Rotator Cuff Pathology Clinical Presentation

Updated: Nov 30, 2015
  • Author: R H Bilal, MBBS, MRCS; Chief Editor: S Ashfaq Hasan, MD  more...
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Presentation

History

Patients with rotator cuff pathology commonly present with an activity related dull ache in their upper lateral (outer) arm and shoulder. Activity is usually most difficult above shoulder level. Many people have little or no discomfort with below-shoulder-level activities such as golf, bowling, gardening, writing, or typing. Conversely, tennis, baseball/softball, basketball, swimming, and painting are more problematic.

A complete medical history should be obtained to direct the physical examination and make the correct diagnosis. Most of the time, the diagnosis can be made following a systematic history. Relevant history findings, treatments, and test results should complement the history of the present injury. Sometimes, relevant social and family histories are necessary.

Patients with degenerative rotator cuff disease are almost always older than 40 years. About 50% of patients have a progressive onset of shoulder pain, whereas the other 50% can identify a specific event responsible for the onset of pain. The evolution of rotator cuff disease is characterized by variable episodes of recurrence following more intensive shoulder activities, followed by remission with rest or treatment.

As the disease progresses, shoulder pain becomes more constant. Overhead and arm-length activities typically increase the pain. Discomfort and night pain can also be present. With time, the individual can notice some weakness during shoulder elevation. Crepitus can also be noted. With evolution of the disease, shoulder pain can be accompanied by cervical and mid-back pain.

The following questions should help the physician assess the patient:

  • What is the patient's age? Shoulder pain in young overhead athletes suggests underlying shoulder instability. In older patients, degenerative rotator cuff disease or frozen shoulder is suggested by shoulder pain.
  • What is the patient's occupation or sport? Repetitive overhead activities and sports predispose to rotator cuff tendinitis.
  • What was the mechanism of injury? A fall on an outstretched arm could indicate a dislocation of the glenohumeral joint or a fracture of the humeral neck. Repetitive overhead motions can cause tendinitis and, in the long run, chronic degenerative changes. A fall or a trauma on the tip of the shoulder can result in an acromioclavicular sprain.
  • What was the onset? Insidious, slow onset may suggest tendinitis or osteoarthritis. Sudden onset is usually due to a trauma causing a fracture, dislocation, or a rotator cuff tear.
  • Where is the pain located? Pain located on the superior or lateral aspect of the shoulder suggests rotator cuff tendinitis. Pain on the anterior aspect of the shoulder may result from bicipital tendinitis, an acromioclavicular sprain, or anterior instability. Neck pain and radicular pain or paresthesias suggest a cervical spine disorder.
  • What is the severity of the pain? An acute burning pain could indicate an acute bursitis. An intermittent dull pain may be due to a degenerative rotator cuff disease.
  • What is the type of pain? Sharp, burning pain suggests a neurologic origin. Bone and tendon pain is deep, boring, and localized. Muscle pain is dull and aching, is not localized, and may be referred to other areas. Vascular pain is aching, cramplike, and poorly localized, and it may be referred to other areas.
  • What is the duration of the symptoms? Frozen shoulder has three stages that can last up to 3-4 years. Acute bursitis has a short-term evolution and responds well to nonsteroidal anti-inflammatory drugs (NSAIDs).
  • What is the timing of the pain? Predominantly night pain suggests frozen shoulder. Morning pain and stiffness improved by activity may be caused by a synovitis. Pain that increases with activity is usually the result of a rotator cuff tendinitis.
  • Which activities/positions increase the pain? Pain increased by overhead activities or arm-length activities suggests rotator cuff tendinitis. Pain increased when throwing is likely to be due to anterior instability. Pain increased by lying on the affected shoulder may be caused by an acromioclavicular sprain.
  • Which activities/positions relieve the pain?
  • Is there any weakness or paresthesia in the upper extremities? Neurologic symptoms are caused by a cervical radiculopathy or peripheral nerve entrapment/lesion.
  • Are the symptoms constant or intermittent? Intermittent symptoms usually result from soft-tissue or joint disorders. Constant symptoms suggest a neurologic lesion.
  • Is joint-motion restriction present? Passive and active joint restriction in all directions of range of motion (ROM) is caused by a frozen shoulder or glenohumeral synovitis. Restriction in internal rotation suggests an impingement syndrome due to rotator cuff tendinitis. The inability to perform active abduction suggests a rotator cuff tear or a frozen shoulder.
  • Is some crepitus noted? Crepitus is the result of degenerative rotator cuff changes. Crepitus is not a normal finding in the shoulder.
  • Have any changes in the color of the arm occurred? Color changes may be due to ischemia secondary to vascular insufficiency. Reflex sympathetic dystrophy (also termed complex regional pain syndrome, type 1) can cause skin-color changes.
  • Has the patient had any treatments such as oral medication, injections, or physical therapy to date?
  • Has the patient had any diagnostic tests performed to date?
  • What is the evolution of the symptoms?
  • Has the pain changed?
  • Has the pain spread or moved?
  • Has the pain subsided or increased? The last 3 questions help in deciding the appropriate treatment and management.

