diagnostic value of a modified Neer test in identifying subacromial impingement
Goushen Y, Chongxi R,
Guoqing C, Junling X, and Hailong J. Eur
J Orthop Surg Traumatol.
2017. [Epub Ahead of Print].
Home Message: A modified Neer test may be beneficial at differentiating between
subacromial impingement syndrome and frozen shoulder.
Subacromial impingement syndrome is a
common shoulder injury in both athletes and non-athletes. While the Neer test
is the most common special test for diagnosing subacromial impingement syndrome,
it is also positive in patients with frozen shoulder. Therefore, Goushen and colleagues
completed a single-center, prospective study to evaluate the diagnostic accuracy
of a modified Neer test in diagnosing subacromial impingement syndrome and
ruling out frozen shoulder. The authors included 82 consecutive outpatients (50
males, 85 shoulders, 15 to 65 years of age) complaining of symptoms relating to
shoulder disease. Following x-ray, magnetic resonance imaging, and clinical
exam, a clinician confirmed the diagnosis based on established diagnostic
criteria. The most common diagnoses were ~47% of shoulders with subacromial
impingement syndrome, 15 shoulders with frozen shoulder, 13 shoulders had
reoccurring dislocations and 9 had labrum injuries and rotator cuff tears. Clinicians
also performed both the modified and classical Neer test on all patients. The
modified Neer test differs from the classical Neer test as the patient’s affected arm is abducted to 90 degrees in
the scapular plane with the palm down and then will be externally rotated to 90
degrees with the onset of symptoms being a positive test. Overall, the
specificity and sensitivity of the modified Neer test for impingement syndrome was
96% and 85% respectively (overall accuracy = 91%). This was an improvement
compared to the classical Neer test, which had a sensitivity and specificity of
90% and 50% respectively (accuracy = 69%). The classical Neer test was
incorrectly positive when patients had frozen shoulder. In contrast, the
modified Neer test correctly tested negative for these patients.
Overall, the authors introduce a
modified version of the Neer test that may be useful, especially when the
patient may have frozen shoulder. The results of this study suggest that the
modified Neer test is a more accurate test compared to the classical Neer test.
This modified test was not only accurate in its diagnosis of subacromial
impingement syndrome but it also accurately ruled out frozen shoulder. For
example, 34 out of 36 shoulders with a positive modified test had impingement
syndrome and the test only missed 6 cases of impingement syndrome. In contrast,
the classical Neer test missed classified 22 shoulders with impingement and
missed 4 cases of impingement. It’s important to note that it is unclear
whether the assessor was blinded to the diagnosis. While this is likely, it
would be beneficial to see these findings replicated by an independent group in
another sample of patients. The clinical usefulness of these results may depend
on your patient population. While all clinicians should strive to use the most
accurate tests, clinicians who see patients at high risk for frozen shoulder,
will find this test more useful than those clinicians who rarely see these
patients. Ultimately, the modified Neer test may be a new, valuable tool in the
clinician’s arsenal for evaluating shoulder pathology. Until more research can
verify these results, clinicians should consider using both tests to get the
best overall impression of their patient’s injury and to determine which test
they think is performing best in their clinic with their patients.
Questions for Discussion: What setting are you currently
in and within that setting, do you encounter many patients with frozen
shoulder. If so, would you consider using the modified Neer test in future
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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