Neer Test – Impingement Test

Neer Test (or Neer Impingement Test) is a special test for shoulder joint that is used mainly to check for rotator cuff impingement syndrome.

It was first described by Dr. Charles S. Neer, an orthopedic surgeon, in 1972.

How do you perform Neer test?

• With the patient in a seated or standing position, with the shoulder, elbow, and wrist begin in the anatomical position.
• The examiner stands lateral or forward to the involved side, with one hand stabilizes the scapula and the opposite hand grasps the patient’s arm distal to the elbow joint.
• The examiner raises the affected arm in forced forward elevation with one hand, while stabilizing the scapula with the other hand.
• This maneuver is thought to bring the pathologic anterolateral acromion into contact with the affected portion of the rotator cuff and greater tuberosity, thereby producing pain.
• This maneuver produces pain with impingement lesions of all stages.

See Also: Yocum test

What does a positive Neer Test mean?

If an impingement syndrome is present, subacromial constriction or impingement of the diseased area against the anterior inferior margin of the acromion will produce severe pain with motion.

If the Neer test shoulder is positive when done with the arm externally rotated, acromioclavicular joint dysfunction may be the cause, this can be examined by Cross body adduction test.

See Also:  Cross body adduction test 

Sensitivity & Specificity

A study by MacDonald¹ to assess the diagnostic accuracy of the Neer and Hawkins Kenedy test for the diagnosis of subacromial bursitis or rotator cuff pathologies. He found that the two tests have a high sensitivity, but Specificity and positive predictive values for them were low:

• Sensitivity: 75%
• Specificity: 48%

In cases of bursal involvement only (i.e., the rotator cuff is not damaged), the sensitivity improves to 0.86, but the specificity decreases to 0.49 (LR+ = 1.69).

Both Fodor et al. and Kelly et al. used ultrasonic evaluation to determine the sensitivity and specificity of the Neer test in the diagnosis of subacromial impingement. Interestingly, although each study reported similar sensitivity values, their specificity values were divergent (95 % and 10 %, respectively). These results highlight the significant variability that may exist in the performance and interpretation of physical examination findings, specifically with regard to subacromial impingement syndrome.

Diagnostic accuracy of Neer Test:

Population	Reference Standard	Sens	Spec	+LR	-LR
Pooled estimates from five studies (n = 1127)	Impingement syndrome diagnosed by arthroscopy	.78 (.68, .87)	.58 (.47, .68)	1.9	.38
Pooled estimates from seven studies (n = 946)	Impingement syndrome diagnosed by arthroscopy, MRI, or ultrasound	.72 (.60, .81)	.60 (.40, .77)	1.8 (1.2, 2.6)	.47 (.39, .56)
Pooled estimates from four highquality studies	Impingement syndrome diagnosed from subacromial injection or surgery	.79 (.75, .82)	.53 (.48, .58)	1.7	.40
69 patients with shoulder pain	Evidence of subacromial impingement via sonographic examination	.80 (.67, .89)	.52 (.30, .73)	1.7	.39

Notes

Stabilization of the scapula is essential to maximize the utility of the Neer test since upward rotation of the scapula (and therefore the acromion) with forward elevation will decrease the likelihood of reproducing cuff impingement under the acromion.

If the pathology is present in the rotator cuff group (especially the supraspinatus) or the long head of the biceps brachii tendon, the Neer test motion impinges these structures between the greater tuberosity and the inferior side of the acromion process and coracoacromial ligament.

Neer Test is nonspecific. A variety of other conditions can cause positive test results, including:

1. Bursitis.
2. Limited shoulder mobility.
3. Anterior instability of the shoulder.
4. Calcific tendinitis.
5. Bone tumors.
6. Rotator cuff tears.

Pain that is elicited by the Neer impingement sign and eliminated by the subacromial injection of local anesthetic is usually caused by rotator cuff impingement or tear.

See Also: Neer subacromial Injection Test

Impingement Relief Test (Modified Neer Test)

Guosheng et al. recommend doing the Neer test in two positions, calling the test the Modified Neer Test.

The first part of the test is done similar to the Neer test with the patient seated and the examiner stabilizes the clavicle and scapula with one hand while abducting the test arm, in which the elbow is flexed to 90° and the palm faces the floor, as far as possible. The examiner then laterally rotates the abducted arm.

A disappearance of pain with the second part of the test is considered a positive sign for impingement. If the pain did not disappear in the second part of the test or if the patient is unable to abduct the arm, the test is negative for impingement.

See Also: Rotator Cuff of the Shoulder

Impingement Syndrome

Codman, in 1931, was the first to note that many patients with inability to abduct the arm had incomplete or complete ruptures of the supraspinatus tendon, rather than primary bursal problems. In 1972, Neer described impingement syndrome characterized by a ridge of proliferative spurs and excrescences on the undersurface of the anterior process of the acromion, apparently caused by repeated impingement of the rotator cuff and the humeral head with traction of the coracoacromial ligament.

The concept of impingement syndrome has evolved to encompass four types of impingement:

1. Primary impingement.
2. Secondary impingement
3. Subcoracoid impingement
4. Internal impingement.

Primary impingement is subcategorized further into intrinsic and extrinsic types. Primary impingement is the classic version and occurs without any other contributing pathology.

Secondary impingement occurs when there is instability of the glenohumeral joint allowing translation of the humeral head, typically anteriorly, resulting in contact of the rotator cuff against the coracoacromial arch.

Intrinsic impingement occurs when the structures passing beneath the coracoacromial arch become enlarged resulting in abutment against the arch, examples of this condition include:

1. Thickening of the rotator cuff.
2. Calcium deposits within the rotator cuff
3. Thickening of the subacromial bursa.

Extrinsic impingement occurs when the space available for the rotator cuff is diminished; examples include:

1. Subacromial spurring.
2. Acromial fracture or pathological os acromiale.
3. Osteophytes off the undersurface of the acromioclavicular joint.
4. Exostoses at the greater tuberosity.

Acromial morphology has been implicated as contributing to impingement.

See More on Subacromial Impingement Syndrome

Reference

1. 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. PMID: 10979525
2. 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.
3. 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
4. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42:80-92, discussion 92.
5. Toprak U, Ustuner E, Ozer D, et al. Palpation tests versus impingement tests in Neer stage I and II subacromial impingement syndrome. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):424-429.
6. Park, HB, et al: Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg, 87-A:1446, 2005.
7. Fodor D, Poanta L, Felea I, et al. Shoulder impingement syndrome: correlations between clinical tests and ultrasonographic findings. Orthop Traumatol Rehabil. 2009;11(2):120–6.
8. Kelly SM, Brittle N, Allen GM. The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy. Clin Rehabil. 2010;24(2):149–58.
9. Clinical Tests for the Musculoskeletal System, Third Edition book.
10. Mark Dutton, Pt . Dutton’s Orthopaedic Examination, Evaluation, And Intervention, 3rd Edition Book.
11. Millers Review of Orthopaedics, 7th Edition Book.