Original Articles
An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs*,**

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Abstract

The purpose of this study was to assess the diagnostic accuracy of the Neer and Hawkins impingement signs for the diagnosis of subacromial bursitis or rotator cuff pathosis. Eighty-five consecutive patients undergoing shoulder arthroscopy by a single surgeon were documented prospectively for the positive and negative clinical and arthroscopic pathologic findings. The Neer sign was found to have a sensitivity of 75% for the appearance suggestive of subacromial bursitis; this compared with 92% for the Hawkins sign. For rotator cuff tearing, the sensitivity of the Neer sign was 85% and the sensitivity of the Hawkins sign was 88%. Specificity and positive predictive values for the two tests were low, being not much higher than pretest probability. The two tests had a high negative predictive value (96% for bursitis, 90% for rotator cuff tearing) when they were combined. The results are compared with those reported in the literature. We conclude that the Neer and Hawkins signs are sensitive for appearances suggestive of subacromial bursitis and rotator cuff partial or complete tearing with a high negative predictive value. However, they lack specificity in comparison with arthroscopic findings. (J Shoulder Elbow Surg 2000;9:299-301.)

Section snippets

Materials and methods

Because there is no peer-reviewed method of evaluating the subacromial bursa for information, we formulated criteria for “appearances suggestive of subacromial tendinitis and bursitis.” These include (1) erythema and bleeding of subacromial tissue, (2) swelling and difficult visualization, and (3) vascular engorgement of the bursal sides of the rotator cuff, causing bleeding from the surface of the cuff. All of these had to be present for our definition to be met.

Information on 85 consecutive

Results

Patient age ranged from 16 to 72 years; the average age was 40 years. Seventy-three percent of the patients were male and 27% were female. The specificity, sensitivity, positive predictive value, and negative predictive value of the Neer and Hawkins impingement signs were calculated for the clinical diagnosis of rotator cuff bursitis and rotator cuff pathosis, as shown in Tables I-III.

. Bursitis

SignSensitivity(%)Specificity (%)Positive predictive value (%)Negative predictive value (%)
Neer7547.536

Discussion

Many shoulder tests today are in wide use with no documentation of their diagnostic accuracy. Our attempt here is to analyze these tests with respect to a syndrome that is difficult to define. Gartsman2 has stated that impingement syndrome is a clinical diagnosis and its definition therefore somewhat imprecise. He has further indicated a belief that many people have painful impingement without incitement of any inflammatory reaction. With this in mind, one can see an obvious weakness in our

Conclusion

We are assured that when these signs are used, a negative test goes a long way toward ruling out possible rotator cuff tendinitis or tearing. However, the possibility of other pathosis exists when the tests are positive. We encourage further study that would look at other tests, particularly in advance of their widespread use in clinical practice.

Acknowledgements

We thank Ahmed Abdoh, MD, BCh, MSPH, MPH, PhD, clinical epidemiologist, for his statistical analysis of this article.

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*

Reprint requests: Peter B. MacDonald, MD, St Boniface General Hospital, 409 Tache Ave, Z-3043, Winnipeg, MB R2H 2A6, Canada.

**

J Shoulder Elbow Surg 2000;9:299-301.

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