The importance of obtaining a systematic and detailed history cannot be overemphasized. Any attempt to shortcut the process leads to a nonfocused physical examination and an inaccurate diagnosis. In one study assessing the interobserver agreement of a diagnostic classification of shoulder disorders based on history and physical examination, there was only moderate agreement between experienced observers.

Next:

Physical Examination

A systematic examination of the shoulder region includes the following:

  • Careful observation
  • Palpation of the bones and soft tissues
  • Assessment of passive and active ROM
  • Impingement and topographic tests, complemented, as needed, by instability tests, labrum tests, and special tests

The examination is completed by a cervical spine examination, along with neurologic and vascular examination.

Observation

The observation begins from the moment the patient enters the room. The smoothness and symmetry of the shoulders and the movements of the upper extremities are evaluated, as is the patient's gait. The examiner must be aware of any signs of painful posturing and irregularity of motion of the affected shoulder. Bilateral examination allows for comparison of the affected shoulder with the unaffected one.

The patient then must be asked to remove the appropriate amount of clothing to facilitate proper assessment of the bone and soft tissues. The shoulder, cervical region, and entire upper extremity must be assessed. The examiner should assess bones and joints for possible asymmetry or deformities and should assess for soft-tissue changes (eg, swelling, erythema, white shiny skin, loss of hair, atrophy) suggestive of vasomotor abnormalities. Scars and abrasions also must be noted. The observer should assess bony contours first and then soft tissues. Observation of the patient must be completed from the front, side, and back.

Looking at bony contours, the examiner makes a general assessment. The dominant side may be lower than the nondominant one; the head and neck should be in the midline; the clavicle should be symmetric without any deformity of the acromioclavicular joint and sternoclavicular joint.

Each of these parts is then examined in more detail. Because of its superficial location, a fracture of the clavicle or a subluxation or dislocation of both ends is easy to identify. A step deformity of the acromioclavicular or sternoclavicular joint, with the clavicle side of the joint migrating superiorly, is due to a dislocation of these joints.

Observation of the soft tissues is directed first at the contours of the deltoid. The mass of the deltoid should be round, with the anterior and posterior aspects symmetric. Flattening of the muscle suggests atrophy of the deltoid and is usually due to a neurologic lesion such as an axillary nerve neuropathy, an upper trunk brachial plexopathy (Erb palsy), or a C5-6 radiculopathy.

An anterior dislocation of the glenohumeral joint produces flattening of the deltoid with bulging of the anterior aspect of the muscle due to the dislocated head of the humerus, with the patient holding the shoulder in slight adduction and across the trunk. A bulge observed in the middle third of the belly of the biceps when the elbow is flexed suggests rupture of the long head of the biceps tendon.

The side view allows the examiner to assess thoracic spine kyphosis, which is indicated by a protraction of the head or the shoulders. Deltoid atrophy also can be observed.

