference is of having them stand sitting like the standard
position versus laying down. Oh.
I never thought that because. Sometimes I do this when they're
laying down. Oh, OK.
'Cause I. Can get a better grip with them
moving and it doesn't hurt my elbow.
It doesn't hurt me. But I don't know.
(16:13):
I like, I haven't done the research.
I haven't done the study to figure out if like positioning
when I feel like it wouldn't affect it that much.
Yeah, for sure. Except.
That they're not usually not usenot using their postural muscles
like stay seated. But yeah, I feel.
Like that'd be fine. That's kind of a cool way of
doing it. I just.
Added in like biceps load yurgisin.
(16:36):
No, that's good. I mean, that one has a
specificity of 95, but then you're looking at a sensitivity
of 12, so. So what does?
That mean so. Basically what that's saying is
if it's positive like oh man youyou might feel pretty good about
them having a slap tear but if it's negative it means.
Nothing that definitely. Doesn't mean they don't have
(16:58):
one. So that kind of led to that
positive likelihood ratio of 2.49.
So again, it's OK, right? But the negative likelihood
ratio was .91. That's not good.
So again, that's why the combination of tests has been
kind of advocated for. And again, the position
(17:18):
statement kind of gave three, but the best one that they had
was if they have a history of popping, clicking or catching.
And then if they had a positive anterior slide, which that's the
one where hand on your hip and then you basically load the
joint and kind of like shift that like put like an anterior
translation on. If that's positive, that would
(17:39):
indicate possibly a slap tear. I really.
Like anterior slide, yeah. But it's a good, it's good in
this in this combo, this one that just combination had a
sensitivity of 40%, a specificity of 93%.
So that kind of gives us the positive likelihood ratio of 60.
That's the. Highest we've had so far so far.
Right. And then a negative likelihood
(18:01):
ratio of 0.6, right. So again, it's a little bit
better than some of just the tests that we've talked about in
general. So that's a good way of just
kind of looking at how you can kind of compare how tests
performed compared to each other.
What about labrum? So yeah, for labrum you I feel
like there have been like a ton because like again.
(18:22):
Hundreds. Yeah.
Yeah, like. Crank jerk grind, like all the
things that sound terrible for your shoulder, but the only one
that I really kind of saw that was looked at was the crank
test. So that's basically putting
their arm in like 90° of AB duction and basically taking
them into like internal externalrotation.
I've seen this where they're sitting, so they're sitting
(18:44):
upright and then you put them upinto there and you're doing
that. Or you can do it like supine,
but the sensitivity of that was 57%, specificity 72%.
So again, just kind of leads to just like all right, numbers
like positive likelihood ratio 2.4, negative likelihood ratio
of .5, you know, I got. To say I have I do this test in
(19:07):
every single one of my shoulder evals and I really don't think
I've ever had a positive for this.
It's not my favorite Labrum 1 aswe talk about clinical
application, like I'll I'll be able to talk a little more of
what I like to do for labour andbut yeah, that crank I'm like,
yeah, like I. Do it to do it.
(19:29):
Just to do it. But honestly, like, yeah, no,
I've never felt like, I've neverfelt anything.
They've never complained. Like sometimes they'll be like,
oh, like it's like maybe they don't want me to get in that
full like internal extra rotation, but not like a
positive test for sure. So finally going into our
(19:50):
rotator cuff and we kind, I kindof broke it down into just kind
of different muscles. So supraspinatus if anything, I
think the rotator cuff test actually performed the best out
of all the pathologies like so we should be able to identify
rotator cuff tear pretty good. We don't really see that many,
(20:10):
no. But theoretically we should be
able to. That was the one problem with
like rotator cuff tears. It's like that tends to be like
older population ish. Then like maybe like again,
traditional setting of like college athlete, high school
athlete, but still something important to know.
And maybe you can find some things with like rotator cuff
(20:32):
strains. All right, so you had a job's
test, which I was like, what thehell is that?
That's empty can. I did not know it as jobs, so I
did have to look that one up. I'm like, oh, all right, good to
know. Yeah.
So that's empty can. Sensitivity was 88% and then
(20:53):
specificity was 62%. So again, that's leading to 2.3
on positive likelihood ratio and1.9 you feel like a lot.
Of these have a higher sensitivity to rule things out,
yeah. You, you feel a lot better about
it. Oh well.
Not that, not that, not that. Full can did better sensitivity
(21:14):
of 70%, specificity of 81. OK, I'll take, I'll take.
A specificity higher, yeah, for.Sure.
And then again that led to a positive likelihood ratio 3.75,
negative likelihood ratio of .37, right.
So that's pretty solid. What do you?
Use full can for. Supraspinatus.
So I like to do it for like testing supraspinatus strength.
(21:36):
I feel like and integrity I have.
I have three different programs that I've worked with for
students and some of them have different full can pathologies.
