Medscape is available in 5 Language Editions – Choose your Edition here.


Rotator Cuff Injuries Clinical Presentation

  • Author: Eileen C Quintana, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
Updated: Feb 12, 2016


Assess any patient with shoulder pain with respect to the patient's age and occupation. Characterize pain according to its duration of onset, location, radiation, timing, and quality. In addition, investigate pain for its relationship to activities and sport.

  • Pain is the most common symptom encountered with rotator cuff injury.
    • Pain usually is located anterolaterally and superiorly and referred to the level of the deltoid insertion with full-thickness tears.
    • Pain is aggravated in activities where the arm must be in an overhead or a forward-flexed position.
    • In an acute injury, pain suddenly is elicited after a fall, after lifting of a heavy object, or even after a trivial amount of force.
  • Following pain, weakness and limitation of motion are the next most common symptoms of a rotator cuff tear.
  • The patient also may complain of clicking, catching, stiffness, and crepitus.

In a study of 217 patients who presented to an emergency department after a trauma to the shoulder without fracture or dislocation, one year after trauma, 20 patients were diagnosed with a symptomatic rotator cuff rupture. The authors noted that normal radiography does not exclude the presence of a rotator cuff tear in patients with a history of shoulder trauma and that regular follow-up is essential for discovering rotator cuff injuries. In this study, 32% still suffered from shoulder pain 1 year after shoulder trauma, and reexamination revealed a prevalence of 9% symptomatic rotator cuff ruptures.[11]



Approach the shoulder examination systematically in every patient with inspection, palpation, range of motion, strength testing, neurologic assessment, and performances of special shoulder tests. Also, include evaluation of the cervical spine and upper extremity.

  • Inspect for scars, color, edema, deformities, muscle atrophy, and asymmetry.
  • Palpate the bony and soft-tissue structures, noting any areas of tenderness.
    • The subdeltoid and subacromial bursae can be palpated anteriorly under the acromion, and laterally with the deltoid muscle and the arm in extension.
    • The supraspinatus is palpated anteriorly when the arm is externally rotated and flexed.
    • Hyperextension permits the palpation of the infraspinatus.
  • Assess active and passive range of motion. Note any pain elicited and loss of motion.
    • Determine muscle strength.
    • The supraspinatus is isolated with the arm forward 90 degrees in the scapular plane and the forearm rotated into pronation (ie, thumbs down). If drooping of this position occurs, full-thickness rotator cuff tears are suggested.
    • The subscapularis may be tested with the arm at the side with internal rotation resistance. However, this can produce false-negative results; instead, place the arm internally rotated with the dorsum on the buttock surface and actively lift the hand from the buttocks against resistance.
    • The external rotators, teres minor, and infraspinatus can be tested with the arm on the side and in 90 degrees of abduction.
  • Neer impingement test: An injection of 1% lidocaine into the subacromial bursae, using the lateral or posterior approach, creates signs of relief on forward flexion in patients with rotator cuff disease, distinguishing cuff disease from other sources of shoulder pain. However, rotator cuff tears are not distinguished from early stages of inflammation or fibrosis.
    Neer impingement test. The patient's arm is maximaNeer impingement test. The patient's arm is maximally elevated through forward flexion by the examiner, causing a jamming of the greater tuberosity against the anteroinferior acromion. Pain elicited with this maneuver indicates a positive test result for impingement.


An emerging consensus suggests that the etiology of rotator cuff disease is multifactorial. Extrinsic factors exist, such as the morphology of the coracoacromial arch, tensile overload, repetitive use, and kinematics abnormalities. Intrinsic factors also exist, such as altered tendon vascular supply, microstructural collagen fiber abnormalities, and regional variations.

Contributor Information and Disclosures

Eileen C Quintana, MD Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children; Adjunct Clinical Professor, Departments of Pediatrics and Emergency Medicine, Temple University Hospital

Eileen C Quintana, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

  1. Yuen CK, Mok KL, Kan PG. The validity of 9 physical tests for full-thickness rotator cuff tears after primary anterior shoulder dislocation in ED patients. Am J Emerg Med. 2012 Oct. 30 (8):1522-9. [Medline].

  2. Millstein ES, Snyder SJ. Arthroscopic evaluation and management of rotator cuff tears. Orthop Clin North Am. 2003 Oct. 34(4):507-20. [Medline].

  3. Dalton SE. The conservative management of rotator cuff disorders. Br J Rheumatol. 1994 Jul. 33(7):663-7. [Medline].

  4. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg. 2010 Apr. 110(4):1170-9. [Medline].

  5. Douglas D. Synthetic Patch Associated With Better Outcomes Than Collagen in Rotator Cuff Repair. Medscape. Apr 3 2014. [Full Text].

  6. Ciampi P, Scotti C, Nonis A, et al. The benefit of synthetic versus biological patch augmentation in the repair of posterosuperior massive rotator cuff tears: a 3-year follow-up study. Am J Sports Med. 2014 Mar 14. [Medline].

  7. Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. J Bone Joint Surg Br. Feb 2009. 91(2):196-200. [Medline].

  8. Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. 2007 Jun. 15(6):340-9. [Medline].

  9. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician. 1998 Feb 15. 57(4):667-74, 680-2. [Medline].

