Subacromial Impingement-Producing Maneuvers
When an athlete presents with tenderness over the greater tuberosity (especially with vague complaints involving the whole deltoid with overhead activity), one should already strongly suspect impingement. The following are provocative maneuvers that should lead one toward the diagnosis of subacromial impingement.
Neer Sign This test is performed by placing the symptomatic arm in maximum passive forward flexion while stabilizing the scapula (Fig. 16-4). A positive test is signified by production of pain. The Neer sign has been shown to be 88.7% sensitive for
subacromial impingement and 85% sensitive for rotator cuff tearing but has poor specificity.7,8
Hawkins Sign This test is performed by placing the arm in 90 degrees of forward flexion, with the elbow flexed 90 degrees. The examiner then internally rotates the arm maximally (Fig. 16-5). A positive test is signified by production of pain. This test has been shown to reflect contact between rotator cuff and the coracoacromial ligament.5 It has been shown to have a sensitivity of 92% for subacromial impingement and 88% for rotator cuff tearing.8 Like the Neer sign, however, this test is not very specific for these conditions.
Painful Abduction Arc Sign This test is performed by having the patient perform resisted abduction in or just posterior to the coronal plane (Fig. 16-6). Reproduction of the patient's symptoms of pain constitutes a positive sign.5,9 Unlike the Neer and Hawkins signs, this test is more specific than it is sensitive.7
If these signs are positive, subacromial impingement may be strongly suspected. Suspicion can be strengthened further with a Neer impingement test (see Fig. 16-1), especially if the test becomes negative after injection.
One should be mindful that subacromial impingement syndrome may be associated with a tear of the rotator cuff. Because rotator cuffs are often painful, any workup for impingement should include testing for a tear of the cuff. Although these tests are usually looking for weakness, any impingement examination should include an evaluation of the cuff.
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