Looking at bony contours, the examiner seeks evidence of a scoliosis of the thoracolumbar spine and then observes the scapulae. Each scapula extends from the spinous process of T2 (superomedial angle) to the spinous process of T7 (inferomedial angle). The scapulae should be at the same height and at the same distance from the spine.

The examiner should check for a winging of the scapula (ie, a displacement of the medial side of the scapula away from the thorax). When the winging is present with medial displacement of the scapula toward the spine, a serratus anterior muscle palsy is suggested. This palsy usually is due to a long thoracic nerve injury. When the winging is noted with lateral displacement of the scapula, a trapezius muscle palsy or, more rarely, a rhomboid muscle palsy must be suspected.

A trapezius muscle palsy can be due to a spinal accessory nerve (cranial nerve XI) injury, and a rhomboid muscle palsy can be due to a dorsal scapular nerve injury. A prominent spine of the scapula may be due to a supraspinatus and infraspinatus muscle atrophy caused by a suprascapular nerve injury in the suprascapular notch or a rotator cuff tear.

Observation of the soft tissues is directed at the posterior aspect of the deltoid muscle. The trapezius muscle is then observed. Atrophy resulting from palsy of the muscle has been discussed previously. Because the rhomboid is overlapped by the trapezius, atrophy of the rhomboids is more difficult to assess.

Palpation

Like observation, palpation must be performed in an orderly manner, beginning with the anterior structures and finishing with the posterior structures. Palpation must include bony structures and soft tissues. Irregular joint surfaces, swelling, heat, crepitus, pain, tenderness, and muscle tension and spasms must be sought. Palpation can be performed more conveniently with the patient standing. In this position, the examiner can more easily move around the patient. The examiner should stand behind the patient for the palpation.

Beginning with the anterior structures, the examiner palpates the sternoclavicular joint. Superior migration of the medial end of the clavicle is palpated if the joint is dislocated. The examiner must remember that the clavicle is superior to the manubrium. Always compare the affected side with the contralateral side.

The sternocleidomastoid also must be palpated, looking for tension and spasms. The muscle contracts to turn the head on the contralateral side. The muscle is easier to identify and palpate in this position. The sternal and clavicular heads of the muscle must be palpated. Hands can be moved medially to palpate the suprasternal notch. The first rib, the costochondral joints, and the sternum also should be assessed.

The clavicle should be palpated along its whole length, looking for bumps (suggesting callus formation resulting from fracture), loss of continuity, and crepitus. The acromioclavicular joint is a common site of pain and must be palpated with care. Because the acromioclavicular joint is a superficial joint, swelling, synovial thickening, and/or crepitus can be palpated. Step deformities with superior migration of the lateral end of the clavicle, seen in dislocation or subluxation, are easily palpable.

The coracoid process can be palpated approximately 2.5 cm (1 in.) inferior and just medial to the acromioclavicular joint. The coracoid process is the site of origin of the short head of the biceps tendon, the coracobrachialis muscle, and the insertion of the pectoralis minor. The pectoralis major and minor also must be palpated. Muscle tension and spasms are commonly associated with shoulder disorders.

The acromion and subacromial space are palpated. The subacromiodeltoid bursa can be palpated indirectly in the subacromial space. Because it is overlapped by the deltoid muscle, the bursa cannot be felt under the fingers; however, the examiner, through pressure on the deltoid muscle, applies indirect pressure on the inflamed bursa, causing pain.

The examiner follows by palpating the greater tuberosity, the long head of the biceps tendon, and the lesser tuberosity. These structures can be identified easily in a lean patient by an experienced examiner. This identification may be more difficult in an overweight patient or one with abundant muscle mass. By rotating the shoulder medially (eg, by putting the dorsal aspect of the hand on the buttock), the examiner can feel the greater tuberosity on the anterior aspect of the shoulder, just inferior to the acromion. The supraspinatus, infraspinatus, and teres minor tendons all insert into this structure and, when inflamed, can produce pain upon palpation of the greater tuberosity.

