Hawkins' Test and Neer's Test Are Positive in Shoulder Impingement
The Hawkins' test and Neer's test are the two primary physical examination maneuvers that are positive in shoulder impingement, though both are highly sensitive (79-92%) but poorly specific (25-59%), meaning they are better at ruling out impingement when negative than confirming it when positive 1.
How to Perform These Tests
Hawkins' Test
- Technique: Passively flex the patient's arm forward to 90 degrees, then forcibly internally rotate the humerus
- Positive result: Elicits pain
- Diagnostic accuracy: 92% sensitivity, 25% specificity 1
- Clinical utility: Excellent for ruling out impingement when negative
Neer's Test
- Technique: Perform full forward flexion of the arm, particularly observing between 70-120 degrees
- Positive result: Elicits pain during this motion
- Diagnostic accuracy: 79-88% sensitivity, 33-63% specificity 1, 2, 3
- Clinical utility: Good screening test to rule out impingement when negative 4
Understanding the Diagnostic Limitations
A critical pitfall is over-relying on a single positive test to confirm impingement. The poor specificity means many false positives occur. Recent evidence suggests:
- For ruling OUT impingement: A negative Neer's test is useful (negative likelihood ratio 0.35) 4
- For ruling IN impingement: You need ≥3 positive tests out of 5 standard tests (Neer, Hawkins-Kennedy, painful arc, empty can, external rotation resistance) to achieve acceptable diagnostic accuracy 4
Additional Tests to Consider
While Hawkins' and Neer's are the classic impingement tests, combining them with other maneuvers improves accuracy:
- Painful arc test: Pain during active abduction between 60-120 degrees (positive likelihood ratio 2.25) 4
- External rotation resistance test: Better specificity than Neer's or Hawkins' (positive likelihood ratio 4.39) 4
- Empty can (Jobe) test: Highest positive likelihood ratio at 3.90 for confirming impingement 4
Clinical Algorithm
- Start with Neer's and Hawkins' tests as initial screening maneuvers
- If both are negative: Impingement is unlikely; consider alternative diagnoses
- If either is positive: Add painful arc, empty can, and external rotation resistance tests
- Confirm impingement diagnosis: Requires ≥3 out of 5 tests positive 4
- Consider imaging: MRI or ultrasound are equivalent for evaluating underlying rotator cuff pathology when clinical suspicion is high 5
Important Caveats
The mechanism of impingement involves the supraspinatus tendon being compressed against the coracoacromial arch during abduction with internal rotation 1. However, these tests cannot distinguish between primary impingement (structural) and secondary impingement (from rotator cuff weakness or instability) 6. In younger athletes, secondary impingement from rotator cuff dysfunction is more common and requires different treatment approaches focused on strengthening rather than decompression 6.
The Viggo-Cochin test, a newer modification of the Neer test, may better predict response to physiotherapy with dynamic humeral centering, though it requires further validation 7.