• Double-row, transosseous equivalent rotator cuff repair has been shown to be biomechanically stronger than single-row repairs, but until recently, functional outcomes were equivalent.¹,²,³

• Recent clinical studies demonstrate improved strength and decreased re-tear rates in rotator cuff tears larger than 3 cm with adequate tendon mobility.⁴,⁵

• Advantages of double-row repair¹:

• Better footprint coverage

• Greater surface area contact

• Decreased motion at footprint bone-tendon junction

• Pressurized contact area

• Overall posture and position of the shoulder (protraction vs retraction) are evaluated.

• The shoulder is inspected for atrophy of the supraspinatus and infraspinatus fossa and for deltoid atrophy.

• Tenderness to palpation is tested over the greater tuberosity.

• By extending the elbow behind the body, and palpating the greater tuberosity while internally and externally rotating the arm, the examiner can feel for any palpable defects in the rotator cuff tendons.

• Active and passive range of motion is compared to the contralateral shoulder.

• Manual strength testing is graded on a five-point scale.⁶

• Supraspinatus

• Jobe empty-can test: weakness and/or pain with resisted forward elevation with the shoulder internally rotated in the scapular plane.

• Supraspinatus isolation test: weakness and/or pain with resisted forward elevation with the arm in neutral, thumb up (full can test), in the plane of the scapula.

• Whipple test: weakness and/or pain with resisted forward flexion with the arm in neutral in front of the contralateral shoulder indicates scapular dyskinesis or partial-thickness supraspinatus tear.

• Drop arm test: the patient is unable to slowly and smoothly lower the arm from 90 degrees of abduction to his or her side.

• Infraspinatus

• Weakness with external rotation.

▪ With the arm adducted and in 30-40 degrees of external rotation, external rotation strength is checked against resistance.

▪ In the 90/90 position for partial upper infraspinatus tears.

• External rotation lag sign: with the shoulder adducted, the arm is passively externally rotated as far as possible, and the patient is unable to maintain this position once the examiner releases the arm.

• Teres minor

• With the elbow supported and the arm abducted to 90 degrees, external rotation strength is checked against resistance.

• Hornblower’s sign: while the arm is supported in 90 degrees of shoulder abduction, 90 degrees of elbow flexion, and 90 degrees of external rotation, the patient is unable to maintain the arm in maximal shoulder external rotation, and the arm drops forward.

• Subscapularis

• Lift-off test: the patient, positioned with the dorsum of the hand against the lumbar spine, is unable to lift off away from the back.⁷

▪ For partial tears, strength is compared to the contralateral side.

• Belly press test: with patient’s palm on the abdomen, he or she is unable to bring the elbow forward, anterior to the plane of the body, or more subtly is unable to keep the hand on the belly when the examiner manually holds elbow forward.

• Bear hug test: patient places hand of the affected shoulder on the contralateral shoulder and experiences pain and/or weakness when the examiner attempts to lift the hand superiorly off the shoulder while pushing down on the elbow.⁸

• Radiographs

• Standard shoulder series including Grashey and axillary lateral views

▪ Evaluate for proximal humeral migration, degenerative changes, any abnormal bony morphology, calcific tendinosis.

▪ Evaluate the lateral acromion for overhand and acromial index.

• Ultrasound

• Can detect partial-thickness tears, full-thickness tears, and biceps tendonitis

• Inexpensive, high sensitivity/specificity

• Operator dependent

• Magnetic resonance imaging (MRI)

• Can detect partial-thickness tears, full-thickness tears, and biceps tendonitis

▪ Magnetic resonance arthrography (MRA) is the most sensitive and specific for full-thickness rotator cuff tears.

• Also evaluates muscle atrophy, fatty infiltration, specific tendon involvement, and degree of rotator cuff retraction

• Can evaluate acromion morphology, acromiohumeral distance, acromioclavicular joint, and suprascapular nerve

• Indications for rotator cuff repair:

• Pain and functional impairment despite appropriate nonoperative management

• Complete tear in young active individual

• Indications for double-row rotator cuff repair

• Full-thickness tears, 2.5 cm or larger

• Good tendon thickness and quality.

• Tendons are easily reducible to the lateral border of the greater tuberosity, to ensure repair under minimal tension.

• Full passive range of motion.