Keeping the fingers on the greater tuberosity, the examiner rotates the shoulder laterally. The fingers feel the bicipital groove where the long head of the biceps tendon can be palpated. Pain or thickening of the tendon sheet indicates an inflamed tendon, whereas its absence suggests a rupture or dislocation. By rotating the shoulder more laterally, the examiner can palpate the lesser tuberosity. The tendon of the subscapularis inserts on that structure, and when it is inflamed, the tendon is painful to palpation. With the shoulder back to a neutral position, extension of the shoulder allows palpation of the subacromiodeltoid bursae under the anterior edge of the acromion.

All of these structures must be palpated gently because they may be tender. Any painful palpation must be compared with the contralateral shoulder. A positive finding is when pain is more significant on the affected side than on the contralateral shoulder. Any excessive pain caused by a vigorous palpation makes the examination less sensitive.

The biceps muscle should be palpated, looking for any bulging that indicates a long head of the biceps tendon rupture. The deltoid muscle also must be palpated to look for painful spasm or tension. Tone and atrophy also are assessed.

The examination is continued by palpation of the posterior structures. Bony structures can be rapidly assessed because they are rarely a source of pain. The spine of the scapula is palpated, followed by palpation of the superior medial angle of the scapula. The levator scapulae muscle that inserts on this angle is a common site of pain. The medial border of the scapula is then palpated from the superior to the inferior medial angle. The bony palpation is completed by palpation of the spinous processes of the dorsal and cervical spine.

Because muscle spasm and tension are frequently associated with a rotator cuff disease, the posterior muscles must be palpated with care to identify and treat those muscles. The superior trapezius is commonly tense and painful and must be palpated from its cervical and occipital origin to its insertion on the spine of the scapula and the acromion. Under this muscle, lying in the supraspinatus fossa, the supraspinatus muscle also should be palpated.

The rhomboid muscles, from C7 to T5, run downward to attach on the medial border of the scapula. These muscles, often a source of pain, are difficult to distinguish from the overlying middle trapezius muscle. The rhomboid muscles can be identified by asking the patient to put his or her hand behind the back, with the shoulder internally rotated and the elbow flexed, and to push posteriorly against a resistance. The muscle belly of the rhomboid muscles then becomes palpable. Muscle palpation is completed by assessing the infraspinatus, teres major and minor, and latissimus dorsi muscles.

Range of motion

Both active and passive ROM must be evaluated. Although some authors suggest that an assessment of passive ROM is not necessary if the patient is able to perform complete active ROM without pain, passive ROM must be assessed systematically. Some patients with glenohumeral ROM restrictions have learned to compensate with increased scapulothoracic mobility and seem to have near-normal active ROM.

Movements (with the normal ranges provided) that should be assessed are abduction (70-180°), adduction (30-45°), flexion (160-180°), extension (45-50°), external rotation (80-90°), and internal rotation (90-110°).

Active movements are evaluated first. With the observer behind the patient (who is standing), active abduction is performed.

The scapulohumeral rhythm is observed. If a painful arc (ie, pain or inability to abduct because of pain) is observed at 45-120°, a subacromial impingement syndrome is suggested. If the pain is greater after 120°, when full elevation is reached, an acromioclavicular joint disorder is suggested.

If a reverse scapulohumeral rhythm (ie, an abduction initiated by the scapulothoracic joint rather than by the glenohumeral joint) is observed, a frozen shoulder is suggested. Look for a winging of the scapula caused by trapezius or rhomboid muscle weakness. Active flexion is also evaluated. In the presence of a subacromial impingement syndrome, this movement can also be painful. Active flexion may elicit a winging of the scapula caused by a serratus anterior weakness.

Other motions can be evaluated through a combination of active movements. The Apley scratch test is probably the most well known. This test combines internal rotation and adduction of one shoulder with external rotation and abduction of the other.

