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A Review of Hawkins-Kennedy and Neer’s Tests for Should Impingement Syndrome
By: Chris Schepel
Grand Valley State University
7 December, 2012
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Context
Shoulder Impingement syndrome (SIS) is one of the most common causes for
shoulder pain. Of the population that sees a doctor for shoulder pain, SIS is the diagnosis
40% of the time7. According to Starkey, et al.5 impingement occurs when there is a
decreased space through which the rotator cuff muscle tendons pass under the
coracoacromial arch. The space where impingement occurs most often is deep to the
acromion and is referred to as the sub-acromial space. The structures that make up the
sub-acromion space that are commonly involved in SIS are the long head of the biceps
brachii, supraspinatus tendon, sub-acromial bursa, acromion process, and the
coracoacromial ligament5. The most common causes of impingement are, but not limited
to, an irregularly shaped acromion, inflammation of the sub-acromial bursa, thickening or
enlargement of the rotator cuff tendons, repetitive overhead movements, glenohumeral
instability and poor posture5.
Objective
Hawkins-Kennedy and Neer’s are two tests that are commonly used to diagnose
SIS. The question that will be attempted to answer in this paper is, “For a patient who is
complaining of shoulder pain due to SIS, which special test, Hawkins-Kennedy or
Neer’s, more accurately diagnoses SIS based on sensitivity, specificity and accuracy?”
The method for determining which test more accurately diagnoses SIS is examining each
test’s sensitivity and specificity. When taking a look at each test’s sensitivity and
specificity, the higher the score, the more accurate the test. If a test has a high sensitivity
and a high specificity the test is more accurate at diagnosing the injury and the likelihood
of a false-positive or a false-negative are much lower. Taking a look at the sensitivity and
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specificity for Hawkins-Kennedy and Neer’s will be used to determine which test more
accurately diagnoses SIS.
Data Sources
The information that was gathered and used to compare Hawkins-Kennedy and
Neer’s was found using online databases such as PubMed and CINAHL. Articles related
to SIS were found on these databases using specific key words, such as; shoulder
impingement syndrome, sub-acromial bursitis, Hawkins-Kennedy, Neer’s, supraspinatus
and tendonitis. There were no specific limitations used in searching for articles, such as
timeframe and subjects chosen for the study.
Study Selection
Studies that review the Hawkins-Kennedy and Neer’s special tests for SIS were
chosen for this paper. The articles that were collected comprised of studies reviewing
each special test for SIS or systematic reviews and meta-analysis of studies on SIS
special tests. Content of these studies ideally included the sensitivity, specificity and
validity for each of the special tests as a basis for comparison to determine which test was
more effective in diagnosing SIS.
Data Extraction
Hawkins-Kennedy and Neer’s are two common tests for SIS. Hawkins Kennedy
has the patient’s elbow and shoulder flexed to 90 degrees and then the examiner
internally rotates the humerus 7.A positive test would be reproduction of impingement
symptoms such as pain or a pinching feeling in the posterior shoulder. Neer’s has the
patient standing and the patient’s arm is elevated while the scapula is being stabilized.
The reproduction of pain at the anterior portion of the shoulder is considered a positive
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test for SIS 7.There is a slight variance in the execution of the Neer’s special tests. Some
studies had the arm passively forward flexed, while others had the arm elevated in the
plane of the scapula. Of the studies that were chosen for this paper comparing HawkinsKennedy to Neer’s, six tested the specificity, sensitivity and validity of each special test,
One study took 69 healthy patients, 48 women and 21 men with a mean age of 48,
with a clinical diagnosis of unilateral subacromial impingement6. For the patients to
qualify for the study, they must have experience unilateral shoulder pain for more than
six months, normal ranges of motion and no history of shoulder surgery. These patients
underwent Neer’s, Hawkins-Kennedy and palpation tests to determine the presence of
SIS6. They recorder both positive and negative results for each special test, they then used
these along with a sonographic examination, as a follow up test, to determine the
sensitivity, specificity and accuracy of the three tests performed. These results were then
compared with results of previous studies on the sensitivity and specificity of special tests
used to diagnose SIS.
