What special test should I perform for suspected subacromial impingement of the shoulder joint?

Special Tests for Suspected Subacromial Impingement of the Right Shoulder

For suspected subacromial impingement of the right shoulder joint, the Hawkins-Kennedy impingement test, Neer impingement sign, and painful arc test should be performed as they have the highest sensitivity and reliability for detecting this condition.

Primary Diagnostic Tests for Subacromial Impingement

High Sensitivity Tests

1. Hawkins-Kennedy Impingement Test

   • Technique: Flex the shoulder and elbow to 90°, then internally rotate the shoulder
   • Performance: 92.1% sensitivity 1
   • Reliability: Moderate to substantial agreement (kappa=0.39-0.40) 2

2. Neer Impingement Sign

   • Technique: Stabilize the scapula while passively flexing the arm in internal rotation
   • Performance: 88.7% sensitivity 1
   • Reliability: Fair strength of agreement (kappa=0.39-0.40) 2
   • Note: A modified Neer test has shown improved diagnostic accuracy (90.59%) and specificity (95.56%) 3

3. Painful Arc Test

   • Technique: Patient actively abducts the arm, noting pain between 60-120° of abduction
   • Performance: Sensitivity varies, but shows good positive likelihood ratio (+LR=2.25) 2
   • Reliability: Moderate to substantial agreement (kappa=0.45-0.67) 2

High Specificity Tests

1. Empty Can (Jobe) Test

   • Technique: Arms at 90° abduction, 30° forward flexion, thumbs pointing down, resist downward pressure
   • Performance: High positive likelihood ratio (+LR=3.90) 2
   • Reliability: Moderate to substantial agreement (kappa=0.45-0.67) 2

2. External Rotation Resistance Test

   • Technique: Arms at sides, elbows flexed 90°, resist external rotation
   • Performance: Highest positive likelihood ratio (+LR=4.39) 2
   • Reliability: Moderate to substantial agreement (kappa=0.45-0.67) 2

Diagnostic Algorithm

1. Start with high sensitivity tests:

   • Hawkins-Kennedy test
   • Neer impingement sign
   • Painful arc test

2. Follow with high specificity tests:

   • Empty can (Jobe) test
   • External rotation resistance test

3. Interpret results using the 3/5 rule:

   • If 3 or more tests are positive out of these 5 tests, this confirms the diagnosis of subacromial impingement syndrome
   • If fewer than 3 tests are positive, this effectively rules out subacromial impingement syndrome 2

Clinical Pearls and Pitfalls

• Standardization is crucial: All four maneuvers (Neer, Hawkins-Kennedy, Patte, and Jobe) have shown almost perfect agreement (Kappa 0.91-1.00) when performed with proper standardization 4

• Avoid over-reliance on a single test: Individual tests have limitations as structural discriminators, so using a combination improves diagnostic accuracy 4, 2

• Consider timing of presentation: Patients with longer duration of symptoms before treatment have poorer outcomes with conservative management (b = -4.4,95% CI: from -7.2 to -1.6) 5

• Assess acromial morphology: Type II or III acromion is associated with poorer outcomes with conservative management and may require more invasive interventions 5

• Remember these tests identify pain patterns: These tests are highly reproducible for identifying subacromial pain but have limitations as structural discriminators 4