What? Do you mean?
Like some like some people use full can and empty can for like
(22:00):
impingement, some people use it for like bicep, some people use
it for AC joint. Interesting.
Yeah. That's very interesting, right?
She's always like. Yeah, I've always known as Super
Spinatus. That's interesting.
I could see that with like O'Brien's right too.
(22:21):
Like O'Brien's like I think it was originally supposed to be
for like slap tear but then likeit does really good for AC
joint. Yeah, yeah.
Well, I mean it kind of makes sense you're crossover and then
put it, you know putting pressure on it, it's going to
start jamming in the AC joint. And then finally for
(22:45):
supraspinatus we have drop arm which sensitivity was 24% not
great specificity 96%. Oh, here the.
Positives here that rules in what?
Which one's drop arm? That's the one where like
they're had, they have their armat 90° and then they slowly,
they're supposed to slowly breathe their arm back down to
their side, not like. They don't start like at the top
(23:08):
it. When I read about it, it
literally just specifically saidat 90 and down and a positive is
like if their arm just like falls or they just can't control
that motion. So positive likelihood ratio was
6.45, negative likelihood ratio .79.
So that again, at least positivewise, hey, if you got a positive
(23:29):
test, you're like so. Supraspinatus, we can count on
the positives. Everything else, you're kind of
yeah, if it's. Negative.
Well, that you're still in the weeds, right?
Then moving into infraspinatus, Basically all these tests had an
awful sensitivity, like they were bad, like we're talking
(23:51):
like 12%. Yeah.
So just because it's negative does not mean infraspinatus is
not damaged. But if it's positive,
infraspinatus is damaged. The best test that was kind of
reported was external rotation lag at 0°.
So that's the one where they're at 0° of AB duction.
They're an external rotation. You gently, like you basically
(24:13):
push against them. You don't have.
Any shoulder AB duction? No, this was truly at 0.
Oh. Interesting.
I do it with some reduction. That's how I normally do it.
But yeah, this was at 0. You just basically push and then
you let go and then if they start to lose it and they start
to literally just start to drop into internal rotation, that
would be the positive specificity was 98%.
(24:38):
Wow. And that that led to a
likelihood ratio of 6 point O 6.So again, one of the higher
tests we're we're. Climbing.
Yeah, we're climbing. And then one that surprisingly
there was a lot of research on is looking at subscap.
And again, as with kind of most things, a combination of tests
was recommended. They use the bear hug, which
(25:01):
when I think bear hug, I'm literally thinking like, oh,
you're wrapping your arms like both arms around.
Like no, it's not that intense. It's literally just there the
test, the hand that the arm thatyou're testing touches like
holds on to the opposite shoulder.
So if I'm testing my right, I would hold my left shoulder and
then basically you're trying to pull them away like you're
(25:21):
trying to pull their elbow up and off like their shoulder.
That's bear hug and then belly press them pushing into into
their their abdomen. That had positive likelihood
ratio of 18.29. I thought you could only go.
Up to 10. Oh wait, closer to 10.
Is better. Oh.
Wow, yeah. And then a negative likelihood
(25:44):
ratio of .2. So a lot of.
Research on this one, yes. Seriously.
So overall, just like that's just those are the numbers.
So now I feel like clinically like we all have our own again,
based on the test that we like, we do that we feel comfortable
with. And I feel like a few of those I
(26:05):
do, like I said, like I like to do full can, I'll do empty can.
Do you do empty can? Uh huh.
Yeah, I'll do. It but I'm like, yeah.
I don't really, I think I do it not necessarily for the positive
negative like of ruling something in ruling something
(26:27):
out. I think I do it as part of my
eval to more just see their motion to like, oh, if I change
this like, well, how does it change your test?
You know, like it gives me a little bit more to the full can
for me, I feel like. Empty.
Can I feel more just like I'm trying to see, I'm trying to
(26:47):
identify impingement. I feel like, I feel like I'm not
really testing, testing the integrity of super spinners.
I feel like I'm just testing, like oh can I just elicit pain?
I do a ton of impingement tests because I feel like, again,
that's like a lot of what we see.
Yeah. For.
Sure, for sure. I think the one that is pretty
(27:09):
variable is labrum. Like for me, like I really don't
use a ton of special tests. I really like just like joint
translation for labrum because Ifeel like I can actually feel it
shift out or maybe I can feel itcatch.
So I do a lot of translations for labrum and I've found some
pretty good success doing that, like just being able to do, oh,
(27:32):
do anterior translation, Antero inferior, like translation and
actually see if I can catch certain areas.
