What are Hawkins and Neer's tests?

Hawkins and Neer Tests for Subacromial Impingement

The Hawkins and Neer tests are highly sensitive (79-92%) but poorly specific (25-59%) physical examination maneuvers used to screen for subacromial impingement syndrome and rotator cuff tendinopathy. 1, 2, 3

Test Techniques

Hawkins Test

• Position the patient's arm in 90 degrees of forward flexion 1
• Apply forcible internal rotation of the humerus while maintaining this position 1
• A positive test elicits pain, indicating subacromial impingement 1
• Sensitivity: 79-92% 1, 2, 4
• Specificity: 25-59% 1, 2, 3

Neer Test

• Passively elevate the patient's arm in full forward flexion 1
• Pain occurring between 70-120 degrees of elevation indicates a positive test 1
• Sensitivity: 79-89% 1, 2, 4
• Specificity: 33-53% 1, 2, 3

Clinical Interpretation and Utility

These tests are best used as screening tools to rule out subacromial impingement when negative, rather than to confirm the diagnosis when positive. 2, 3

Diagnostic Performance

• Both tests demonstrate high sensitivity but poor specificity, meaning they effectively identify patients who may have impingement but generate many false positives 1, 3, 4
• The negative likelihood ratios (0.35 for Neer, variable for Hawkins) make them useful for ruling out disease when negative 2
• The positive likelihood ratios are insufficient to confirm diagnosis based on these tests alone 2, 3

Reliability Considerations

• Intra-observer reproducibility is poor to moderate (kappa 0.48-0.64) 5
• Inter-observer reproducibility ranges from poor to good depending on the examiner 5
• The Hawkins test shows fair to moderate agreement (kappa 0.39-0.56) between examiners 5, 2

Clinical Application Algorithm

When evaluating for subacromial impingement:

1. Perform both Hawkins and Neer tests along with painful arc, empty can, and external rotation resistance tests 2
2. If 3 or more of these 5 tests are positive, this confirms subacromial impingement syndrome with acceptable diagnostic accuracy (AUC=0.79) 2
3. If fewer than 3 tests are positive, subacromial impingement is effectively ruled out 2
4. A negative Neer test alone has sufficient negative predictive value to help exclude impingement 2

Important Caveats

• These tests cannot determine the specific location or type of rotator cuff lesion (supraspinatus vs. infraspinatus vs. subscapularis involvement) 6
• Positive tests do not correlate with tear size in patients with rotator cuff defects 6
• The tests detect impingement as a pathogenic process but require imaging (ultrasound or MRI) for definitive anatomic diagnosis 1
• Specificity is particularly poor (25-33%), meaning many patients without true impingement will test positive 1, 3

Underlying Mechanism

The tests work by reproducing the mechanical impingement of the supraspinatus tendon against the coracoacromial arch during combined abduction and internal rotation movements 1. This narrow anatomic space becomes symptomatic with repetitive overhead activities in athletes and manual laborers 1.