How do I perform the Hawkins (Hawkins test) and Neer's (Neer test) tests on an adult patient with suspected impingement syndrome?

How to Perform the Hawkins and Neer Tests for Shoulder Impingement

The Hawkins test is performed by flexing the shoulder forward to 90 degrees and then forcibly internally rotating the arm, while the Neer test is performed by passively elevating the arm in forward flexion while stabilizing the scapula. 1

Hawkins Test Technique

Position the patient's shoulder at 90 degrees of forward flexion, then forcibly internally rotate the arm to compress the supraspinatus tendon against the anterior acromion. 1

Key Technical Points:

• The arm should be flexed forward at exactly 90 degrees before applying internal rotation 1
• This maneuver narrows the subacromial space and creates contact between the supraspinatus and infraspinatus tendons with the acromion 2
• The test can also be performed with the arm in an abducted position as a variant 3
• A positive test reproduces the patient's anterior or anterolateral shoulder pain 1

Test Performance Characteristics:

• Sensitivity: 92% 1
• Specificity: 25% 1
• The high sensitivity makes this test excellent for ruling out impingement when negative, but poor specificity means many false positives occur 1
• Moderate intra-observer reproducibility (kappa 0.56) and inter-observer reproducibility (kappa 0.54) 4

Neer Test Technique

Stabilize the patient's scapula with one hand, then passively elevate the arm in forward flexion (in the scapular plane) to compress the rotator cuff against the anteroinferior acromion. 1

Key Technical Points:

• The examiner must stabilize the scapula to prevent scapulothoracic compensation 1
• The arm is elevated in the plane of the scapula (approximately 30 degrees anterior to the coronal plane) 2
• Maximum elevation should be attempted to fully compress the subacromial space 2
• A positive test reproduces the patient's pain during elevation beyond 90 degrees 1, 5

Test Performance Characteristics:

• Sensitivity: 88% 1
• Specificity: 33% 1
• Good inter-observer reproducibility (kappa 0.64) but poor intra-observer reproducibility 4
• Like the Hawkins test, high sensitivity but low specificity limits diagnostic utility 1

Critical Interpretation Caveats

Internal Impingement Confounding:

• Both tests can provoke internal impingement mechanisms, potentially causing false positive results 6, 2
• The Neer test creates posterosuperior internal impingement with supraspinatus contact against the posterior glenoid in most subjects 6, 2
• The Hawkins test creates anterosuperior internal impingement with subscapularis and supraspinatus contact against the anterior glenoid 6, 2
• This means a positive test may reflect intraarticular pathology rather than subacromial impingement 2

Clinical Context Requirements:

• Pain specifically during overhead activities and abduction beyond 90 degrees supports true subacromial impingement 1, 5
• Pain only with movement (not at rest) suggests mechanical impingement rather than inflammatory arthropathy 5
• The presence of multiple positive impingement tests (≥4 out of 5 tests) has greater predictive value for surgical outcomes than isolated positive tests 3

Diagnostic Limitations:

• Neither test reliably determines the specific location or extent of rotator cuff lesions 7
• Poor specificity means these tests cannot confirm impingement diagnosis in isolation 1, 7
• Imaging (ultrasound or MRI) is required for definitive diagnosis and should never be omitted based solely on clinical testing 1, 5

Practical Algorithm for Test Interpretation

When both Hawkins and Neer tests are positive in a patient with anterolateral shoulder pain worsening with overhead activities, subacromial impingement is likely but requires imaging confirmation. 1, 5

• If both tests are negative, subacromial impingement is effectively ruled out (high sensitivity) 1
• If either test is positive, proceed to imaging (ultrasound or MRI) to confirm diagnosis and assess rotator cuff integrity 1, 5
• Consider alternative diagnoses (internal impingement, rotator cuff tears, glenohumeral pathology) if clinical presentation doesn't match typical impingement pattern 1, 6