And it has also helped me with like laxity and instability
because like I'll feel it kind of shift out or I'll feel them
guard like I actually feel theirmuscles like fire or like it
gets like you can all of a sudden see their shoulder going
(27:52):
with it. I'm like, bro, does that make
you nervous? And then I think too, when we
evaluate shoulder, right, another thing again, we're not
just looking at the shoulder, right, evaluating the scapula as
well, right? Understanding, like it take
impingement, right? The understanding of why could
we be seeing impingement issues?Or maybe we just don't have good
rhythm. And this is where a lot of like
(28:13):
the scapular tests can come intoplay.
So scapular assistance, so that tests like they're going into
like I think it's like a reduction and flexion, shoulder
flexion, the patient and you basically are helping upwardly
rotate the scapula and if that takes away their pain, you're
like, oh, it's because you don'tdo that very well.
(28:35):
So that's what we have to train.Yeah, that's what we have to
work on. Or even like the scapula
retraction test, which you have them in scaption and then you'd
like test their strength. And if, if this test is
positive, I could be weak. But if you were to put the
scapula into retraction and thentest it and all of a sudden
they're strong, you're like, oh,well, that's the problem.
Your scapula is not set. So your rotator cuff muscles
(28:58):
aren't stabilizing the shoulder very well, right?
So those tests can give you a kind of an indicator of like,
oh, we need to work on scap stuff too.
And of course, visual inspectionor I feel like we all kind of do
this where we're watching and being like, oh, whoa, oh, you
see a flare there? You see a wing, right?
But what's interesting is like research has shown like it's,
(29:21):
we're not really good at using that to say this is your
diagnosis, like, oh, Scapula's doing that impingement, right?
But that doesn't mean it's not important, right?
I still think it's important to kind of help understand, paired
with their history, paired with their test that you've already
(29:41):
done to say, oh, this is the structure that's damaged, to
understand that, oh, this is a problem.
This might be the contribution we need to fix this.
It's all pieces to the puzzle. And I think that's why like we
were talking about earlier, likewhen I do empty can, it's not
necessarily for a positive negative or like some of these
things. It's not necessarily for trying
(30:04):
to rule in or rule out. It's more like comprehensive in
your in your evaluation for sure.
For sure. Do you have an action?
Item for this. I think at the end of the day,
like pick the test that you're comfortable with.
I mean, don't pick like like do your best to pick like something
that does have really strong stats with it.
(30:27):
But at the end of the day, like they didn't do a study on you,
right, on how your test performed.
So I think it's important that you pick a test that you feel
like you can execute comfortablyand that you have really liked
the results that you've seen if you ever have.
The chance to watch Randy do hisshoulder evaluation.
It is like beautiful, like artistry, like the way that the
(30:51):
way that you move like your arm and the and your patient's arm
is just like so smooth. Oh, thanks.
Sometimes. That drives me nuts when they're
not relaxed and then I have to. It slows down the flow.
I'm like bro, relax. So this is a CEO episode like we
said before. So if you would like ACU
(31:12):
certificate, make sure you Scroll down the show notes or
episode description wherever you're listening to this or
watching on YouTube or Spotify. We have the links below.
We also have different episodes that you can listen to other
than CU episodes. We have story episodes with
stories from real life athletic trainers all over the world.
(31:35):
And we also have spotlight interviews where we bring on
highlight topics from someone who is more of an expert in that
area than we are. So with that, I think we're
going to keep the fine print short today.
Thank you for helping us. Showcase athlete training behind
the tape Bye.
Hey, this is Sandy. And Randy?
And we're here on AT Corner. Being an Athi trainer comes with
ups and downs, and we're here toshowcase it all.
Join us as we share our world insports medicine.
Welcome back to another episode of AT Corner.
For this week's episode, we havean episode dedicated to the
(00:24):
shoulder evaluation process. This is a request and I think
Carly said it best. Carly T says.
Could you guys do an episode on the shoulder for Orthoclass?
We are learning it. I want to be great at it because
I know it is everyone's least favorite, so I want to make it
my favorite. That's the Spirit.
Yeah, I thought that was a pretty good attitude because
honestly, shoulder could be rough.
(00:49):
It can be rough, but I feel likethere's only so much that could
be going on with the shoulder that if I feel like if you break
it down into like, well, it's either an impingement.
Everything's impingement, that'swhat it feels.
Like, but it just depends on thestructure that's impinged too,
which we'll kind of talk about when we talked about those
(01:09):
special tests in general. With such a mobile joint, it's
hard. Yeah, there's a lot that can go
wrong. So this is a CEU episode.
So what that means is if you're listening to this right as it
comes out, it is actually free. Thank you so much to Clinically
Pressed and athletic training chat.
Afterward, check the show notes to determine how to get your
(01:30):
certificate. There is a link directly to the
clinically Pressed website so you can sign up for the course.
You can get your certificate by doing your course evaluation and
quiz, and it's pretty straightforward.
And then you could check out some of our SC US.
So what are we talking about in this episode, Randy?
