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Physical Exam

A thorough physical examination should include careful evaluation of the cervical spine to rule out a neurologic problem such as a herniated cervical disc that can mimic shoulder pathology. This is especially true if a patient presents with bilateral symptoms.

If subacromial impingement is suspected, specific tests should be used and documented. The Neer and Hawkins signs for impingement are used commonly and have been found to be reproducible and helpful. In attempting to elicit a positive Neer sign the examiner stabilizes the patient’s scapula while raising the arm passively in forward flexion.

This decreases room available in the subacromial space, thus causing the rotator cuff and overlying bursae to be compressed under the coracoacromial arch. In attempting to elicit a positive Hawkins sign the patient’s arm is passively flexed to 90 degrees. The elbow is also bent to 90 degrees and the arm is forcibly internally rotated.

This brings the greater tuberosity under the acromion, compressing the cuff and bursae. Individually, both exams have been shown to be sensitive but not very specific for diagnosing subacromial impingement. When combined, however, these two tests have a negative predictive value greater than 90%.

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