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Rotator Cuff Injury Clinical Presentation

  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Mar 25, 2015
 

History

A detailed history is important to diagnose a rotator cuff injury and can help rule out other diagnoses in the differential (eg, referred pain from the cervical spine, more serious referred symptoms of cardiac origin) (see Differential Diagnoses and Other Problems to Be Considered).

First, determine the patient's chief symptom (eg, pain, weakness, instability, limited ROM).

Direct further questions at how and when the problem began.

Determine if the patient's symptoms are related to a specific injury or event or to a repetitive motion or are of a more insidious onset.

Activities and arm positions that increase or decrease symptoms are also helpful in diagnosing and guiding treatment. Previous episodes of similar symptoms may give a useful clue to the patient's present condition.

The presence of associated symptoms (eg, instability, weakness, swelling, numbness, loss of motion, catching or popping of the shoulder) also provides helpful information.

Ask if previous treatments have been tried, including the use of ice, heat, or medications (eg, acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]).

Questions regarding previous medical treatment should include physical therapy, previous injections, and any surgical interventions.

A social history should include the patient's occupation and sport (including position) and level of athletic participation.

Pain, weakness, and loss of shoulder motion are common symptoms reported with rotator cuff pathology. Pain is often felt over the anterolateral part of the shoulder and is exacerbated by overhead activities. Night pain is a frequent symptom, especially when the patient lies on the affected shoulder.

Symptoms may be relatively acute, either following an injury or associated with a known repetitive overuse activity.

In elderly patients, symptoms are often insidious and with no specific injury. Repetitive motion can be associated with the symptoms.

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Physical

Approach the shoulder examination systematically in every patient with a suspected rotator cuff injuries. Expose the entire shoulder and perform inspection, palpation, ROM testing, motor strength testing, and special shoulder tests as clinically indicated.

Inspection

Examination begins with patient observation during the history portion of evaluation. Carefully inspect the shoulder from the anterior, lateral, and posterior positions. Note any swelling, atrophy, asymmetry, or other findings.

Supraspinatus and infraspinatus atrophy can be observed in massive rotator cuff tears and in entrapments of the suprascapular nerve.

Scapular winging is rare in rotator cuff injuries; however, ST motion abnormalities are often present and should be addressed as part of the treatment plan.

Palpation

Tenderness is often localized to the greater tuberosity and subacromial bursa.

The biceps tendon is palpated anteriorly in the bicipital groove and can become inflamed and painful in this condition.

ROM

Evaluate total active and passive ROM in all planes and scapulohumeral rhythm.

Maximal total elevation occurs in the plane of the scapula, which lies approximately 30° forward of the coronal plane.

Patients with rotator cuff tears tend to have a decrease in GH motion and an increase in ST motion during active shoulder elevation.

Decreased active elevation with normal passive ROM is usually observed in rotator cuff tears secondary to pain and weakness. When both active and passive ROM are decreased similarly, this usually suggests onset of adhesive capsulitis.

Assess internal rotation by having the patient reach an extended thumb up the spine. Patients with normal internal rotation reach the T5-T10 level. Note that overhand throwers often develop excess external rotation (up to 15-20°) on the throwing side, which is usually accompanied by loss of internal rotation on the same side.

Note any accompanying pain and specific pain location in ROM testing.

The impingement syndrome associated with rotator cuff injuries tends to cause pain with elevation ranging from 60-120° when the rotator cuff tendons are compressed against the anterior acromion and coracoacromial ligament.

Strength testing

Perform strength testing to isolate the relevant muscles individually.

The anterior cuff (subscapularis) can be assessed using the lift-off test, which is performed with the arm internally rotated behind the back.

Lifting the hand away from the back against resistance tests the strength of the subscapularis muscle.

The posterior cuff (infraspinatus and teres minor) is isolated best in 90° of forward flexion with the elbow flexed to 90°, testing external rotation.

Significant weakness in external rotation is observed in large rotator cuff tears.

Using either of 2 techniques described in the literature can test the supraspinatus muscle. Jobe and Moynes suggested that the best position for isolating the supraspinatus is with the elbow extended, the shoulder in full internal rotation, and the arm in the scapular plane (thumbs down position).[20]

In another report, Blackburn et al recommended testing in the prone position, with the elbow extended and the shoulder abducted to 100° and externally rotated while the patient lifts in abduction (thumbs up position).[17]

Malanga et al noted that although both techniques significantly activate the supraspinatus muscle, neither truly isolates this muscle for testing because other muscles are active in both positions.[21]

Dropping of the arm in either position usually indicates a significant supraspinatus muscle tear. More subtle weakness may represent early degeneration of the rotator cuff.

Testing of the scapula rotators (trapezius and serratus anterior) is also important. Serratus anterior weakness can be observed by having the patient lean against a wall. Winging of the scapula as the patient pushes against the wall indicates serratus anterior weakness.

Drop-arm test

Abduct the patient's shoulder to 90° and ask the patient to lower the arm slowly to the side in the same arc of movement.

Severe pain or inability of the patient to return the arm to the side slowly indicates a positive test result.

A positive result indicates a rotator cuff tear.

Neer impingement test

The shoulder is forcibly forward flexed and internally rotated, causing the greater tuberosity to jam against the anterior inferior surface of the acromion.

Pain reflects a positive test result and indicates an overuse injury to the supraspinatus muscle and possibly to the biceps tendon. See the image below.