Yeah. So we're going to discuss the
(01:51):
various metrics used to evaluatejust the quality and just like
the accuracy of special tests, we'll examine the evidence of of
special tests for just some of the common shoulder pathologies
and we'll just kind of discuss the application of just special
tests in the clinic. Sweet to get started, why don't
(02:12):
we talk about just special testsfor the common shoulder
pathologies? Yeah.
So I feel like with the shoulder, I feel like we've all
kind of heard this, that the special tests are just kind of
crap. Like there's, there's already a
ton of them. Like I think labrum like there's
like probably 100 or so, like there's some insane amount.
(02:32):
So like obviously we're not going to do all of them.
So you have to be able to kind of.
Pick you don't do 100 on your athletes.
Just for one pathology, no, but some of the conditions we'll
cover are like impingement, which in the shoulder it seems
to be like everything. It's always impingement, labrum
and then a rotator cuff. So going into impingement, I
(02:54):
feel like most of the common tests that were kind of looked
at were nears, the Hawkins, Kennedy and then painful arc.
So nears, that's the one, right?We're bringing their arm up like
passively bringing them a remote.
In internal rotation. Yeah.
So that one had a sensitivity oflike 72%.
(03:16):
So sensitivity remember is the snout.
So it's actually being able to like rule out a condition.
So if you have a negative and a sensitivity like you feel
basically like 72% confident that that's going to not that
they don't have that condition, just the drawback to sensitivity
is it does allow for false positives.
(03:38):
So that's kind of the concern. That's why like you can't, it's
hard to judge a test just on that.
But again, if, if that's all youhave, I mean, you got to make a
the best decision, you have to right.
The specificity of nears was 60%.
So again, specificity is the spin, right?
(03:58):
So being able to actually rule in the condition.
So if it's positive, you're thinking, oh, like I'm 60%
confident that or like 60% confident that they have this
condition. But again, that does allow, like
just using spin does allow for that kind of false negative.
So another way that you can kindof dive a little bit deeper into
(04:19):
kind of choosing your task as asopposed to just comparing
percentages is actually using likelihood ratios.
So for nears, the positive likelihood ratio was 1.8.
So a positive likelihood ratio is basically what's the chance
that if you have a positive testthat they have the condition.
(04:39):
And the nice thing with these ratios is it's really not hard
to determine. So if like an article doesn't
like put it in, it's literally just taking the sensitivity and
then dividing it by 1 minus specificity, right?
So to give you a barometer of well, what these are just
numbers to me at this point, like what's good, what's bad?
(04:59):
Anything over one point O is a good test, so. 1.8 is good for
impingement. Yes, but the closer to 10 the
better. Oh OK, that changes it.
Yeah. So it's a big range, right?
So 1.8, it's all right. I mean it basically just says
this test isn't trash. OK, I'll take it.
(05:21):
And then for the negative likelihood ratio, again, this is
now saying what's the chance if it's negative that they actually
don't have this condition? And it's pretty much just the
reverse. It's 1 minus sensitivity divided
by specificity. Anything less than one is is
good, but if you are closer to 0, that's better.
(05:41):
OK. And what's for nears and?
Nears is 0.46. OK, so all right, not bad.
So do you ever use these? I think it's nice to use them if
you're like torn between tests and you're trying to think,
well, which one should I do? There's so many.
Like when. You're when you're putting
(06:01):
together your shoulder routine, Yeah.
Right, if you're starting to put, or maybe you're learning a
new test, right, then what you learned in school, you can now
evaluate it to what it how it isand evaluate it to all the other
special tests that you do. And maybe you're like, wow, this
one's really better. Like maybe I should start trying
(06:22):
to work this one in or practice it and get used to it.
I think something to remember isbecause we don't work in 100%,
it's so much better to have a slew of tests instead of just
one and done. Yeah, for sure.
And you know what? With a lot of shoulder stuff, it
was about a combination of tests.
(06:43):
I mean, that makes sense. Yeah, 'cause individually these
tests are kind of poopy. So I think especially for a lot
of the shoulder pathologies, it was combining tests.
OK, so then going into the Hawkins Kennedy, right?
Your sensitivity is 79%, specificity is 59% and that gave
(07:03):
us a positive likelihood ratio of 1.92 and a negative
likelihood ratio of 0.35. So it's.
Kind of similar to yours, Pretty.
Similar. Not much better.
OK. Just kind of there.
These ones both test the same impingement.
See, that's the thing that like,I feel like such a limitation
when we're talking about like impingement, like when you're
trying to look at these studies,because there's some that looked
(07:25):
at impingement, but then there'ssome that looked at like rotator
cuff tendonopathy, which could happen with impingement, right?
So it really depends on how the study determined what they were
testing and just work like basically semantics.
That's what's so hard like in literature, because there's so
much out there, but it's hard tocompare them.
Yeah, especially like again whenyou're talking about impingement
(07:47):
because almost anything in the shoulder can be impinged, right.