Another study examined the inter-examiner reproducibility of clinical tests used
to diagnose SIS. The special tests for SIS that was reviewed by Vind et al.8 are HawkinsKennedy, Neer’s, Jobe’s, and Apprehension test. This study took two examiners, with a
maximum 6 months of clinical experience and performed special tests for SIS. The
subjects involved in the study consisted of 44 subjects involved in overhead sports8. The
study was broken up into three different phases to ensure reproducibility; training, overall
agreement and study phase8. The training phase used the four tests to initially diagnose
SIS in the athletes involved in the study. The overall agreement phase had each examiner
test a sample of athletes, switch samples and then calculate agreement. In the study
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phase, a case was considered 3 or more positive tests for SIS and a control was
considered one or less positive tests for SIS. In this phase, one examiner selected and
tested a minimum of 20 subjects (10 cases and 10 controls) and sent them to the other
examiner to be tested8. The other examiner repeated the same procedure and sent them to
the other examiner. The used the results from the three phases and Cohen’s K statistics to
calculate the level of agreement between the two examiners with 95% confidence
intervals8. For the purpose of this paper, the results of Hawkins-Kennedy and Neers will
be the main area of focus.
Kelly et al.7 took 59 participants with chronic shoulder pain to test the diagnostic
accuracy of common physical tests for SIS. The physical tests consisted of; Neers,
Hawkins-Kennedy, painful arc of abduction, empty and full can, resisted isometric should
abduction, and resisted isometric shoulder external rotation. To qualify for the study, the
participants must have experienced chronic shoulder pain for more than four months. Of
the 59 participants that met the inclusion criteria, only 34 participated in the study7. Ages
of participants ranged from 20-80 years of age7. The 34 participants underwent each of
the physical tests and then received an ultrasound and a two-way contingency table to
determine the sensitivity, specificity, and overall accuracy of the special tests7.
The following study aims to test the diagnostic values of clinical diagnostic tests
for SIS. This study by Calis et al.1 took 120 patients, between the ages of 18 and 70, who
complained of shoulder pain. These patients underwent magnetic resonance imaging
(MRI) and physical special tests to test for SIS1. After that, they had a SIT test to separate
them into two groups; SIS group and non-SIS group. The SIS group had a positive
response to SIT (relief of symptoms) and non-SIS group had no response to SIT1. These
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results of the clinical tests were then compared against the SIT to calculate the sensitivity,
specificity and accuracy of each clinical test for SIS.
Michener et al.3 also conducted a study on the reliability and diagnostic accuracy
of special tests for SIS. Michener et al.3 took a group of 55 patients (mean age=40.6y)
who complained of shoulder pain and evaluated them with 5 physical examinations for
SIS3. These 5 physical examinations for SIS included; Neer’s, Hawkins-Kennedy, painful
arc, empty can, and external rotation resistance tests. These results were then compared
against surgical diagnosis. Diagnostic accuracy was calculated with a receiver operating
characteristic curve, and sensitivity, specificity, positive likelihood ratio, and negative
likelihood ratio3.
Similarly, MacDonald et al.4 analyzed the diagnostic accuracy of HawkinsKennedy and Neer’s SIS tests. Specifically, MacDonald et al.4 was testing for
subacromial bursitis or rotator cuff pathologies. This specific study took 85 patients who
were undergoing shoulder arthroscopy by a single surgeon. The surgeon used Neer’s and
Hawkins-Kennedy tests along with arthroscopic findings to determine positive and
negative results4. These results were then compared along side results found in other
literature to compare sensitivity and specificity of Neer’s and Hawkins-Kennedy.