Neer impingement test. The patient's arm is maxima 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.

Hawkins-Kennedy impingement test

Perform this test by forward flexing the shoulder and elbow to 90° and forcibly internally rotating the shoulder.

Pain indicates a positive test result and is due to supraspinatus tendon and greater tuberosity impingement under the coracoacromial ligament and coracoid process. See the image below.

Hawkins test. The examiner forward flexes the arms Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.

Apprehension test

Abduct the arm 90° and fully externally rotate, while placing anteriorly directed force on the posterior humeral head from behind.

The patient becomes apprehensive and resists further motion if chronic anterior instability is present.

Relocation test

Perform the apprehension test with the patient supine and the shoulder at the edge of the table.

In a positive relocation test result indicative of anterior instability, a posteriorly directed force on the proximal humerus causes resolution of the patient's apprehension and usually allows more external rotation of the humerus.

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Causes

Several primary causes of rotator cuff pathology have been described, including age-related degeneration, compromised microvascular supply, and primary outlet impingement. Secondary factors (eg, GH instability) also appear to be related to rotator cuff injuries.

Age-related degeneration [22]

Intrinsic tendinopathy is an age-related degenerative process.

Uhthoff and Ozaki found an increase in frequency of partial-thickness and full-thickness tears with increasing age.

Increased degenerative changes are observed in athletes and workers who perform overhead motions.

Compromised microvascular supply

In 1934, Codman first described a critical zone in the supraspinatus tendon where a tenuous blood supply exists.[1]

A decrease in vascularity is noted with aging.

In 1970, Rathburn and Macnab showed that shoulder position is important for proper vascular supply to the rotator cuff.[23]

The term "wringing out" was coined to describe the reduced blood flow that occurs upon shoulder adduction.

The microvascular pattern of the supraspinatus tendon is thought to be nonhomogenic in cadavers.[24]

In 1990, Lohr and Uhthoff found that the bursal side of the supraspinatus tendon has a higher blood supply compared to the articular surface.[24] This difference in blood supply is thought to contribute to the increased incidence of articular surface tears compared with bursal tears.

Outlet impingement

The rotator cuff is surrounded by the coracoacromial arch, which comprises the supraspinatus outlet and consists of the acromion, coracoacromial ligament, and coracoid process.

The shape of the acromion has been implicated in rotator cuff pathology.

Bigliani and Morrison classified 3 types of acromions based on cadaveric examination, as follows[6] :

  • Type I – Flat
  • Type II – Curved
  • Type III – Hooked

Bigliani noted a significant increase in rotator cuff tears in curved (type II) and hooked (type III) acromions. This work has led to the belief that rotator cuff pathology occurs secondary to the type of acromion and that treatment should be directed toward correcting pathoanatomic changes by making the acromion smoother and flatter. However, debate exists concerning whether the acromion shape causes pathology to the rotator cuff or is a result of a diseased rotator cuff that secondarily causes bony changes to the acromion.

Neer proposed that acromial changes are secondary to rotator cuff tendinopathy.[3] According to this view, the initial process is migration of the humeral head superiorly with repeated impingement, followed by secondary bony changes to the undersurface of the anterior acromion. This view was further corroborated by the work of Yamanaka and Fukuda, who found a greater incidence of partial rotator cuff tears on the articular surface of the rotator cuff rather than the bursal surface.[22] If acromial changes actually caused rotator cuff tendinopathies, one would expect the opposite (ie, higher incidence of pathology on the bursal surface).

The rotator cuff contacts the coracoacromial arch undersurface in the normal shoulder.

The coracohumeral ligament is often resected in order to decompress the supraspinatus outlet, which can lead to increased superior translation of the humeral head, particularly in the young athlete.

Rotator cuff abrasions and fiber failure occur when repeated and excessive compression from humeral head migration is present.

This occurs secondary to underlying muscular imbalance and loss of rotator cuff depressor effects.

Instability

Most people with ligamentous laxity are functionally stable. In patients with inherent shoulder or generalized laxity, instability may develop with minimal or no injury.

Ligamentous laxity may be acquired by repetitive stretching of the joint, as observed in swimmers, gymnasts, and tennis players.

Dynamic stability may be lost if the shoulder becomes deconditioned. As a result, a vicious self-perpetuating cycle of instability, less use, more muscle weakness, and more instability is present.

These patients frequently have relative rotator cuff muscle weakness, particularly the external rotators and scapular stabilizers.

Subtle instability patterns may contribute to the impingement development.

Increased anterior and superior translation of the humeral head, as observed in athletes with generalized laxity and multidirectional instability of the shoulder, may predispose to impingement along the coracoacromial arch, resulting in rotator cuff injury.

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Contributor Information and Disclosures
Author

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Coauthor(s)

Jay E Bowen, DO Assistant Professor, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School

Jay E Bowen, DO is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, North American Spine Society, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American College of Sports Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

Christopher J Visco, MD Assistant Professor, Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons; Assistant Residency Program Director, New York Presbyterian Hospital

Christopher J Visco, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Medical Student Association/Foundation, Association of Academic Physiatrists, International Spine Intervention Society

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.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Andrew L Sherman, MD, MS Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of Medicine

Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Acknowledgements

Stephen G Andrus, MD Sports Medicine Fellow, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey

Stephen G Andrus, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

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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.
Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.
Rotator cuff injury.
 
 
 
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