Introduction
Critical evaluation of a patient’s clinical history, physical examination, and imaging findings is fundamental in establishing a diagnosis of rotator cuff pathology. All three components must work in tandem to confidently guide medical decision making. Taking a detailed patient history guides the physician for a focused physical examination and places imaging findings in the context of clinical history and symptoms. Although the structural presence of a tear can be reliably demonstrated using various imaging modalities, symptomatic rotator cuff disease is a clinical syndrome, and the diagnosis is made on matching the physician’s clinical impression with positive radiographic evidence.
Patient history
A comprehensive history is essential in the initial evaluation of a patient with suspected rotator cuff pathology. This first step guides the subsequent diagnostic and therapeutic decision-making process and provides context to those decisions. Importantly, many older patients present with asymptomatic rotator cuff tears on imaging, even when full thickness and large. It is therefore of paramount importance that treatment recommendations reflect the actual symptomatology of the patient and not necessarily be based on imaging alone. Concordantly, the size of the tear may not necessarily correlate with the severity of discomfort and functional limitations reported by the patient. , Although patients with symptomatic rotator cuff tears often present with pain, they can also initially present with weakness, stiffness, crepitus, or perceived instability.
Presentation
Baseline information of the patient’s presenting symptoms should be collected. Hand dominance should be elucidated to provide context of the functional disability experienced by the patient. The onset of symptoms should be defined as chronic or acute. Degenerative tears typically present insidiously over a longer time course. Older patients presenting with suddenly increased pain following a low-energy mechanism (i.e., lifting a moderately heavy object, or an overhead motion such as reaching for something on a shelf) may in fact represent an acute-on-chronic injury of a long-standing degenerative tear. Further questioning often reveals an insidious time course of shoulder discomfort and weakness prior to this event and likely an exacerbation of symptoms and decompensation related to the extension of the preexisting tear. Acute tears are typically encountered in the younger population following a high-energy injury (e.g., motor vehicle accident, glenohumeral dislocations) with no shoulder dysfunction reported before the incident. In all patients, prior treatment, including physical therapy, injections, and any previous surgery, should be noted.
Pain secondary to rotator cuff pathology is often localized over the anterolateral or lateral aspect of the shoulder, given that the supraspinatus is the most commonly affected tendon. However, it is often ill defined and described as a deep vague discomfort that may be anywhere about the shoulder girdle. Pain is reproduced with overhead activities and can present with concomitant weakness. It may be difficult for the patient to control the arm in space with active range-of-motion deficits. Stiffness is often due to relative disuse of the shoulder from chronic discomfort. Patients may complain of night pain when lying supine and experience difficulty finding a position of comfort. Crepitus associated with discomfort during shoulder range of motion may be reported. Lastly, any radicular symptoms, paresthesias of the distal extremity, or medial scapular pain is not likely secondary to rotator cuff pathology and may be a sign of cervical pathology. In these patients, a comprehensive cervical spine evaluation is critical prior to any intervention. Any concern should prompt a detailed neurologic history and examination, followed by cervical spine radiographs and magnetic resonance imaging (MRI) if indicated. Electromyography of the affected extremity may further delineate any cervical root or peripheral nerve abnormalities. Lastly, differential diagnostic injections of the subacromial space and facets or foramina of the cervical spine may help further delineate these pathologies.
Age
Physiologic age is an important factor in considering the etiology and treatment plan for each patient. Older patients typically present with degenerative rotator cuff tearing, whereas younger patients often sustain traumatic tearing through an acute injury. Traumatic glenohumeral dislocations in persons older than 40 years have a strong association with rotator cuff tears.
Chronologic age is an important predictor of rotator cuff repair healing. Older patients are less likely to achieve a durable repair, likely secondary to decreased vascularity, compromised tissue quality, and decreased healing potential. Elucidating baseline activity level is important because individual patient functional demands may vary significantly despite chronologic age. However, it is also important to note that the functional demands of the patient do not affect the healing potential. The surgeon must balance these factors to deliver patient-centered care specific to each individual’s needs.
