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Neer Impingement Test
The Neer Impingement Test is a physical exam maneuver used to diagnose shoulder impingement syndrome. It is done by asking the patient to hold their arm out in front, perpendicular to their body with the thumb pointing up. The examiner then places their hands around the side of the shoulder and applies downwards pressure while rotating the shoulder inward. This can reproduce the pain associated with shoulder impingement syndrome, allowing diagnosis of the condition.
Transcript
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This is Brent of the Brookbush
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...blank
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Institute, and in this video we're going over
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the Neer Impingement Test, a special or
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orthopedic test used during our shoulder
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examination. I'm going to have my friend,
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Melissa, come out. She's going to help me
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demonstrate. This isn't a
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particularly complicated test. I'm going
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to take Melissa through passive shoulder
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flexion in the scapular plane with her
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humorous internally rotated, and then I'm
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going to add a little over-pressure to
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see if I can provoke symptoms.
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I'm going
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to grab Melissa just underneath the
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elbow with an underhanded grip. I'm
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going to use this hand to stabilize her
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scapula and thorax, because as I
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push up this way, I don't want a bunch of
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scapular elevation. That's not great.
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As I go into over-pressure, I don't
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want to just push her off the table
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Last I checked, if you push
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somebody over the table, they don't come
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back, and then you're not fixing anything.
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We want to make sure she stays on the
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table and that she's stabilized. I'm going to go
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ahead and turn her arm in this way, take
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her through all the flexion she has in
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the scapular plane, and then like I said,
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I'm going to add a little bit of over-
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pressure. I'll take her just past that
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normal end range. Here's the key,
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"Are those the symptoms you were talking
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about?" If those are the symptoms that she
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was talking about, then I have a positive
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Neer Test and a good indication that
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impingement is what is bothering Melissa.
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Keep in mind that if she had pain
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but those was not her symptoms, I need to
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continue doing my testing to figure out
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where her pain is coming from.
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Although she may or may not have
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shoulder impingement, that's not what she
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came in complaining about. I need to fix what
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she's complaining about first. Maybe we
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can address this at a later date.
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What's the intent of the Neer Test?
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The intent of the Neer Test is to
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provoke symptoms in inflamed tissues.
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With an impingement syndrome, we're
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assuming that these inflamed
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tissues are being caused by pinching
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between the humeral head and what we can
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call the roof of the shoulder, which is
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the inferior surface of the acromion
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and the coracoacromial ligament.
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Under there, we have things like your
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supraspinatus and infraspinatus tendon,
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the biceps tendon, the long head
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of your biceps tendon, we have your
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subacromial bursa, and we
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even have the superior portion of the
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capsule itself for the shoulder. All those
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things could be getting inflamed, because
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Melissa's shoulder isn't working right.
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Let's say she has some sort of arthrokinematic
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dyskinesis that is causing
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these tissues to get compressed or
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rubbed more than they can handle during
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functional activities. Maybe she's a
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volleyball player and just continually
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reaching overhead with poor shoulder
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mechanics is causing all of this stuff
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to get irritated. In the Neer Test, I've
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taken the greater tubercle and moved it
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into a position where I can smash it
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against the roof of the shoulder here,
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that subacromial space. If I get her
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symptoms, I should have a pretty good
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indicator that that's what's bothering
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her. Why is this such a commonly used
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test? I think this is a commonly used
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test, because it looks very much like the
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Maitland joint exams that we've
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all done- that active motion with
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over-pressure. "Melissa, can you raise
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your arm up? Good. Does that hurt?
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Does that hurt? No, all right. Clear. Good. Let
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me have you go out into abduction all
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the way up. Does that hurt? Good.
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Does that hurt? If I do this,
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though,
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does that hurt? Yes." Maybe we're
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getting a little bit more sensitivity
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out of the fact that we're internally
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rotating the humorous and she's doing this
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in the scapular plane. Maybe that's a
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more provocative test. The truth of the
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matter is that the Neer Test isn't a
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great test by itself. Why am I
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teaching this to you? It's important
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that you know this test. This is a very
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commonly used test, and you're going to
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see things like a positive Neer on
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various paperwork that heads your way.
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Maybe a doctor notes positive Neer Test
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and you need to understand what that is.
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What is happening now, because of
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research, when we talk about things like
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sensitivity and specificity, is we're
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realizing a lot of these orthopedic
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tests or special tests
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aren't great, so we'll cluster them.
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The Neer Test is part of many of those
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clusters. I think part of the problem
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with all of our impingement tests is the
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fact that they're usually okay too good
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on the sensitivity part,
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but the specificity is really bad. I
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think what you guys will find as you
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practice is that just about every
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dysfunction of the shoulder starts
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leading to some impingement syndrome
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signs, and that should kind of
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make sense to us. If you have
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a labral tear, your shoulder's not going
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to move well. If it doesn't move well,
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things are going to get rubbed and then
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pinched, and it's going to start getting
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inflamed. Something like bashing your
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humeral head into the underside of your
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shoulder is going to hurt. We don't
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have a very specific test, because if
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somebody has a labral tear, maybe rotator
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cuff tear, maybe posterior capsule impingement
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versus internal- it all kind of
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gets mashed together in these tests.
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How do I use these tests? I'm going
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to go ahead and start with her
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subjective examination. That's going to
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help a lot. Did this come on
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gradually or was it acute trauma? If it's
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acute trauma, impingement might not be my
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first hypothesis.
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If she has signs of upper body
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dysfunction in my movement assessment,
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like in my overhead squat assessment her
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arms fall forward and she has scapular
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elevation, and she said that this came on
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gradually during her subjective
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assessment. Okay. I'm starting to
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think towards impingement. So, where does
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Neer come in? I'm probably
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going to do Neer in a cluster of tests,
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which we're going to go over as we break
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down each one of these tests
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individually. Most importantly, is this
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the test that gets me to her symptoms? If
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it does, this becomes a great quick test
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for me to do pre- post-assessment both as
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she's coming in from session to session,
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as well as maybe I'm going to try a new
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intervention and I want to see if it has
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any affect on her shoulder. I can quickly
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do this test. Let's say I have her
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come in, "How do you feel? Pain?
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Yes." I do posterior deltoid release. "How
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does this feel? Any better? Yes." Oh, good.
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That's one more intervention that I know
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is going to be effective, or maybe it's even
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something I could add to her home
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exercise program. That's where
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tests like this become super, super
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helpful. The other thing you might think
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of, which is a little outside of the
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box, is as we show you different
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special tests, you'll see that this one
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is very flexion related. If I'm
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missing a bunch of flexion and flexion
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causes her pain, I might start thinking
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about, "Well, what's restricting flexion? Is
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there a movement impairment that I can
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draw from this test? The
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muscles that happen to restrict end range
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flexion are also my internal rotators.
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We know a lot of us sit like this, so
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maybe I need to look at releasing things
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like my subscapularis, my latissimus
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dorsi, my teres major, my pectoralis
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major, and maybe do a little stretching and
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lengthening of those structures to see
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if I can get a little extensibility back
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and bring everything back down
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to normal. Here's one more
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review of what the Neer Test looks like.
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Grab just below the elbow, internally
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rotate, go through the scapular plane with
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over-pressure, and then ask, "Does that replicate the
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symptoms you were talking about?" If she
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says yes, then I have a positive Neer and
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one more indicator in a cluster of signs-
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this is just one clue- that we might have
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impingement syndrome. I hope you guys
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enjoyed this video. I'll talk with you soon.
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