Hawkins-Kennedy Test for Shoulder Impingement

The Hawkins-Kennedy test is a hands-on clinical maneuver used to detect subacromial impingement in the shoulder, where soft tissues get pinched beneath the bony arch at the top of the joint. A clinician lifts your arm to 90 degrees in front of you and then rotates it inward; if that provokes your familiar shoulder pain, the test is considered positive. It is one of the most commonly performed shoulder special tests in orthopedic and sports medicine clinics, though its real strength lies in helping rule out impingement rather than confirming it.

How the Test Is Performed

The setup is straightforward. You stand or sit while the examiner brings your arm up to shoulder height with the elbow bent at a right angle, so your forearm points forward. The examiner then stabilizes your shoulder blade with one hand and uses the other to push your forearm downward, forcing the shoulder into internal rotation. This motion drives the top of the upper arm bone (the greater tuberosity) toward the roof of the shoulder joint. If you feel a sharp or familiar pain during that rotation, the test is positive.

The whole thing takes a few seconds. There is no equipment involved, no imaging, no injection. That simplicity is part of why it has remained a staple of shoulder examination since Robert Hawkins and Richard Kennedy first described it in 1980. But the speed and ease of the test also mean that small differences in how a clinician positions the arm or applies force can change the result, a point that matters when you hear about the test’s accuracy numbers.

What Is Actually Getting Pinched

The internal rotation of the Hawkins-Kennedy maneuver narrows the space beneath the acromion (the bony shelf at the top of the shoulder) more than most other impingement tests. MRI-based studies of volunteers in the Hawkins position show that the gap between the supraspinatus tendon’s attachment point and the acromion shrinks significantly, and in most people the supraspinatus and infraspinatus tendons physically contact the underside of the acromion during the maneuver.¹ The Hawkins position actually produces greater subacromial narrowing and more rotator cuff contact than the Neer test, a related impingement sign that uses overhead forward flexion instead of internal rotation.

But the pinching is not limited to the classic subacromial space. Cadaver research found that the Hawkins maneuver also increases pressure at the coraco-acromial ligament, which compresses the biceps tendon, and at the front of the acromion, which impinges structures in the rotator interval, the gap between the supraspinatus and subscapularis tendons.² In living subjects studied with open MRI, the distance between the supraspinatus and the coracoid process was at its smallest in the Hawkins position, and the coracohumeral distance narrowed as well.³

This is relevant because it means a positive Hawkins-Kennedy does not isolate one specific structure. The test squeezes multiple tissues at once. Pain during the maneuver could be coming from the supraspinatus tendon, the infraspinatus, the biceps tendon, the subacromial bursa, or the rotator interval capsule. That anatomical reality underlies many of the diagnostic limitations you will hear about.

How Accurate Is the Test

The Hawkins-Kennedy test is better at catching impingement when it is present than at confirming it is the true cause of pain. A systematic review and meta-analysis pooling data from multiple studies found that for subacromial impingement syndrome, the test’s pooled sensitivity was in the range of 0.69 to 0.78, while specificity was lower, in the range of 0.57 to 0.62.⁴ In plain terms, if you do have impingement, there is roughly a 70 to 80 percent chance the test will be positive. But if you do not have impingement, there is still about a 40 percent chance the test will light up anyway.

That pattern makes the Hawkins-Kennedy more useful for ruling out impingement than for ruling it in. A negative result provides reasonable confidence that classic subacromial impingement is not the primary problem. A positive result, by contrast, needs to be interpreted cautiously because too many other shoulder conditions can trigger pain in the same position.

One study that compared several common physical tests against ultrasound findings reported that the Hawkins-Kennedy test had the highest overall accuracy for diagnosing any degree of subacromial impingement, at about 71 percent.⁵ That sounds decent in isolation, but 71 percent overall accuracy means nearly one in three results is wrong in some direction. Clinicians who rely on this test alone are flipping a coin more often than they might expect.