  10. Hayes K, Ginn KA, Walton JR, Szomor ZL, Murrell GA. A randomised clinical trial evaluating the efficacy of physiotherapy after rotator cuff repair. Aust J Physiother. 2004. 50(2):77-83. [Medline].

  11. Valkering KP, Stokman RD, Bijlsma TS, Brohet RM, van Noort A. Prevalence of symptomatic rotator cuff ruptures after shoulder trauma: a prospective cohort study. Eur J Emerg Med. 2014 Oct. 21 (5):349-53. [Medline].

  12. SooHoo NF, Rosen P. Diagnosis and treatment of rotator cuff tears in the emergency department. J Emerg Med. 1996 May-Jun. 14(3):309-17. [Medline].

  13. Fuchs S, Chylarecki C, Langenbrinck A. Incidence and symptoms of clinically manifest rotator cuff lesions. Int J Sports Med. 1999 Apr. 20(3):201-5. [Medline].

  14. Miniaci A, Salonen D. Rotator cuff evaluation: imaging and diagnosis. Orthop Clin North Am. 1997 Jan. 28(1):43-58. [Medline].

  15. Hashefi M. Ultrasound in the diagnosis of noninflammatory musculoskeletal conditions. Ann N Y Acad Sci. Feb 2009. 1154:171-203. [Medline].

  16. McGarvey C, Harb Z, Smith C, Houghton R, Corbett S, Ajuied A. Diagnosis of rotator cuff tears using 3-Tesla MRI versus 3-Tesla MRA: a systematic review and meta-analysis. Skeletal Radiol. 2016 Feb. 45 (2):251-61. [Medline].

  17. Roy JS, Braën C, Leblond J, Desmeules F, Dionne CE, MacDermid JC, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. Br J Sports Med. 2015 Oct. 49 (20):1316-28. [Medline].

  18. Hanusch BC, Goodchild L, Finn P, Rangan A. Large and massive tears of the rotator cuff: functional outcome and integrity of the repair after a mini-open procedure. J Bone Joint Surg Br. Feb 2009. 91(2):201-205. [Medline].

  19. Zumstein MS, Jost B, Hempel J, Hodler J, Gerber C. The clinical and structural long-term results of open repair of massive tears of rotator cuff. J Bone Joint Surg Am. Nov 2008. 90(11):2423-31.

  20. Morse K, Davis AD, AFra R, Kaye EK, Schepsis A, Voloshin I. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. Sept 2008. 26(9):1824-1828. [Medline].

  21. Tonino PM, Gerber C, Itoi E, Porcellini G, Sonnabend D, Walch G. Complex shoulder disorders: evaluation and treatment. J Am Acad Orthop Surg. 2009 Mar. 17(3):125-36. [Medline].

  22. Rudzki JR, Shaffer B. New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears. Clin Sports Med. 2008 Oct. 27(4):691-717. [Medline].

  23. Barr KP. Rotator cuff disease. Phys Med Rehabil Clin N Am. 2004 May. 15(2):475-91. [Medline].

  24. Kweon C, Gagnier JJ, Robbins CB, Bedi A, Carpenter JE, Miller BS. Surgical Versus Nonsurgical Management of Rotator Cuff Tears: Predictors of Treatment Allocation. Am J Sports Med. 2015 Oct. 43 (10):2368-72. [Medline].

  25. Lazarides AL, Alentorn-Geli E, Choi JH, Stuart JJ, Lo IK, Garrigues GE, et al. Rotator cuff tears in young patients: a different disease than rotator cuff tears in elderly patients. J Shoulder Elbow Surg. 2015 Nov. 24 (11):1834-43. [Medline].

  26. Wessel J, Razmjou H, Mewa Y, Holtby R. The factor validity of the Western Ontario Rotator Cuff Index. BMC Musculoskelet Disord. 2005 May 4. 6:22. [Medline]. [Full Text].

  27. Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am. 2012 Apr 18. 94(8):e481-6. [Medline].

  28. Abate M, Schiavone C, Di Carlo L, Salini V. Prevalence of and risk factors for asymptomatic rotator cuff tears in postmenopausal women. Menopause. 2013 Jun 10. [Epub ahead of print]. [Medline].

  29. Brooks M. Silent rotator cuff tears common in older women. Reuters Health Information. July 5, 2013. Available at Accessed: July 22, 2013.

  30. Quillen DM, Wuchner M, Hatch RL. Acute shoulder injuries. Am Fam Physician. 2004 Nov 15. 70(10):1947-54. [Medline].

  31. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Long-term functional outcome of repair of large and massive chronic tears of the rotator cuff. J Bone Joint Surg Am. 1999 Jul. 81(7):991-7. [Medline].

  32. Soslowsky LJ, Carpenter JE, Bucchieri JS, Flatow FL. Biomechanics of the rotator cuff. Orthop Clin North Am. 1997 Jan. 28(1):17-30. [Medline].

Rotator cuff, normal anatomy.
Rotator cuff tear, anterior view.
The acromioclavicular arch and the subacromial bursa.
Neer impingement test. The patient's arm is maximally elevated through forward flexion by the examiner, causing a jamming of the greater tuberosity against the anteroinferior acromion. Pain elicited with this maneuver indicates a positive test result for impingement.
Rotator cuff injury.
Normal intratendinous signal.
Partial-thickness tear seen better on angled oblique sagittal views.
Full-thickness tear.
Normal plain radiograph of the shoulder in internal, external, and neutral positions.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.