And I think too, like a lot of these conditions like, well, if
you have a torn labrum like morethan likely doing something on
like a Nears or Hawkins Kennedy,that might hurt maybe.
You just have a painful shoulder, like right?
Yeah. So I think that's what also
makes it really hard to talk about shoulder special tests.
(08:09):
Then you had painful ARC. So that's just basically their
arm coming up into flexion. And at what areas do they have
the pain is? Is that that's at scaption
right? I.
Think it's in scaption. And I think it's like the
positive is if they have pain, Ithink between 60 and 120, OK,
sensitivity was 53%, specificitywas 76%.
(08:32):
So getting a little bit better on being able to actually
probably roll in this condition.So that gave us that positive
likelihood ratio of 2.2. So a little bit better than the
other ones, but the negative likelihood ratio was 0.61.
So again, like if it's positive,right, you feel a little more
confident maybe than the other ones to say, hey, maybe that's
(08:53):
impingement. But again, I feel like, man, if
I had a torn labrum and I did that, that would probably hurt
too. Yeah, I mean, it makes sense if
you start to think about like what is going on though.
Like if you if you think about like where the humerus is
translating when you like lift your arm.
Like I can see why painful art could be better than some of
(09:16):
these like passive tests for. Sure.
Yeah, for sure. But for impingement, there was
actually a great flow chart in the British Journal of Sports
Medicine that kind of helped guide which structure or what
could be the cause of like the impingement.
It was, it was a pretty dope kind of flow chart that kind of
(09:37):
looked at, OK, if this test was,was positive, right, it kind of
you kind of would lean into like, OK, maybe, maybe this kind
of condition, it could be causing it.
So it kind of helps dictate treatment.
I thought that was actually veryfunctional.
There were no like metrics on it.
Like they didn't necessarily test like, oh, how good is it
actually at determining all that?
(09:59):
But I, I thought it was a prettygood one to help kind of guide
what could be impinged and how do you kind of necessarily treat
that? Can you kind of like overview
it? Yeah.
So basically if if someone had like those impingement symptoms,
so I just like that shoulder pain or it hurts when I bring my
arm up to here and like stuff like that, right.
(10:20):
They had certain positive tests like a folk or an empty can or
if they had a positive nears, which is interesting because
they also had it to where if if the pains like anterior or
posterior, right, that kind of change your direction on the
flow chart. If Hawkins Kennedy was also
positive or if they had apprehension, right?
(10:41):
You go to that next step, right?And now it's like testing the
stability part. So like our relocation test, if
that makes that better or if it's negative, then you kind of
go down to the next one and thenstart doing more of your like
scapular special tests, like what is it the scapular
(11:04):
assistance test? So actually bringing your
scapula into upward rotation andseeing if that takes care of the
symptoms. So it's all just stuff that's
able to like kind of gear towards, OK, yes, you have
impingement symptoms, but like what's the structure slash?
How do I treat it? It's really cool that they put
together like that map that kindof leads you to, I mean, that's
(11:27):
how I learned shoulder was we just kind of did sections.
So like if like let, I don't want to say let it guide your
treatment 'cause I know when I'mworking with a lot of students
now, I feel like they're so focused on finding out what it
is instead of what it isn't. Yeah.
(11:49):
And especially with the shoulder, you want to rule out
what it is not so you can kind of narrow down what you're
thinking, especially since a lotof the things you're going to be
doing similar treatments. Yeah.
So it's not necessarily you don't need to know exactly the
exact pinpoint thing. I mean, even I was talking to
(12:13):
some of our team docs and they're like honestly shoulders
like clinically you can only tell so much.
Like then you send it to MRI. So like, if, if something really
bad is going on in the shoulder and like you will know and
they're not going to be able to be functional and then you're
just going to refer that out. And that's beyond our scope.
(12:35):
So I think those maps kind of like help guide you to like, OK,
maybe I'm going to test this theory of impingement.
So I'm going to do all my impingement tests and then maybe
I'm going to OK, so impingement like not very likely.
(12:55):
Let me let me go look at thoracic out listener or
something like that. And then we kind of go into like
something else, but we we kind of like testing all of the same
thing at once and then all of the same thing at once and then
all the same thing at once for like different pathologies.
So I kind of really like this idea of this map.
(13:15):
Yeah, for. Sure, I think.
I think it does at least give a little more like substance to
just an impingement diagnosis. You can like be able to kind of
determine what might be causing the impingement or what
structure. So it kind of helps give you an
idea of treatment instead of just throwing the kitchen sink
of those treatments, right? You can maybe tailor it a little
bit more and hopefully save you a little time as well 30.
(13:39):
Minute shoulder exams. Yeah, seriously.
To that kind of moving from justimpingement.
Now going a little more specificinto the labrum.