Data Synthesis
The first study listed above, by Toprak et al.6, tested impingement test against
palpation tests. Palpation tests had a tendency to score higher accuracy rates 79 and 62%
than the impingement tests 74 and 62% in identifying impingement syndrome in the
supraspinatus and biceps tendon6. But for the purpose of this paper, we will concentrate
on the results of Neer’s and Hawkins-Kennedy. They found that the Neer’s test had a
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sensitivity of 80 (95% CI), a specificity of 52 (95% CI), and an accuracy of 74. HawkinsKennedy on the other hand had a sensitivity of 67 (95% CI), specificity of 47% (95% CI),
and accuracy of 626. In the cases of supraspinatus tendonosis, Neer’s proved to be the
more effective test. But in the cases of supraspinatus partial tear, Hawkins-Kennedy
proved to be more effective.
In another study, Vind et al.8 examines the inter-examiner reliability of clinical
tests for SIS. Of those clinical tests, Hawkins-Kennedy and Neer’s are included in the
list. To determine the levels of inter-examiner agreement, Cohen’s K statistic and 95%
CIs were used8. In the study phase of the experiment, the K statistic for diagnosis of SIS
was 0.95. Neer’s scored the highest out of all of the test with a K value of 0.95 while
Hawkins-Kennedy scored a 0.608.
Using a two-way contingency table, Kelly et al.2 used this to measure the value of
diagnostic accuracy of physical tests for SIS. This was determined by measuring the
sensitivity, specificity, likelihood ratios, and overall accuracy were calculated using the
contingency table2. When using using ultrasound as the reference standard, Neer’s had a
sensitivity of 62.1, specificity of 0 and an accuracy of 54.5 while Hawkins-Kennedy had
a sensitivity of 74.1, a specificity of 50.0 and an accuracy of 71 in any degree of SIS. In
more specific stages of SIS, Full thickness tear, partial thickness tear and
subdeltoid/subacromial fluid, Neer’s had sensitivity of 45.5, 72.7 and 72.7, specificity of
22.7, 17.4 and 40.9, and accuracy of 30.3, 35.3 and 51.5 respectively2. Hawkins-Kennedy
had a sensitivity of 66.7, 55.6 and 88.9, a specificity of 36.4, 13.0, 40.9, and accuracy of
45.2, 25.0 and 54.82.
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Calis et al.1 also tested the diagnostic accuracy of clinical tests for SIS. Diagnostic
accuracy was based off of the clinical diagnostic test’s sensitivity, specificity and
accuracy. Hawkins-Kennedy was found to have a sensitivity of 92.1, a specificity of 25.0
and an accuracy of 72.81. Neer’s was found to have a sensitivity of 88.7, a specificity of
30.5 and an accuracy of 72.01.
Michener et al.3 used Kappa coefficients and percentage agreement to assess
inter-rater reliability and ROC curve and sensitivity, specificity, positive likelihood ratio
(+LR) and negative likelihood ratio (-LR) to determine diagnostic accuracy of clinical
tests for SIS. Neer’s had a Kappa of 0.40 and a percentage agreement of 713 HawkinsKennedy had a Kappa of 0.39 and a percentage of agreement of 693. Neer’s had a
sensitivity of 0.81, specificity of 0.54, and +LR of 1.76, and -LR of 0.35. HawkinsKennedy had a sensitivity of 0.63, specificity of 0.62, +LR of 1.63, and –LR of 0.613.
MacDonald et al.4 assessed the diagnostic accuracy of Hawkins-Kennedy and
Neer’s test for SIS caused by subacromial bursitis and rotator cuff pathosis. They used 85
patients undergoing shoulder arthroscopy along with Hawkins-Kennedy and Neer’s to
determine the sensitivity and specificity of the impingement tests. In cases of subacromial
bursitis, Neer’s had a sensitivity of 75 and specificity of 47.5 and Hawkins-Kennedy had
a sensitivity of 91.7 and specificity of 44.34. In cases of rotator cuff pathosis, Neer’s had
a sensitivity of 83.3 and specificity of 50.8 and Hawkins-Kennedy had a sensitivity of
87.5 and a specificity of 42.64.
