If you think you may have shoulder impingement syndrome, a doctor may refer you to a physical therapist (PT) who will perform tests to help identify exactly where the impingement is located and the best treatment plan.
Common tests include the Neer, Hawkins-Kennedy, coracoid impingement, and cross-arm impingement tests, along with several others. During these assessments, a PT will ask you to move your arms in different directions to check for pain and mobility problems.
“Physical therapists don’t hang their hats on one test. A multitude of tests leads us to a diagnosis,” said Steve Vighetti, a fellow of the American Academy of Orthopaedic Manual Physical Therapists.
Many doctors use X-rays, CT scans, MRI scans, and ultrasound testing to clarify and confirm the results of physical examinations.
Studies show that imaging tests are highly effective at pinpointing the precise location of an injury. Ultrasound has the advantage of being easy to perform and less expensive than other imaging tests.
If there are tears, or lesions, in the rotator cuff, imaging tests can show the degree of the injury and help doctors determine whether a repair is needed to restore your abilities.
Shoulder impingement is a painful condition. It happens when the tendons and soft tissues around your shoulder joint become trapped between the top of your upper arm bone (the humerus) and the acromion, a bony projection that extends upward from your scapula (shoulder blade).
When the soft tissues are squeezed, they can become irritated or even tear, causing you pain and limiting your ability to move your arm properly.
The term “shoulder impingement syndrome” is just the starting point to a correct diagnosis and treatment plan.
“It’s a catch-all phrase,” Vighetti said. “It just tells you that a tendon is irritated. What a good physical therapist will do is determine which tendons and muscles are involved.”
Neer test or Neer sign
In the Neer test, the PT stands behind you, pressing down on the top of your shoulder. Then, they rotate your arm inward toward your chest and raise your arm as far as it will go.
During the Hawkins-Kennedy test, you’re seated while the PT stands beside you. They flex your elbow to a 90-degree angle and raise it to shoulder level. Their arm acts as a brace underneath your elbow while they press down on your wrist to rotate your shoulder.
Coracoid impingement test
The coracoid impingement test works like this: The PT stands beside you and raises your arm to shoulder level with your elbow bent at a 90-degree angle. Supporting your elbow, they press down gently on your wrist.
In the Yocum test, you place one hand on your opposite shoulder and raise your elbow without raising your shoulder.
In the cross-arm test, you raise your arm to shoulder level with your elbow flexed at a 90-degree angle. Then, keeping your arm in the same plane, you move it across your body at chest level.
The PT may gently press your arm as you reach the end range of motion.
During Jobe’s test, the PT stands to your side and slightly behind you. They raise your arm out to the side. Then, they move the arm to the front of your body and ask you to keep it elevated in that position while they press down on it.
All of these tests aim to decrease the amount of space between the soft tissues and bone. The tests can gradually become more intense as the PT’s examination moves along.
“We’ll leave the most painful tests for the end of the assessment so the shoulder is not irritated the whole time,” Vighetti said. “If you do a painful test too early, then the results of all the tests will appear to be positive.”
A test is considered positive if it elicits the same pain you’ve been experiencing in your shoulder. The Neer test, Vighetti said, will often get a positive result, because it forces the arm into full flexion.
“You’re at the end range of motion with the Neer test,” he said. “Almost anyone who comes into the clinic with a shoulder issue is going to experience pinching at the upper end of that range.”
Location of the pain
During each test, the PT pays close attention to where your pain occurs. This indicates which part of your shoulder complex is likely to be impinged or injured.
Pain at the back of the shoulder, for example, could be a sign of an internal impingement. Once therapists know which muscles are involved, they can be more specific in their treatments.
Even if you’re not experiencing pain during a test, the muscles involved in shoulder impingement have a slightly different response to pressure testing.
“We use light, two-finger resistance to test specific motions at the rotator cuff,” Vighetti said. “If someone has an issue with the rotator cuff, even that really light resistance is going to elicit symptoms.”
Mobility and joint stability issues
“Pain is what brings patients in,” Vighetti pointed out. “But there is an underlying problem causing the pain. Sometimes the problem is related to joint mobility. The joint is moving too much or not enough. If the joint is unstable, the cuff is rotating hard to try and provide dynamic stability.”
When muscles work this hard, problems can arise — not necessarily because the muscles are overused but because they’re being used incorrectly.
For that reason, a good PT looks at the activities you do to see if you’re moving in a way that’s going to lead to injury. Vighetti videotapes activities like running to identify any disfunction in the movement.
Doctors and PTs use diagnostic imaging and physical examinations to identify where and to what degree your shoulder may be injured.
During the physical exam, a PT will take you through a series of motions to try to replicate the pain you’re feeling as you move your arm in different directions. These tests help the PT find out where you’re injured.
The main goals of treatment are to decrease your pain, increase your range of motion, make you stronger and your joints more stable, and train your muscles to move in a way that makes future injuries less likely.
“It’s all about education,” Vighetti said. “Good physical therapists teach patients how to manage on their own.”