The Reliability Problem

Accuracy numbers assume two examiners performing the test the same way. In practice, they often do not. One study measuring how well different clinicians agreed when performing the Hawkins-Kennedy found only “fair” interexaminer reliability, with a kappa statistic of 0.36 to 0.38.⁶ A separate study using strict standardized technique reported much better numbers, with kappa values between 0.91 and 1.00 for the Hawkins-Kennedy and three other impingement maneuvers, though that study also noted the tests were limited as structural discriminators even when performed consistently.⁷

The gap between those two findings is striking. When examiners follow a rigid protocol for arm position, rotation speed, and stabilization, they agree almost perfectly on whether the test is positive. When they perform it however they were trained, agreement drops to a level barely above chance. This means the specific clinician performing your Hawkins-Kennedy may matter as much as the test itself. If your shoulder exam was rushed or performed differently from the textbook description, the result carries less weight.

Why a Positive Test Does Not Mean One Thing

A common misunderstanding is that a positive Hawkins-Kennedy equals “impingement” as if that were a single, precise diagnosis. In reality, “subacromial impingement syndrome” is an umbrella that covers bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears, among other things. Research has evaluated whether impingement tests can distinguish between these different severity levels, examining tests including the Hawkins-Kennedy to determine their diagnostic values for bursitis, partial tears, and full tears separately.⁸ The test can flag that something in the subacromial space is unhappy, but it cannot tell you whether that something is an inflamed bursa, a fraying tendon, or a complete tear.

Beyond rotator cuff problems, the Hawkins-Kennedy position can also provoke pain from conditions that have nothing to do with the subacromial space. Biceps tendinopathy, superior labral tears, acromioclavicular joint arthritis, and even cervical spine problems can all produce a false-positive result. The internal rotation component loads structures at the front of the shoulder that are vulnerable in many different pathologies. If your clinician tells you “the Hawkins test was positive,” the appropriate next question is not “so I have impingement?” but rather “what else could explain the pain, and do we need imaging to sort it out?”

Combining Tests for Better Answers

Because no single shoulder test is precise enough on its own, experienced clinicians use clusters of tests and interpret the pattern. A proposed evidence-based examination algorithm reviewed the literature on 26 shoulder special tests and identified 15 that met statistical thresholds for clinical usefulness, organized around six different shoulder conditions.⁹ The Hawkins-Kennedy generally appears in these algorithms as one piece of a multi-test battery for impingement, not as a standalone diagnostic.

A typical clinical approach might combine the Hawkins-Kennedy with the Neer sign, the painful arc test, and a resisted strength test for the supraspinatus. If all of those are positive, the probability of subacromial impingement goes up substantially compared to any single test. If the Hawkins-Kennedy is positive but the others are negative, the clinician may start looking at the biceps, the labrum, or the AC joint instead. The individual test result matters far less than the clinical picture it fits into, which includes your history, how the pain started, where exactly it hurts, and what movements bother you most.

Can the Test Predict How Well Treatment Will Work

Beyond diagnosis, researchers have looked at whether a positive Hawkins-Kennedy before surgery predicts better outcomes after subacromial decompression, the procedure that shaves bone or tissue to create more space in the subacromial area. The answer appears to be yes, at least modestly. One study found that patients who had a positive Hawkins-Kennedy sign before surgery showed significantly greater improvement in their Constant scores (a composite shoulder function measure) after decompression, compared to patients whose Hawkins-Kennedy was negative preoperatively.¹⁰ This makes intuitive sense: if the test specifically provokes pain from subacromial compression, and the surgery relieves that compression, the people whose pain genuinely came from that source should improve the most.

That finding is clinically useful but narrow. It applies to patients already selected for surgery, not to everyone with shoulder pain. And it speaks more to surgical decision-making than to what you should do if you just got a positive test in an outpatient visit. Most people with subacromial pain never need surgery; physical therapy, activity modification, and sometimes a corticosteroid injection resolve symptoms for the majority. The Hawkins-Kennedy’s prognostic value in conservative treatment has not been studied as directly.