Now, labrum's also difficult because like you have like
different types of labrum tears.It's not just a labrum tear,
right? Because you have labrum tears,
which could be like anterior, posterior, like inferior, like
all that, but you can also have like a slap tear.
(14:02):
All right? So that's also again, really
hard when you're trying to look at like evaluations because you
just say labrum, but then it's like, OK, well, which one,
right? Because you know, some are
looking at slap, some are just looking at labrum, which did
they put slap in there, right? So it can be really hard to kind
of determine, again, semantics, but for slap tears specifically,
the NATA did put out a position statement in 2018 that just
(14:24):
examined like a good way to kindof evaluate slap tears.
So we actually did a position statement episode on that one.
So take a listen, right? We broke that down as well.
But just as a quick review here,individual tests for slap just
don't really like perform that well.
(14:45):
They again recommended just combining some tests, like
really the best one for individually was kind of
Jurgensen's, which is what I always learned it as a biceps
subpluxation test. Yeah, me.
Too, but it really. Pops up for slap a lot but
that's I mean that it kind. Of makes sense like the yeah,
(15:06):
the biceps, Yeah, all right, that's.
The Jurgensen's, if you're not familiar, that's where you're
basically like like in a handshake grip and then you
resist them going into external rotation and supination.
And then you're also supposed tobe bow painting the biceps
tendon as well to see because again, you're trying to feel for
the subluxation you just have. To be careful because you're not
(15:28):
trying. To blow them up.
No, I feel like they could blow you up.
Oh yeah. That's.
True, I've gotten hurt doing during this test before so I'm
also working with people like three times my weight.
So probably need to position yourself really well for this
test for sure. I also wonder what the
(15:51):
difference is of having them stand sitting like the standard
position versus laying down. Oh.
I never thought that because. Sometimes I do this when they're
laying down. Oh, OK.
'Cause I. Can get a better grip with them
moving and it doesn't hurt my elbow.
It doesn't hurt me. But I don't know.
(16:13):
I like, I haven't done the research.
I haven't done the study to figure out if like positioning
when I feel like it wouldn't affect it that much.
Yeah, for sure. Except.
That they're not usually not usenot using their postural muscles
like stay seated. But yeah, I feel.
Like that'd be fine. That's kind of a cool way of
doing it. I just.
Added in like biceps load yurgisin.
(16:36):
No, that's good. I mean, that one has a
specificity of 95, but then you're looking at a sensitivity
of 12, so. So what does?
That mean so. Basically what that's saying is
if it's positive like oh man youyou might feel pretty good about
them having a slap tear but if it's negative it means.
Nothing that definitely. Doesn't mean they don't have
(16:58):
one. So that kind of led to that
positive likelihood ratio of 2.49.
So again, it's OK, right? But the negative likelihood
ratio was .91. That's not good.
So again, that's why the combination of tests has been
kind of advocated for. And again, the position
(17:18):
statement kind of gave three, but the best one that they had
was if they have a history of popping, clicking or catching.
And then if they had a positive anterior slide, which that's the
one where hand on your hip and then you basically load the
joint and kind of like shift that like put like an anterior
translation on. If that's positive, that would
(17:39):
indicate possibly a slap tear. I really.
Like anterior slide, yeah. But it's a good, it's good in
this in this combo, this one that just combination had a
sensitivity of 40%, a specificity of 93%.
So that kind of gives us the positive likelihood ratio of 60.
That's the. Highest we've had so far so far.
Right. And then a negative likelihood
(18:01):
ratio of 0.6, right. So again, it's a little bit
better than some of just the tests that we've talked about in
general. So that's a good way of just
kind of looking at how you can kind of compare how tests
performed compared to each other.
What about labrum? So yeah, for labrum you I feel
like there have been like a ton because like again.
(18:22):
Hundreds. Yeah.
Yeah, like. Crank jerk grind, like all the
things that sound terrible for your shoulder, but the only one
that I really kind of saw that was looked at was the crank
test. So that's basically putting
their arm in like 90° of AB duction and basically taking
them into like internal externalrotation.
I've seen this where they're sitting, so they're sitting
(18:44):
upright and then you put them upinto there and you're doing
that. Or you can do it like supine,
but the sensitivity of that was 57%, specificity 72%.
So again, just kind of leads to just like all right, numbers
like positive likelihood ratio 2.4, negative likelihood ratio
of .5, you know, I got. To say I have I do this test in
(19:07):
every single one of my shoulder evals and I really don't think
I've ever had a positive for this.
It's not my favorite Labrum 1 aswe talk about clinical
application, like I'll I'll be able to talk a little more of
what I like to do for labour andbut yeah, that crank I'm like,
yeah, like I. Do it to do it.
(19:29):
Just to do it. But honestly, like, yeah, no,
I've never felt like, I've neverfelt anything.
