Rotator Cuff Injury Management in the ED Clinical Presentation

Updated: Aug 02, 2021
  • Author: Eileen C Quintana, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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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 and usually is located anterolaterally and superiorly and referred to the level of the deltoid insertion with full-thickness tears. It is aggravated by activities in which 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, 1 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% of symptomatic rotator cuff ruptures. [25]



Approach the shoulder examination systematically in every patient with inspection, palpation, range of motion, strength testing, neurologic assessment, and performance 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 90º 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 90º  of abduction.

In the Neer impingement test (see the image below), 1% lidocaine is injected into the subacromial bursae, using the lateral or posterior approach. In patients with rotator cuff disease, there are signs of relief on forward flexion, distinguishing it 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 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.