Neer and Hawkins Tests: Performance and Interpretation
The Neer and Hawkins-Kennedy tests are highly sensitive (75-92%) but poorly specific screening maneuvers for subacromial impingement syndrome—use them primarily to rule out rotator cuff pathology when negative, but always confirm positive findings with imaging (MRI or ultrasound) before definitive treatment.
Test Performance Technique
Neer Impingement Sign/Test
- Position: Stabilize the scapula with one hand
- Maneuver: Passively forward flex the patient's arm to maximum elevation while internally rotating the shoulder
- Mechanism: Forces the greater tuberosity and rotator cuff against the anterior acromion 1
- Anatomic contact: Creates impingement between soft tissues and the medial acromion, plus contact between the articular surface of rotator cuff tendons and anterosuperior glenoid rim 1
Hawkins-Kennedy Test
- Position: Forward flex the shoulder to 90 degrees, elbow flexed to 90 degrees
- Maneuver: Passively internally rotate the shoulder by lowering the forearm
- Mechanism: Drives the greater tuberosity under the coracoacromial ligament 1
- Anatomic contact: Consistent contact between soft tissues and the coracoacromial ligament, with impingement of the rotator interval at the anterior acromion 2, 1
Positive test: Reproduction of the patient's pain during either maneuver
Diagnostic Performance
Sensitivity and Specificity
The Hawkins test demonstrates superior sensitivity compared to Neer:
- Hawkins sensitivity: 88-92% for rotator cuff pathology 3
- Neer sensitivity: 75-85% for rotator cuff pathology 3, 4
- Combined specificity: Poor (approximately 63%), barely exceeding pretest probability 3, 4
Reliability
When performed with standardized technique, both tests show excellent reproducibility:
- Intra- and inter-examiner reliability: Kappa coefficients 0.91-1.00 5
- This high reliability makes them consistent screening tools, though not definitive diagnostic tests
Clinical Interpretation Algorithm
When Tests Are Negative (Both Neer AND Hawkins)
- High negative predictive value: 90-96% 3
- Action: Subacromial impingement and rotator cuff tears are unlikely; consider alternative diagnoses
When Tests Are Positive (Either or Both)
- Positive predictive value: Only 90% 3—not sufficient for definitive diagnosis
- Action: Proceed directly to imaging:
Critical Caveats
Structural Discrimination Limitations
These tests are limited as structural discriminators 5—they cannot reliably differentiate between:
- Subacromial bursitis
- Partial-thickness rotator cuff tears
- Full-thickness rotator cuff tears
- Biceps tendon pathology
- Rotator interval lesions
Anatomic studies reveal why: The Hawkins test may impinge structures other than rotator cuff tendons, including biceps brachii and the rotator interval 2. Both tests create contact patterns involving multiple structures simultaneously 1.
Diagnostic Accuracy Varies by Pathology
- Highest accuracy: Partial supraspinatus tears (90% sensitivity) 4
- Lower accuracy: Isolated subacromial bursitis (70.4% diagnostic accuracy) 4
- Overall diagnostic accuracy: 76-81.6% depending on underlying pathology 4
Clinical Application Strategy
- Use as screening tools: Perform both tests in all patients with shoulder pain suspicious for impingement
- Interpret negative results confidently: Combined negative tests effectively rule out rotator cuff pathology
- Never rely on positive results alone: Always obtain imaging (MRI or ultrasound) before surgical intervention or prolonged conservative management
- Standardize technique: Use consistent positioning and stabilization to maximize reliability 5
- Consider pretest probability: These tests add limited value when pretest probability is already high or low
The fundamental principle: These are sensitive screening maneuvers with excellent negative predictive value, making them most useful for ruling out impingement rather than confirming it 3.