They've never complained. Like sometimes they'll be like,
oh, like it's like maybe they don't want me to get in that
full like internal extra rotation, but not like a
positive test for sure. So finally going into our
(19:50):
rotator cuff and we kind, I kindof broke it down into just kind
of different muscles. So supraspinatus if anything, I
think the rotator cuff test actually performed the best out
of all the pathologies like so we should be able to identify
rotator cuff tear pretty good. We don't really see that many,
(20:10):
no. But theoretically we should be
able to. That was the one problem with
like rotator cuff tears. It's like that tends to be like
older population ish. Then like maybe like again,
traditional setting of like college athlete, high school
athlete, but still something important to know.
And maybe you can find some things with like rotator cuff
(20:32):
strains. All right, so you had a job's
test, which I was like, what thehell is that?
That's empty can. I did not know it as jobs, so I
did have to look that one up. I'm like, oh, all right, good to
know. Yeah.
So that's empty can. Sensitivity was 88% and then
(20:53):
specificity was 62%. So again, that's leading to 2.3
on positive likelihood ratio and1.9 you feel like a lot.
Of these have a higher sensitivity to rule things out,
yeah. You, you feel a lot better about
it. Oh well.
Not that, not that, not that. Full can did better sensitivity
(21:14):
of 70%, specificity of 81. OK, I'll take, I'll take.
A specificity higher, yeah, for.Sure.
And then again that led to a positive likelihood ratio 3.75,
negative likelihood ratio of .37, right.
So that's pretty solid. What do you?
Use full can for. Supraspinatus.
So I like to do it for like testing supraspinatus strength.
(21:36):
I feel like and integrity I have.
I have three different programs that I've worked with for
students and some of them have different full can pathologies.
What? Do you mean?
Like some like some people use full can and empty can for like
(22:00):
impingement, some people use it for like bicep, some people use
it for AC joint. Interesting.
Yeah. That's very interesting, right?
She's always like. Yeah, I've always known as Super
Spinatus. That's interesting.
I could see that with like O'Brien's right too.
(22:21):
Like O'Brien's like I think it was originally supposed to be
for like slap tear but then likeit does really good for AC
joint. Yeah, yeah.
Well, I mean it kind of makes sense you're crossover and then
put it, you know putting pressure on it, it's going to
start jamming in the AC joint. And then finally for
(22:45):
supraspinatus we have drop arm which sensitivity was 24% not
great specificity 96%. Oh, here the.
Positives here that rules in what?
Which one's drop arm? That's the one where like
they're had, they have their armat 90° and then they slowly,
they're supposed to slowly breathe their arm back down to
their side, not like. They don't start like at the top
(23:08):
it. When I read about it, it
literally just specifically saidat 90 and down and a positive is
like if their arm just like falls or they just can't control
that motion. So positive likelihood ratio was
6.45, negative likelihood ratio .79.
So that again, at least positivewise, hey, if you got a positive
(23:29):
test, you're like so. Supraspinatus, we can count on
the positives. Everything else, you're kind of
yeah, if it's. Negative.
Well, that you're still in the weeds, right?
Then moving into infraspinatus, Basically all these tests had an
awful sensitivity, like they were bad, like we're talking
(23:51):
like 12%. Yeah.
So just because it's negative does not mean infraspinatus is
not damaged. But if it's positive,
infraspinatus is damaged. The best test that was kind of
reported was external rotation lag at 0°.
So that's the one where they're at 0° of AB duction.
They're an external rotation. You gently, like you basically
(24:13):
push against them. You don't have.
Any shoulder AB duction? No, this was truly at 0.
Oh. Interesting.
I do it with some reduction. That's how I normally do it.
But yeah, this was at 0. You just basically push and then
you let go and then if they start to lose it and they start
to literally just start to drop into internal rotation, that
would be the positive specificity was 98%.
(24:38):
Wow. And that that led to a
likelihood ratio of 6 point O 6.So again, one of the higher
tests we're we're. Climbing.
Yeah, we're climbing. And then one that surprisingly
there was a lot of research on is looking at subscap.
And again, as with kind of most things, a combination of tests
was recommended. They use the bear hug, which
(25:01):
when I think bear hug, I'm literally thinking like, oh,
you're wrapping your arms like both arms around.
Like no, it's not that intense. It's literally just there the
test, the hand that the arm thatyou're testing touches like
holds on to the opposite shoulder.
So if I'm testing my right, I would hold my left shoulder and
then basically you're trying to pull them away like you're
(25:21):
trying to pull their elbow up and off like their shoulder.
That's bear hug and then belly press them pushing into into
their their abdomen. That had positive likelihood
ratio of 18.29. I thought you could only go.
Up to 10. Oh wait, closer to 10.
Is better. Oh.
Wow, yeah. And then a negative likelihood
(25:44):
ratio of .2. So a lot of.
Research on this one, yes. Seriously.
So overall, just like that's just those are the numbers.
