Hawkins-Kennedy and Neer tests for shoulder impingement: procedure, accuracy, and interpretation
In short
The Hawkins-Kennedy and Neer impingement tests are the clinical benchmark examinations for subacromial shoulder impingement syndrome and rotator cuff tendinopathy. Both tests mechanically compress the supraspinatus tendon against the coracoacromial arch to identify inflamed subacromial structures.
In this guide (5 sections)
Biomechanics of subacromial shoulder impingement
Subacromial impingement syndrome occurs when the tendons of the rotator cuff (primarily the supraspinatus) and the subacromial bursa become compressed between the humeral head and the coracoacromial arch during arm elevation. Special provocative tests intentionally compress these tissues to reproduce familiar pain.
Clinical diagnostic cluster: No single shoulder test is 100% diagnostic in isolation. Clinical guidelines in the British Journal of Sports Medicine recommend using a three-test cluster: Hawkins-Kennedy test, Neer test, and the Painful Arc test (pain between 60° and 120° of active abduction). When all three are positive, diagnostic probability for subacromial impingement exceeds 95%.
How to perform the Hawkins-Kennedy test
Follow these standardized clinician steps to execute the Hawkins-Kennedy maneuver:
- 1. Patient positioning: The patient sits comfortably upright on an examination plinth with arms relaxed by their sides.
- 2. Forward elevation: The clinician passively forward flexes the patient's arm to 90 degrees with the elbow flexed to 90 degrees.
- 3. Scapular stabilization: The clinician places their superior hand firmly over the top of the patient's shoulder to stabilize the acromion and prevent compensatory shoulder hiking.
- 4. Internal rotation force: With their other hand holding the patient's wrist, the clinician smoothly rotates the forearm downward into internal rotation.
- 5. Positive response: The test is positive when internal rotation reproduces the patient's familiar pinching pain in the anterolateral shoulder.
How to perform the Neer impingement test
The Neer test approaches subacromial compression from full forward elevation:
- 1. Starting stance: The patient sits or stands upright with arms relaxed.
- 2. Scapular lock: The clinician places one hand over the posterior scapula to prevent upward rotation during elevation.
- 3. Overhead forward flexion: With the patient's arm fully internally rotated (thumb pointing down and backward), the clinician passively elevates the arm straight forward through full overhead flexion.
- 4. Positive finding: Reproduction of pain between 70 and 120 degrees of forward flexion indicates compression of the greater tuberosity against the anterior-inferior acromial border.
Diagnostic accuracy and comparison table
| Test Name | Primary Target Structure | Sensitivity | Specificity | Key Clinical Limitation | |
|---|---|---|---|---|---|
| Hawkins-Kennedy Test | Supraspinatus tendon and subacromial bursa against coracoacromial ligament | 79% to 88% | 56% to 62% | Low specificity when isolated AC joint arthritis or SLAP tear is present | |
| Neer Impingement Test | Greater tuberosity against anterior-inferior border of the acromion | 75% to 82% | 48% to 54% | Highly sensitive screen but easily triggers false positives from capsular stiffness | |
| Painful Arc Sign | Mid-range subacromial compression between 60° and 120° abduction | 73% to 78% | 68% to 74% | Requires active arm abduction without severe pain inhibition |
Differentiating shoulder impingement from frozen shoulder
- Subacromial Impingement: Passive range of motion is typically preserved. Pain occurs predominantly in the mid-range of movement (the painful arc) and tests positive on Hawkins-Kennedy and Neer maneuvers.
- Frozen Shoulder (Adhesive Capsulitis): Capsular restriction mechanically blocks both active and passive range of motion. External rotation is severely limited even when completely relaxed, and pain occurs at the absolute end-range of motion.
What does a positive Hawkins-Kennedy test mean?
A positive result indicates that passive internal rotation at 90 degrees of flexion reproduces the patient's familiar pinching pain in the front or outer shoulder, indicating subacromial bursitis or supraspinatus tendinopathy.
Can a Hawkins-Kennedy test be false positive?
Yes. Any pathology that occupies the subacromial space, including an acromioclavicular (AC) joint bone spur, long head of biceps tendinopathy, or anterior shoulder instability, can cause pain during this maneuver.
How does physiotherapy treat a positive impingement test?
Treatment focuses on posterior capsule stretching, periscapular strengthening (serratus anterior and lower trapezius) to improve upward scapular rotation, and rotator cuff strengthening to depress the humeral head during overhead movements.
- British Journal of Sports Medicine: Diagnostic accuracy of physical tests for shoulder impingement: https://bjsm.bmj.com
- Journal of Shoulder and Elbow Surgery: Clinical examination of the rotator cuff: https://jshoulderelbow.org
- Indian Association of Physiotherapists: Musculoskeletal Protocols: https://physiotherapyindia.org
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