What Positive Neer and Hawkins Tests Indicate
Positive Neer and Hawkins tests indicate subacromial impingement syndrome, which encompasses a spectrum of pathology from subacromial bursitis to partial or complete rotator cuff tears. 1, 2
Primary Clinical Interpretation
Both tests detect subacromial impingement as a pathogenic process by reproducing mechanical compression of the supraspinatus tendon against the coracoacromial arch during specific shoulder movements. 1, 2, 3
Test Mechanics and Performance
The Hawkins test elicits pain with forcible internal rotation while the arm is passively flexed forward at 90 degrees, demonstrating 92% sensitivity but only 25% specificity for impingement. 1
The Neer test elicits pain with full forward flexion between 70 and 120 degrees while stabilizing the scapula, showing 88% sensitivity but only 33% specificity for impingement. 1, 2
Recent validation confirms the Neer test has 79% sensitivity, 63% specificity, and 76% overall diagnostic accuracy when compared against MRI as the gold standard. 4
Critical Diagnostic Limitations
These tests are highly sensitive screening tools but lack specificity—meaning they effectively rule out impingement when negative but cannot confirm the specific underlying pathology when positive. 1, 2, 5
Understanding Test Performance
The combined negative predictive value is 96% for bursitis and 90% for rotator cuff tears when both tests are negative, making them excellent for exclusion. 5
Positive predictive values are low (not much higher than pretest probability), meaning a positive test requires additional diagnostic workup. 5
Specificity ranges from 25-59% for Hawkins and 33-53% for Neer, indicating many false positives occur. 2
Differential Diagnosis Requiring Imaging
When either test is positive, the following conditions must be distinguished through imaging:
Subacromial bursitis presents with inflammatory changes visible on ultrasound or MRI. 1, 5
Rotator cuff tendinopathy shows tendon thickening and degeneration without discontinuity on imaging. 6
Partial-thickness rotator cuff tears demonstrate the highest sensitivity (90%) with the Neer test but still require MRI confirmation. 4
Full-thickness rotator cuff tears require definitive imaging for surgical planning. 6
Recommended Diagnostic Algorithm
When either test is positive, proceed with imaging rather than assuming a specific diagnosis. 6, 2
Imaging Sequence
Obtain plain radiographs first to exclude bony pathology including acromial morphology, though they cannot visualize tendon tears. 6
Use ultrasound as the initial soft tissue imaging modality for suspected full-thickness tears, with 91% sensitivity and 88% specificity. 6
Order MRI without contrast when diagnosis remains unclear or surgical planning is needed, providing 95% sensitivity and specificity. 6
Clinical Pitfalls to Avoid
Do not assume a positive test indicates a structural tear requiring surgery—the tests detect impingement as a mechanical process, not necessarily structural damage. 3, 5
Age-Specific Considerations
In younger athletes, positive tests more commonly indicate secondary impingement from rotator cuff weakness and scapular dyskinesis rather than structural tears. 6
In older patients, positive tests have higher likelihood of representing degenerative rotator cuff disease or tears. 1
Treatment Implications
Partial-thickness tears require 3-6 months of conservative management before considering surgery, regardless of positive impingement signs. 6
The Viggo-Cochin test may better predict response to dynamic humeral centering physiotherapy than the Neer test alone, with 5-fold higher response rates when positive. 7
Test Reliability
Both tests demonstrate high reproducibility when performed with standardized technique, with kappa coefficients of 0.91-1.00 for intra- and inter-examiner reliability. 8