Conclusion
When determining between Hawkins-Kennedy and Neer’s tests for SIS, many
factors must be taken into consideration. Sensitivity, specificity and accuracy are among
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the ways to factor in a test’s diagnostic accuracy. After summing up all of the data for
Hawkins-Kennedy and Neer’s and finding the average from all of the studies, HawkinsKennedy had an average sensitivity of 76.3, specificity of 40.1 and accuracy of 55.8 and
Neer’s had a sensitivity of 73.1, specificity of 35.1 and accuracy of 52.9. From these
findings, Hawkins-Kennedy clearly has higher averages for sensitivity, specificity and
accuracy. This means that between Neer’s and Hawkins-Kennedy, Hawkins-Kennedy is
the more accurate special test for SIS.
What does this mean in a clinical sense? This means that when a patient comes in
complaining of SIS, Hawkins-Kennedy will diagnose SIS better than Neer’s. Both tests
will be capable of diagnosing SIS accurately with sensitivities >70 but both tests have
specificities that are <45. That is not high enough to feel comfortable ruling out SIS if
there is a negative result for either Hawkins-Kennedy or Neer’s. So both special tests
diagnose SIS well but one will not be able to rule out SIS if there are negative results.
Other special tests will have to be done to completely rule out SIS.
For the question stated earlier in this paper, “For a patient who is complaining of
shoulder pain due to SIS, which special test, Hawkins-Kennedy or Neer’s, more
accurately diagnoses SIS based on sensitivity, specificity and accuracy?” Based off of the
information found in the articles used in this paper, Hawkins-Kennedy will be the more
accurate test for SIS.
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Resources:
1. Calis, M., Akgun, K., Birtane, M., Karacan, I., Calis, H., & Tuzun, F. (2000,
January). Diagnostic values of clinical diagnostic tests in subacromial
impingement syndrom. Annals of the Rhuematic Diseases, 59(1), 44-47.
doi:10.1136/ard.59.1.44
2. Kelly, S., Brittle, N., & Allen, G. (2009, July 15). The value of physical tests for
subacromial impingement syndrome: a study of diagnostic accuracy. Clinical
Rehabilitation, 24, 149-158. doi:10.1177/0269215509346103
3. Michener, L., Walsworth, M., Doukas, W., & Murphy, K. (2009, November).
Reliability and diagnostic accuracy of 5 physical examination tests and
comination of tests for subacromial impingement. Archives of Physical Medicine
and Rebailitation,90(11), 1898-1903. doi:10.1016/j.apmr.2009.05.015
4. MacDonald, P., Clark, P., & Sutherland, K. (2000, July). An analysis of the
diagnostic accuracy of the hawkins and neer subacromial impingement
signs. Journal of Shoulder and Elbow Surgery, 9(4), 299-301.
doi:10.1067/mse.2000.106918
5.
Starkey, C., Brown, S., & Ryan, J. (2010). Examination of Orthopedic and
Athletic Injuries (3rd ed.). Philadelphia, PA: F. A. Davis.
6. Toprak, U., Ustuner, E., Ozer, D., Uyanik, S., Baltaci, G., Sakizioglu, S.,
Karademir, M., & Atay, A. (2012). Palpation tests versus impingement tests in
neer stat I and II subacromial impingement syndrome Knee Surgery, Sports
Traumatology, Arthroscopy doi: 10.1007/s00167-012-1969-7
7.
Tucker, S., Taylor, N., & Green, R. (2011, February). Anatomical validity of the
hawkins-kennedy test-a pilot study. Manual Therapy, 16, 399-402.
doi:10.1016/j.math.2011.02.002
8. Vind, M., Bogh, S., Larsen, C., et al. BMJ Open 2011; doi:101136/bmjopen2010-000042