eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Rotator Cuff Injuries: Differential Diagnoses & Workup

Author: Eileen C Quintana, MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Apr 15, 2009

Differential Diagnoses

Cervical Strain
Dislocations, Shoulder
Myocardial Infarction
Myopathies

Other Problems to Be Considered

Avascular necrosis of humerus
Acromioclavicular injury
Neurologic injuries (C5-C6) caused by repetitive trauma
Septic arthritis
Spleen rupture

Workup

Imaging Studies

  • Routine radiographic evaluations are an essential component of shoulder evaluation in the ED. Perform a routine radiographic examination in every patient with suspected rotator cuff injury. Shoulder radiography should include anteroposterior, axillary, and lateral views.
Normal plain radiograph of the shoulder in intern...

Normal plain radiograph of the shoulder in internal, external, and neutral positions.

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Normal plain radiograph of the shoulder in intern...

Normal plain radiograph of the shoulder in internal, external, and neutral positions.


  • A modified transscapular or supraspinatus outlet view is useful for surgical purposes. Radiographic changes are as follows5,6,7 :
    • Subacromial sclerosis (ie, "eyebrow" sign)
    • Osteophyte formation
    • Sclerosis and cystic changes in the greater tuberosity
    • Reduction of the acromiohumeral distance (<7 mm).

(Only the last 2 points were found to have 78% sensitivity and 98% specificity.)

  • Reserve advanced imaging modalities for suspected rotator tears with no improvement in symptoms, despite adequate therapy for 3-6 weeks.
    • Arthrography of the glenohumeral joint has been used to diagnose rotator cuff disease.8 A complete tear is diagnosed when communication between the glenohumeral joint cavity and the bursae, either subacromial or subdeltoid, is evident. Partial tears are better evaluated with ultrasonography or MRI.
    • Ultrasonography is also used to evaluate rotator cuff disease. The 4 criteria for rotator cuff pathology are nonvisualization of the cuff, localized absence or focal nonvisualization, discontinuity, and focal abnormal echogenicity. Sensitivity and specificity are operator dependent and have been reported to be greater than 90%.9,1
    • Magnetic resonance imaging (MRI) can reveal a great spectrum of rotator cuff disease from degeneration to partial or complete tears. MRI also can reveal soft tissue injuries. As a postoperative imaging modality, it has proven to be invaluable.
Full-thickness tear.

Full-thickness tear.

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Full-thickness tear.

Full-thickness tear.


More on Rotator Cuff Injuries

Overview: Rotator Cuff Injuries
Differential Diagnoses & Workup: Rotator Cuff Injuries
Treatment & Medication: Rotator Cuff Injuries
Follow-up: Rotator Cuff Injuries
Multimedia: Rotator Cuff Injuries
References
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References

  1. 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].

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

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

  4. 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].

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

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

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

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

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

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

  11. 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].

  12. 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.

  13. 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].

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

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

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

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

  18. 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. Jul 1999;81(7):991-7. [Medline].

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

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Further Reading

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Keywords

rotator cuff tears, shoulder pain, rotator cuff dysfunction, rotator cuff disease, glenohumeral instability, impingement syndrome, rotator cuff injury

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Contributor Information and Disclosures

Author

Eileen C Quintana, MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children
Eileen C Quintana, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine
Joseph A Salomone, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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