Hawkins Test: Understanding, Performance, and Interpretation for Shoulder Impingement

What is the Hawkins Test for Shoulder?

The Hawkins test, often referred to as the Hawkins-Kennedy test, is a common orthopedic provocative maneuver used to assess for subacromial impingement syndrome in the shoulder. It aims to compress the structures within the subacromial space, eliciting pain if impingement is present.

Understanding the Hawkins Test

The Hawkins test is a specialized physical examination technique employed by healthcare professionals to evaluate the integrity and health of the structures within the shoulder joint, particularly those susceptible to impingement. Its primary purpose is to provoke pain by narrowing the subacromial space, where the rotator cuff tendons (especially the supraspinatus) and the subacromial bursa reside. When these structures are inflamed or swollen, they can become painfully compressed against the overlying acromion and coracoacromial ligament during specific movements.

Anatomy and Biomechanics Behind the Test

To understand why the Hawkins test works, it's crucial to grasp the anatomy and biomechanics of the shoulder. The shoulder is a complex ball-and-socket joint, and the subacromial space is a critical area just below the acromion (part of the shoulder blade) and above the humeral head (the ball of the upper arm bone). This space houses:

• Supraspinatus Tendon: One of the four rotator cuff tendons, responsible for initiating arm abduction.
• Long Head of Biceps Tendon: Passes through the bicipital groove and can also be affected by impingement.
• Subacromial Bursa: A fluid-filled sac that reduces friction between the tendons and the acromion.

The Hawkins test specifically puts the shoulder into a position of 90 degrees of forward flexion and 90 degrees of elbow flexion, followed by passive internal rotation. This combination of movements drives the greater tuberosity of the humerus (where the rotator cuff tendons attach) directly under the acromion and coracoacromial ligament, thereby compressing the soft tissues in the subacromial space. If these tissues are inflamed or degenerated, this compression will elicit pain.

How to Perform the Hawkins Test

The Hawkins test should ideally be performed by a trained healthcare professional such as a physician, physical therapist, or chiropractor.

• Patient Position: The patient can be seated or standing, with the affected arm relaxed.
• Examiner Position: The examiner stands alongside the patient, supporting the arm.
• Steps:
  1. Flex the Shoulder: The examiner passively flexes the patient's shoulder to 90 degrees (arm raised forward to shoulder height).
  2. Flex the Elbow: The patient's elbow is bent to 90 degrees, with the forearm pointing forward.
  3. Stabilize and Internally Rotate: The examiner stabilizes the patient's elbow with one hand and grasps the wrist or forearm with the other. From this position, the examiner then passively and forcefully internally rotates the shoulder. This means rotating the forearm downwards towards the patient's body while keeping the elbow at 90 degrees.
  4. Observe for Pain: The examiner carefully observes the patient for any signs of pain or discomfort.

Interpreting the Results (Positive Test)

A positive Hawkins test is indicated by the reproduction of the patient's typical shoulder pain, particularly in the anterolateral aspect of the shoulder, during the passive internal rotation movement.

• What a Positive Test Suggests: A positive result strongly suggests the presence of subacromial impingement syndrome. This indicates that the rotator cuff tendons (most commonly the supraspinatus) and/or the subacromial bursa are being compressed and irritated within the subacromial space.
• Differential Diagnosis: While highly indicative of impingement, a positive Hawkins test alone does not definitively distinguish between rotator cuff tendinopathy, subacromial bursitis, or a partial rotator cuff tear. Further clinical examination, imaging studies (like MRI), and other special tests are often required to pinpoint the exact pathology. Pain radiating into the AC joint could also suggest AC joint pathology, though less common for this specific test.

Clinical Utility and Limitations

The Hawkins test is a valuable tool in the assessment of shoulder pain, but it has specific utility and limitations:

• High Sensitivity: The Hawkins test is considered a highly sensitive test for shoulder impingement. This means that if a patient does not have pain with this test, it's less likely they have significant subacromial impingement (i.e., it's good at ruling out the condition when negative).
• Lower Specificity: Its specificity is moderate. A positive test indicates impingement but doesn't precisely identify the specific structure impinged (e.g., supraspinatus tendon vs. bursa) or differentiate it from other conditions that might cause similar pain. This means false positives can occur.
• Part of a Battery of Tests: Due to its moderate specificity, the Hawkins test is rarely used in isolation. It is typically performed as part of a comprehensive orthopedic shoulder examination, alongside other provocative tests (e.g., Neer's test, Jobe's empty can test), range of motion assessment, strength testing, and palpation. Combining multiple tests helps increase the overall diagnostic accuracy.

Who Benefits from This Test?

The Hawkins test is primarily beneficial for:

• Individuals presenting with anterior or lateral shoulder pain, especially pain that worsens with overhead activities, reaching, or sleeping on the affected side.
• Athletes involved in overhead sports (e.g., baseball, swimming, tennis, volleyball) who are prone to impingement syndromes.
• Patients suspected of having rotator cuff tendinopathy, subacromial bursitis, or rotator cuff tears.

Important Considerations

• Professional Assessment: The Hawkins test, like any diagnostic maneuver, should only be performed and interpreted by a qualified healthcare professional. Self-diagnosis based solely on this test is not recommended.
• Patient Comfort: The examiner should always be mindful of the patient's pain tolerance and stop the movement if pain becomes excessive.
• Not a Standalone Diagnosis: A positive Hawkins test is a strong indicator of shoulder impingement, but it is not a definitive diagnosis on its own. It provides valuable information that guides further clinical investigation and helps formulate an appropriate treatment plan.