What is the Hawkins test?

What is the Hawkins Test

The Hawkins test is a clinical shoulder examination maneuver used to screen for subacromial impingement syndrome, performed by passively flexing the patient's shoulder to 90° and then internally rotating the arm, which reproduces pain by mechanically compressing the supraspinatus tendon against the coracoacromial arch. 1, 2

Test Technique

The examiner performs the following standardized steps:

• Position the patient's shoulder in 90° of forward flexion 2
• Passively internally rotate the arm while maintaining the 90° flexion position 2
• A positive test occurs when this maneuver reproduces the patient's shoulder pain 1, 3

The test works by narrowing the subacromial space and forcing the supraspinatus tendon against the coracoacromial arch, reproducing the mechanical impingement that becomes symptomatic with repetitive overhead activities. 1

Diagnostic Performance

Sensitivity and Screening Value

• The Hawkins test demonstrates high sensitivity of 79-92% for detecting subacromial impingement syndrome 1, 3, 4
• This makes it an excellent screening tool—a negative test effectively rules out impingement 1
• When combined with the Neer test, the negative predictive value reaches 96% for subacromial bursitis 4

Specificity Limitations

• The test has poor specificity of only 25-59%, meaning many false positives occur 1, 3
• The Hawkins test detects impingement as a pathogenic process but cannot definitively identify the specific anatomic structures involved 1, 5
• Imaging with ultrasound or MRI is required for definitive anatomic diagnosis 1

Clinical Reliability

The Hawkins test demonstrates acceptable reproducibility when performed with standardized technique:

• Intra-observer reliability is moderate with kappa coefficient of 0.56 5
• Inter-observer reliability is moderate with kappa coefficient of 0.54 5
• When standardized protocols are used, the test achieves almost perfect agreement with kappa coefficients of 0.91-1.00 6

Clinical Application Algorithm

When to Use the Hawkins Test

Use this test as part of the initial evaluation when patients present with:

• Shoulder pain with overhead activities 1, 2
• Tenderness over the greater tuberosity 2
• Pain with repetitive abduction and internal rotation movements 1

Interpretation Framework

If Hawkins test is POSITIVE:

• Proceed with additional testing (Neer test, strength assessment) 2
• Order plain radiographs as first-line imaging to rule out fracture, calcific tendinitis, or bony abnormalities 2
• Initiate conservative management with NSAIDs and activity modification 2
• Reserve MRI for cases where symptoms persist beyond 2-3 months of conservative treatment 2

If Hawkins test is NEGATIVE:

• Combined negative Hawkins and Neer tests make subacromial impingement unlikely 4
• Consider alternative diagnoses for shoulder pain 3

Common Pitfalls

• Do not rely on the Hawkins test alone for definitive diagnosis—its poor specificity means positive results require confirmation 1, 3
• The test identifies impingement as a process but cannot distinguish between subacromial bursitis, partial rotator cuff tears, or complete tears 5, 4
• Ensure standardized technique with consistent shoulder positioning at exactly 90° flexion to maximize reliability 6
• The test's sensitivity and specificity values mean it functions best as a screening tool rather than a confirmatory diagnostic test 1, 3