The evaluation for passive ROM can be performed with the patient standing, sitting, or lying down. For practical purposes, the examination is performed with the patient standing. Passive abduction is assessed with the observer behind the patient. Full abduction is performed first to evaluate the combination of scapulothoracic and glenohumeral motion. Then, the scapulothoracic joint is locked by putting one hand over the scapula and the clavicle to resist any motion of this joint. This maneuver allows for a more selective evaluation of the glenohumeral joint (90-120°).

The same procedure can be used to evaluate full flexion that combines scapulothoracic and glenohumeral motion and flexion performed selectively by the glenohumeral joint. This maneuver is followed by an evaluation of adduction. The external rotation is tested with the elbow held close to the waist and flexed at 90°. Then, the arm is rotated externally. The examination is followed by an evaluation of the extension and an assessment of the internal rotation. The full range of internal rotation is achieved with the forearm passing behind the trunk with the shoulder slightly extended.

Impingement tests

Positive impingement tests result from the reproduction of impingement of the rotator cuff tendon by different provocative maneuvers. [24] With anterosuperior impingement syndrome, the impingement occurs underneath the coracoacromial arch. With posterosuperior impingement syndrome, the impingement is on the posterosuperior border of the glenoid cavity. Finally, with anterointernal impingement syndrome, the impingement occurs in the subcoracoid space or in the coracohumeral interval.

Impingement tests confirm an impingement syndrome; however, they do not determine the location of the rotator cuff lesion.

A study of cadaveric shoulders showed that some provocative impingement tests—namely, the Neer and Hawkins-Kennedy tests—appear to elicit contact consistent with impingement.

The Neer impingement test is described as follows:

  • With the examiner standing behind the patient, the shoulder is passively flexed. Although not originally described by Neer, this author positions the shoulder in internal rotation.
  • When the result is positive, this test produces pain caused by contact of the bursal side of the rotator cuff on the anterior third of the undersurface of the acromion and the coracoacromial ligament, as well as by contact of the articular side of the tendon with the anterosuperior glenoid rim.
  • A positive test result suggests an anterosuperior impingement syndrome. The sensitivity of this test, assessed based on operatively observed anatomic lesions, is 89%.

The Hawkins-Kennedy test is described as follows:

  • With the examiner standing behind the patient, the shoulder is flexed passively to 90°, followed by repeated internal rotation.
  • When the result is positive, this test produces pain caused by contact of the bursal side of the rotator cuff on the coracoacromial ligament and by contact between the articular surface of the tendon and the anterosuperior glenoid rim. Contact between the subscapularis tendon and the coracoid process is also observed.
  • A positive test result suggests an anterosuperior or an anterointernal impingement test.
  • This author uses a modified version of this test with the shoulder positioned initially at 90° of abduction and 30° of flexion in the plane of the scapula. Along with repeated internal rotation motion, the shoulder is brought progressively to 90° of flexion. If pain is present when the shoulder is flexed at 30°, it is caused by an anterosuperior impingement syndrome. If the pain is present only when the shoulder is brought to 90° of flexion, reducing the coracohumeral interval, an anterointernal impingement syndrome is suggested.
  • The sensitivity of this test is 87%.

The Yocum test is described as follows:

  • With the examiner standing behind the patient, the hand on the ipsilateral side of the examined shoulder is placed on the contralateral shoulder. The elevation of the elbow is resisted by the examiner.
  • When the result is positive, this test produces pain caused by contact of the bursal side of the cuff tendon with the coracoacromial ligament and possibly the undersurface of the acromioclavicular joint.
  • A positive test suggests an anterosuperior or an anterointernal impingement syndrome. The sensitivity of this test is only 78%; however, the sensitivity of the 3 tests together is 100%, which justifies that the 3 tests should be systematically performed together.