Shoulder Testing Through a Screen

The rise of telehealth during and after the pandemic raised an obvious question: can you meaningfully assess a shoulder through a video call? A study comparing synchronous telehealth examination to in-person clinical exam found that for rotator cuff pathology, the telehealth approach was noninferior, meaning it was not meaningfully worse at detecting the problem.¹¹ That said, certain hands-on provocative tests like the Hawkins-Kennedy obviously cannot be replicated remotely the same way; a telehealth shoulder exam relies more heavily on active range-of-motion assessment, self-reported pain locations, and observation of movement quality. If your virtual visit leads to a suspected impingement problem, an in-person follow-up for provocative testing or imaging is still the gold standard for narrowing the diagnosis.

Overhead Athletes and Repetitive-Use Populations

Swimmers, baseball pitchers, volleyball players, and anyone whose sport or job involves repetitive overhead motion are among the most common candidates for impingement testing. In these groups, the Hawkins-Kennedy often turns positive even in shoulders that are not yet symptomatic, because chronic overhead use gradually narrows the subacromial space and irritates the bursa and tendons. A positive test in a swimmer with no current pain does not necessarily mean injury is imminent, but it does signal that the tissue margins are tight.

Preventive exercise programs targeting shoulder mechanics in these populations can make a real difference. A case study of collegiate swimmers found that a corrective exercise program focusing on upper-extremity movement dysfunction reduced relative injury risk by about 44 percent over a competitive season.¹² Screening tests like the Hawkins-Kennedy are sometimes used in these programs not as diagnostic endpoints but as movement screens to identify athletes who could benefit from targeted strengthening or mobility work before a problem fully develops.

What To Do if Your Test Comes Back Positive

If a clinician tells you your Hawkins-Kennedy was positive, what happens next depends on the full clinical picture. In most cases, a positive result combined with a history of pain with overhead activity and pain at night when lying on the affected side will point toward subacromial impingement as the working diagnosis. Your clinician will probably also test your rotator cuff strength, check your range of motion, and may perform additional provocative tests to rule out other causes.

Imaging is not always necessary right away. For a first episode of shoulder impingement symptoms, many guidelines suggest trying a course of physical therapy for six to twelve weeks before ordering an MRI or ultrasound. Imaging becomes more urgent if there is significant weakness that suggests a rotator cuff tear, if symptoms are not improving with therapy, or if there was a traumatic injury. An X-ray can show bony spurs or a hooked acromion that might explain the impingement, but it will not show the soft tissue. MRI or diagnostic ultrasound is needed to visualize the tendons, bursa, and labrum directly.

The Hawkins-Kennedy can also serve as a rough tracking tool during rehabilitation. If the test was strongly positive at your first visit and becomes less painful or negative over weeks of therapy, that is an encouraging sign that whatever was being compressed is getting more room, whether from improved posture, stronger rotator cuff muscles pulling the humeral head down, or reduced inflammation. It is not a rigorous outcome measure in the way that a validated questionnaire would be, but the change in provocation over time can help you and your therapist gauge progress.

When the Test Misleads

There are a few situations where the Hawkins-Kennedy is particularly unreliable. In older adults with stiff shoulders from adhesive capsulitis (frozen shoulder), the internal rotation component of the test may be limited by the capsular restriction itself, producing pain that has nothing to do with impingement. The test is essentially forcing a motion the joint cannot comfortably perform for a completely different reason. In people with shoulder instability, especially younger athletes with lax ligaments, the internal rotation can provoke apprehension or pain from the front of the joint being stretched rather than from subacromial compression. And in anyone with significant AC joint arthritis, the compression of the AC joint during the maneuver can be the pain source rather than the subacromial space.

Clinicians who are aware of these pitfalls will combine the Hawkins-Kennedy with other tests specifically designed to assess those alternative diagnoses. A positive cross-body adduction test might point to the AC joint. Apprehension and relocation tests address instability. Passive range-of-motion testing in multiple directions can reveal the global restriction pattern typical of frozen shoulder. The Hawkins-Kennedy’s job is not to be the final word. It is to be a quick, inexpensive first pass that narrows the list of possibilities and guides the next step in the evaluation.