The anterior superior rotator cuff tear includes the subscapularis, the supraspinatus, and the rotator interval structures located between these tendons. Anterior superior rotator cuff tears occur on a spectrum, ranging from articular partial-thickness tears associated with or without biceps instability to massive tears and partial or complete biceps rupture.^1,2 There are unique characteristics of this tear that can have significant sequelae based on treatment choices and timing of intervention. There are a variety of injuries that can create this regional tear. Following trauma, early imaging and treatment will produce the best results. Deep to these tendons are capsular ligaments that can lead to stiffness and continued disability resulting in a painful, stiff shoulder.

The rotator interval complex includes the long head of the biceps tendon (LHBT) and the supporting pulleys (Figure 22-1). Injury to the surrounding tendons, specifically the anterior fibers of the supraspinatus and upper border of the subscapularis, alters this precise pulley system creating additional problems within the biceps tendon and its supporting structures leading to subluxation.³ Surgical intervention includes rotator cuff tendon repair and biceps tenodesis. Nonoperative treatment may create prolonged disability and the need for more complex reconstructive procedures to return the shoulder to normal function.

The anterior superior tear may begin as a mild tendinopathy with a superimposed trauma, or from a single event, as may occur in young athletes.⁴ The rotator interval plays a role in maintaining glenohumeral stability, providing stability of the LHBT, and limiting excessive glenohumeral motion. Therefore, patients with injury or pathology extending into the rotator interval can present with a wide range of symptoms. Rotator interval contracture or scarring following injury plays a role in the development of adhesive capsulitis, and patients often present with painful, decreased active and passive motion. Conversely, laxity of the interval can lead to glenohumeral instability. These patients may complain of continued instability and early fatigue and may exhibit a sulcus sign.⁵

Patients may present similar to an anterior instability event, with the arm held in a position of external rotation at rest. Although shoulder pain is common in patients with an acute injury and subluxation, weakness is more common with injury to the rotator cuff.⁴ Bilateral active and passive range of motion, as well as strength testing, should be completed in all patients. Deficits can be minor or profound. In massive cuff tears, patients can present with significant loss of function and active range of motion loss of the affected shoulder.

Assessment of the subscapularis begins with passive external rotation. Strength testing, utilizing the lift off or belly press tests, can be used to evaluate for internal rotation weakness (Figure 22-2). It is important to differentiate subscapularis weakness versus stiffness when interpreting the belly press test, as patients’ elbows may be positioned close to their side due to the loss of internal rotation in adhesive capsulitis.

Testing the supraspinatus and infraspinatus can often be illustrated with external rotator weakness with the elbow at the side.⁴ Pseudoparalysis can be found in patients with massive tears of the upper subscapularis and supraspinatus, as described by Collin et al⁶ (Figure 22-3). As multitendon tears include supraspinatus and subscapularis tendons, the examiner may be able to more readily determine if dynamic anterosuperior subluxation is present through palpation, rather than observation, under the deltoid muscle during resisted initial abduction.³

Testing of the long head of the biceps should be included in the examination. Tenderness when palpating the biceps groove, Speed test, and clicking with arm rotation can be signs of damage to the biceps or supporting pulleys. Patients need to be aware of the possible addition of biceps treatment to their surgery preoperatively.⁴

Several imaging modalities can be helpful in identifying and characterizing injuries to the rotator cuff. Typically, imaging begins with plain radiographs. These should include an anteroposterior view with neutral rotation, an axillary view, and a transcapular outlet view. It is important to assess for superior migration utilizing an upright radiograph, as the patient will be supine on other imaging modalities, such as magnetic resonance imaging (MRI), and acromiohumeral interval may be reduced.

MRI is common when confirming rotator cuff pathology. The different imaging views are important to identify subscapularis, rotator interval, and supraspinatus tearing⁴ (Figure 22-4).

MRI and computed tomography scans can also be used to determine if muscle changes such as degeneration or atrophy are present. Although operator dependent, ultrasonography can be used to provide a dynamic evaluation of both the rotator cuff and the LHBT. Ultrasonography can be especially useful to assess for retear after repair in a patient presenting with pain and change in function following an acute injury.