What is Neer's special test used for and how is a positive result treated?

Neer's Special Test: Diagnosis and Treatment of Rotator Cuff Impingement Syndrome

Neer's special test is used to diagnose subacromial impingement syndrome of the rotator cuff, and positive results should be treated with a combination of conservative measures including NSAIDs, physical therapy with eccentric exercises, and possible corticosteroid injections, with surgery reserved for cases that fail to respond to 3 months of appropriate treatment.

Diagnostic Purpose and Technique

Neer's test is designed to identify subacromial impingement syndrome (SIS), which occurs when the supraspinatus tendon is compressed between the humeral head and the coracoacromial arch during shoulder movement.

The test is performed by:

• Stabilizing the scapula with one hand
• Using the other hand to forcibly flex the patient's arm forward between 70 and 120 degrees
• A positive test is indicated by pain during this maneuver

Diagnostic Accuracy

• Neer's test has high sensitivity (88.7%) but low specificity (33%) 1, 2
• This means it's excellent for screening (ruling out impingement when negative) but less reliable for confirming the diagnosis when positive
• The test is more valuable when combined with other impingement tests:
  • Hawkins test (92.1% sensitivity)
  • Painful arc test (80.5% specificity)
  • Empty can test (Jobe test)
  • External rotation resistance test 3

Research shows that having 3 or more positive tests out of 5 common impingement tests significantly improves diagnostic accuracy for subacromial impingement syndrome 3, 4.

Treatment Algorithm for Positive Neer's Test

First-Line Treatment (0-6 weeks)

1. Pain Management

   • NSAIDs as first-line medication 5
   • Cryotherapy in the first week to reduce pain 5

2. Initial Physical Therapy (Phase 1)

   • Pain control measures
   • Gentle range of motion exercises within pain-free range
   • Proper positioning education 5
   • Isometric exercises for muscle reactivation if no pain is present 5

Second-Line Treatment (6 weeks-3 months)

1. Progressive Rehabilitation (Phase 2)

   • Progressive ROM exercises
   • Light strengthening exercises for rotator cuff and periscapular muscles
   • Scapular stabilization exercises 5

2. Additional Interventions

   • Corticosteroid injections for significant pain (limited to 3-4 per year to avoid tendon weakening) 5
   • Technique modification for athletes and manual laborers to minimize repetitive stress 1

Third-Line Treatment (After 3 months of failed conservative management)

1. Advanced Rehabilitation (Phase 3)

   • Progressive resistance training
   • Advanced scapular stabilization
   • Sport or activity-specific training 5

2. Surgical Consideration

   • Referral for surgical consultation if no improvement after 3 months of appropriate rehabilitation 1, 5
   • Surgical techniques typically include excision of abnormal tendon tissue and performance of longitudinal tenotomies to release areas of scarring and fibrosis 1

Clinical Pearls and Pitfalls

• Important caveat: A single positive impingement test has limited diagnostic value; combining multiple tests significantly improves accuracy 3, 4
• Modified Neer Test: A modified version of the Neer test has been shown to have higher specificity (95.56%) and accuracy (90.59%) in distinguishing impingement from frozen shoulder 6
• Prognostic value: Patients with positive Neer's test have shown greater improvement in Constant scores after subacromial decompression compared to those with negative tests 4
• Avoid overreliance: Due to its high sensitivity but low specificity, a positive Neer's test should be corroborated with other clinical findings and possibly imaging before initiating invasive treatments
• Treatment response evaluation: Clinical reassessment should occur at 6 weeks to evaluate progress, with consideration of imaging or surgical consultation if symptoms worsen or do not improve by 3 months 5

Remember that supervised physical therapy shows better outcomes than unsupervised home exercise programs for patients with rotator cuff impingement 5.