Hawkins Kennedy test

Hawkins Kennedy test (Hawkins test) is used for impingement syndrome of the rotator cuff of the shoulder, it was first introduced by Canadian Drs. R. Hawkins and J. Kennedy in the 1980s.

With the GH joint abducted to 90° in the scapular plane, the humerus is internally rotated to reproduce the symptoms of rotator cuff impingement.

See Also: Rotator Cuff of the Shoulder

How do you perform the Hawkins test?

• The Hawkins test is done while the patient is standing or sitting
• With the arm flexed at 90° and the elbow also bent to 90 degrees of flexion, the examiner applies a forcible, passive internal rotation to the shoulder joint.

What does a positive Hawkins test mean?

• Pain suggests tendinitis or calcification in the supraspinatus tendon or secondary impingement, caused by anterior acromial margin changes, for example.
• In a positive impingement syndrome, impingement of the greater tubercle or compression of the supraspinatus tendon occurs, causing severe pain on motion (a positive hawkins kennedy test).
• Coracoid impingement is revealed when the arm is further adducted and the supraspinatus tendon also impinges against the coracoid process.
• Jobe introduced a variation of the impingement test (Jobe test) in which the adducted arm is internally rotated, causing primarily the posterior portion of the supraspinatus tendon to become wedged under the coracoacromial arch.

A positive Hawkins test is the result of greater tuberosity contact on the undersurface of the coracoacromial ligament that is thought to reproduce symptoms related to subacromial impingement.

If the humerus is moved towards the sagittal plane, the probability of eliciting a false positive Hawkins test shoulder result secondary to AC joint pathology increases.

See Also: Empty Can Test

Accuracy

A systematic review with meta-analysis of individual tests by Eric J Hegedus ¹ found that the hawkins impingement test has the following accuracy:

• Sensitivity: 79% 
• Specificity: 59% 

Another systematic review and meta-analysis study by Sigmund Gismervik ² found that Hawkins test has a Sensitivity of 58 %, and a Specificity of 67 %.

McDonald et al.³ assessed the diagnostic accuracy of the Neer test and Hawkins test for the diagnosis of subacromial bursitis or rotator cuff pathology in 85 consecutive patients undergoing shoulder arthroscopy by a single surgeon.

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 test. For rotator cuff tearing, the sensitivity of the Neer sign was 85% and that 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.

As with the Neer impingement test, elimination of this pain by subacromial anesthetic injection strengthens the evidence for rotator cuff pathology.

Diagnostic Utility of the Hawkins Test in Identifying Subacromial Impingement:

Population	Reference Standard	Sens	Spec	+LR	-LR
Pooled estimates from six studies (n = 1029)	Impingement syndrome diagnosed by arthroscopy	.74 (.57, .85)	.57 (.46, .67)	1.7	.46
Pooled estimates from seven studies (n = 944)	Impingement syndrome diagnosed by arthroscopy, magnetic resonance imaging (MRI), or ultrasound	.80 (.72, 086)	.56 (.45, .67)	1.8 (1.5, 2.3)	0.35 (0.27, 0.46)
Pooled estimates from four high quality studies	Impingement syndrome diagnosed from subacromial injection or surgery	.79 (.75, .82)	.59 (.53, .64)	1.9	.36
30 patients with new onset of shoulder pain	Subacromial impingement confirmed by MRI	.74	.40	1.2 (.70, 2.3)	.65
847 patients who underwent diagnostic arthroscopy of the shoulder	Partial biceps tendon tear visualized during arthroscopy	.55	.38	.90	1.18

Notes

Rotator Cuff Impingement

• Rotator cuff impingement is a painful disorder which is thought to arise from repetitive compression or rubbing of the tendons (mainly supraspinatus) under the coracoacromial arch.
• Normally, when the arm is abducted, the conjoint tendon slides under the coracoacromial arch.
• As abduction approaches 90 degrees, there is a natural tendency to externally rotate the arm, thus allowing the rotator cuff to occupy the widest part of the subacromial space. If the arm is held persistently in abduction and then moved to and from in internal and external rotation (as in cleaning a window, painting a wall or polishing a flat surface), the rotator cuff may be compressed and irritated as it comes in contact with the anterior edge of the acromion process and the taut coracoacromial ligament.
• This attitude (abduction, slight flexion and internal rotation) has been called the ‘impingement position’.
• Perhaps significantly, the site of impingement is also the ‘critical area’ of diminished vascularity in the supraspinatus tendon about 1 cm proximal to its insertion into the greater tuberosity.

The development of impingement is thought to be due to intrinsic and extrinsic factors.

Intrinsic factors include:

1. Degeneration of the tendon.
2. Changes in the presence of highly sulphated glycosaminoglycans and changes in the collagen composition with loading. Tendon degeneration may be age-related and a cell-mediated response.
3. Changes in vascularity may also contribute.
4. It is thought that these intrinsic changes result in rotator cuff dysfunction resulting in upward displacement of the humeral head and the subsequent development of extrinsic compression.
5. It can also occur in inflammatory conditions such as gout or rheumatoid arthritis.

Extrinsic factors that may cause impingement include:

1. Spurs growing down the coracoacromial
2. Ligament, a laterally sloping acromion.
3. Osteoarthritic thickening of the acromioclavicular joint.

References

1. Eric J Hegedus, Adam P Goode, Chad E Cook, Lori Michener, Cortney A Myer, Daniel M Myer, Alexis A Wright. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78. doi: 10.1136/bjsports-2012-091066. Epub 2012 Jul 7. PMID: 22773322.
2. Sigmund Gismervik, Jon O Drogset, Fredrik Granviken, Magne Rø, Gunnar Leivseth. Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskelet Disord. 2017 Jan 25;18(1):41. doi: 10.1186/s12891-017-1400-0. PMID: 28122541.
3. MacDonald PB, Clark P, Sutherland K: An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg 9:299–301, 2000.
4. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93(2):229-236.
5. Boublik M, Hawkins RJ: Clinical examination of the shoulder complex. J Orthop Sports Phys Ther 18:379–385, 1993.
6. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964-978.
7. Inman VT, Saunders SJB, Abbott LC. Observations on the function of the shoulder joint. 1944. Clin Orthop. 1996;330:3-12.
8. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93(2):229-236.
9. Gill HS, El Rassi G, Bahk MS, et al. Physical examination for partial tears of the biceps tendon. Am J Sports Med. 2007;35:1334-1340.
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