So now I feel like clinically like we all have our own again,
based on the test that we like, we do that we feel comfortable
with. And I feel like a few of those I
(26:05):
do, like I said, like I like to do full can, I'll do empty can.
Do you do empty can? Uh huh.
Yeah, I'll do. It but I'm like, yeah.
I don't really, I think I do it not necessarily for the positive
negative like of ruling something in ruling something
(26:27):
out. I think I do it as part of my
eval to more just see their motion to like, oh, if I change
this like, well, how does it change your test?
You know, like it gives me a little bit more to the full can
for me, I feel like. Empty.
Can I feel more just like I'm trying to see, I'm trying to
(26:47):
identify impingement. I feel like, I feel like I'm not
really testing, testing the integrity of super spinners.
I feel like I'm just testing, like oh can I just elicit pain?
I do a ton of impingement tests because I feel like, again,
that's like a lot of what we see.
Yeah. For.
Sure, for sure. I think the one that is pretty
(27:09):
variable is labrum. Like for me, like I really don't
use a ton of special tests. I really like just like joint
translation for labrum because Ifeel like I can actually feel it
shift out or maybe I can feel itcatch.
So I do a lot of translations for labrum and I've found some
pretty good success doing that, like just being able to do, oh,
(27:32):
do anterior translation, Antero inferior, like translation and
actually see if I can catch certain areas.
And it has also helped me with like laxity and instability
because like I'll feel it kind of shift out or I'll feel them
guard like I actually feel theirmuscles like fire or like it
gets like you can all of a sudden see their shoulder going
(27:52):
with it. I'm like, bro, does that make
you nervous? And then I think too, when we
evaluate shoulder, right, another thing again, we're not
just looking at the shoulder, right, evaluating the scapula as
well, right? Understanding, like it take
impingement, right? The understanding of why could
we be seeing impingement issues?Or maybe we just don't have good
rhythm. And this is where a lot of like
(28:13):
the scapular tests can come intoplay.
So scapular assistance, so that tests like they're going into
like I think it's like a reduction and flexion, shoulder
flexion, the patient and you basically are helping upwardly
rotate the scapula and if that takes away their pain, you're
like, oh, it's because you don'tdo that very well.
(28:35):
So that's what we have to train.Yeah, that's what we have to
work on. Or even like the scapula
retraction test, which you have them in scaption and then you'd
like test their strength. And if, if this test is
positive, I could be weak. But if you were to put the
scapula into retraction and thentest it and all of a sudden
they're strong, you're like, oh,well, that's the problem.
Your scapula is not set. So your rotator cuff muscles
(28:58):
aren't stabilizing the shoulder very well, right?
So those tests can give you a kind of an indicator of like,
oh, we need to work on scap stuff too.
And of course, visual inspectionor I feel like we all kind of do
this where we're watching and being like, oh, whoa, oh, you
see a flare there? You see a wing, right?
But what's interesting is like research has shown like it's,
(29:21):
we're not really good at using that to say this is your
diagnosis, like, oh, Scapula's doing that impingement, right?
But that doesn't mean it's not important, right?
I still think it's important to kind of help understand, paired
with their history, paired with their test that you've already
(29:41):
done to say, oh, this is the structure that's damaged, to
understand that, oh, this is a problem.
This might be the contribution we need to fix this.
It's all pieces to the puzzle. And I think that's why like we
were talking about earlier, likewhen I do empty can, it's not
necessarily for a positive negative or like some of these
things. It's not necessarily for trying
(30:04):
to rule in or rule out. It's more like comprehensive in
your in your evaluation for sure.
For sure. Do you have an action?
Item for this. I think at the end of the day,
like pick the test that you're comfortable with.
I mean, don't pick like like do your best to pick like something
that does have really strong stats with it.
(30:27):
But at the end of the day, like they didn't do a study on you,
right, on how your test performed.
So I think it's important that you pick a test that you feel
like you can execute comfortablyand that you have really liked
the results that you've seen if you ever have.
The chance to watch Randy do hisshoulder evaluation.
It is like beautiful, like artistry, like the way that the
(30:51):
way that you move like your arm and the and your patient's arm
is just like so smooth. Oh, thanks.
Sometimes. That drives me nuts when they're
not relaxed and then I have to. It slows down the flow.
I'm like bro, relax. So this is a CEO episode like we
said before. So if you would like ACU
(31:12):
certificate, make sure you Scroll down the show notes or
episode description wherever you're listening to this or
watching on YouTube or Spotify. We have the links below.
We also have different episodes that you can listen to other
than CU episodes. We have story episodes with
stories from real life athletic trainers all over the world.
(31:35):
And we also have spotlight interviews where we bring on
highlight topics from someone who is more of an expert in that
area than we are. So with that, I think we're
going to keep the fine print short today.
Thank you for helping us. Showcase athlete training behind
the tape Bye.
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