The posterior impingement test is described as follows:

  • With the patient lying down, the shoulder is positioned at 90-100° of abduction and maximally externally rotated.
  • When the result is positive, this test produces pain in the posterior aspect of the shoulder caused by impingement of the articular side of the cuff tendon between the greater tuberosity and the posterosuperior glenoid rim and labrum. Relocation of the humeral head, performed by applying a posteriorly directed force to the humeral head, causes a reduction in pain.
  • The sensitivity of this test is 90%.

Topographic tests

Using resisted isometric contraction of specific muscles of the rotator cuff, the location of the tendon lesion causing the impingement can be identified.

To identify the supraspinatus tendon, use the Jobe test or the full-can test.

In the Jobe test, the shoulder is placed at 90° of abduction and 30° of flexion in the plane of the scapula. Shoulder elevation is resisted. The test result is considered positive if pain is noted. When compared with surgical observations, the sensitivity of this test is 86% and the specificity is 50%. The positive predictive value (the ratio of true positive tests on all the positive tests) of the Jobe test is 96%, and its negative predictive value (the ratio of all the true negative tests on all the negative tests) is 22%.

In the full-can test, the shoulder is placed at 90° of flexion and 45° of external humeral rotation (thumb pointing upward, as if someone is holding a full can right-side-up). Shoulder elevation is resisted. The test result is considered positive if it produces pain. Electromyography (EMG) studies show that this test results in the greatest supraspinatus activation with the least activation from the infraspinatus.

To identify the infraspinatus tendon, use the infraspinatus isolation test or, less optimally, the Patte test.

In the infraspinatus isolation test, the shoulder is positioned at 0° of elevation (elbows against the waist flexed at 90°) and 45° of internal rotation. Shoulder external rotation is resisted. The test result is considered positive if it produces pain. EMG shows this to be the optimal infraspinatus isolation test.

In the Patte test, the shoulder is placed at 90° of abduction, in neutral rotation, and in the plane of the scapula. The examiner holds the elbow of the patient, and the external rotation is resisted. The test result is considered positive if it produces pain. The sensitivity of the test is 92%, but its specificity is only 30%. The positive predictive value is 29%, and its negative predictive value is 93%. A palsy of the external rotator also can be tested. With the elbow held against the waist, the shoulder is positioned passively in external rotation. The test result is positive if the patient is unable to maintain the shoulder in external rotation, suggesting a full tear of the external rotators.

To identify the teres minor tendon, use the same tests used for the infraspinatus tendon. No specific teres minor isolation tests have been developed.

To identify the subscapular tendon, use the Gerber lift-off test or the Gerber push-with-force test.

In the Gerber lift-off test, the shoulder is placed passively in internal rotation and slight extension by placing the hand 5-10 cm from the back with the palm facing outward and the elbow flexed at 90°. The test result is positive when the patient cannot hold this position, with the back of the hand hitting the patient's back. The sensitivity and specificity of this test are 100% when the subscapularis is fully torn.

In the Gerber push-with-force test, the shoulder is placed in the same position as the lift-off test; however, the patient must keep the hand away from the back and must resist a push in the palm of the hand. EMG shows that this is the optimal subscapularis isolation test, with minimal activation of the pectoralis and latissimus dorsi muscles.

To identify the long head of the biceps tendon, use the Speed palm-up test.

In the speed palm-up test, the shoulder is placed at 90° of flexion with the elbow in extension and the forearm in supination, bringing the palm of the hand up. The flexion of the shoulder is resisted. The test result is positive if the maneuver produces pain. The sensitivity of this test is 63%, but its specificity is only 35%. The positive predictive value is 43%, and its negative predictive value is 55%.

The Yergason test, in this author's opinion, is technically difficult and ineffective; therefore, it is not described. Generally, the topographic tests are sensitive but not specific, except for the Gerber lift-off test. The combination of impingement tests and topographic tests helps determine whether a patient's symptoms are caused by rotator cuff disease. As mentioned, the examination must be completed by instability and labrum tests, special tests (eg, thoracic outlet syndrome tests), a cervicothoracic spine examination, and a neurologic and vascular examination, but it is not the purpose of this section to describe them all.

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