Chronicity
Long-standing tears in an older patient often present with concomitant muscle retraction, atrophy, and fatty infiltration, resulting in a compromised healing potential for any potential repair. Traumatic acute tears often occur in younger patients and are associated with a distinct injury, often resulting from a glenohumeral dislocation. Sixty percent of patients older than 60 years sustaining an anterior glenohumeral dislocation are found to have rotator cuff tearing. A systematic review by Gombera and Sekiya found that patients with persistent pain or dysfunction after a shoulder dislocation often had a concomitant rotator cuff tear, especially in contact or overhead athletes, patients older than 40 years, or those with nerve injury. Surgical repair resulted in improved pain relief and patient satisfaction compared with nonoperative management. Early surgical management is often considered in acute tears given that the tendon can often be mobilized and anatomically reduced, the healing potential is favorable, and the muscle has not had an opportunity to retract and atrophy. In these patients, the acute component of their shoulder pain must be differentiated by history and imaging from more chronic symptoms that may have existed prior to the injury.
Medical and social comorbidities
It is important to inquire about medical and social comorbidities such as diabetes mellitus, hypercholesteremia, thyroid disease, and nicotine use. Diabetes mellitus has been proposed to damage tendons through nonenzymatic glycosylation of collagen with advanced glycation end product formation and impaired microcirculation. Hypercholesteremia may lead to fatty infiltration, xanthomatous change in tendons, and subsequent proinflammatory degenerative enzymatic degeneration. Thyroid disease may disrupt tendon homeostasis through the alteration of collagen production and the accumulation of glycosaminoglycans. Diabetes and hypothyroidism have also been associated with rotator cuff calcific tendonitis. Lastly, smoking inhibits tendon healing through the induction of hypovascularity and hypoperfusion and may result in poor cuff repair outcomes for large and massive tears. Understanding the impact of these systemic conditions on potential outcomes and complications is important in the management of rotator cuff disease and expectations with patients.
Physical exam
Visual examination and palpation
The patient should initially be gowned so that his or her entire back and shoulder girdle are visible for evaluation. All physical exam maneuvers should be compared with the contralateral extremity. Occult scapular winging or dyskinesis can be missed without appropriate inspection. The posterosuperior cuff originates on the posterior scapula, and the muscle bulk of the supraspinatus and infraspinatus should be inspected. Patients with chronic tears often have atrophy of the supraspinatus and infraspinatus fossa when compared with the asymptomatic side. Deltoid atrophy may indicate axillary nerve dysfunction. Asymmetric positioning of the scapulae may indicate shoulder dysfunction due to scapular winging. The location of any previous surgical incisions should be noted to correlate with any previous surgical history and for consideration in any potential future operative intervention.
Palpation of the entire shoulder girdle should be performed for any areas of tenderness. Rotator cuff injuries often present with tenderness at Codman’s point, palpated by rotating the proximal end of the humerus under the examiner’s finger at the anterior corner of the acromion. The perimeters of the divot left by a defect in the supraspinatus can be palpable. The defect is usually just posterior to the bicipital groove and medial to the greater tuberosity ( Figs. 52.1 and 52.2 ). Palpation should additionally include the acromioclavicular and sternoclavicular joints for degenerative disease or instability, the biceps groove for biceps tendonitis, the lateral acromion for a symptomatic, mobile os acromiale, and the coracoid process for internal impingement.
Symptomatic crepitus is evaluated by placing the thumb and fingers at the anterior and posterior acromion during passive shoulder range of motion. Subacromial abrasion may be secondary to bursal hypertrophy ( Fig. 52.3 ), adhesions ( Fig. 52.4 ), secondary changes in the undersurface of the coracoacromial arch, loss of integrity and smoothness of the upper aspect of the upper aspects of the cuff tendons, and uncovering of the tuberosities ( Fig. 52.5 ). Crepitus from subacromial abrasion is easily detected by placing the examiner’s thumb and fingers on the anterior and posterior aspects of the acromion while the humerus is moved relative to the scapula. Because many shoulders demonstrate asymptomatic subacromial crepitus, it is important during the examination to ask whether the crepitus noted by the examiner reproduces the patient’s complaints.
Range of motion
A full assessment of active and passive glenohumeral range of motion should be completed. Shoulder motion is a result of four separate articulations: glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular. Therefore stabilization of the scapula is required to isolate motion occurring at the glenohumeral joint. The examiner can place a hand on top of the shoulder, across the clavicle and acromion, while the other hand manipulates the patient’s arm to determine glenohumeral passive motion in relation to the scapula. Simultaneous palpation of the coracoid process can help to identity movement of the scapula. Rotator cuff tearing can present with greater loss of active rather than passive motion. However, capsular stiffness resulting in restricted passive motion is not uncommon secondary to chronic disuse and pain. In patients with restricted passive motion, plain radiographs should be reviewed to rule out glenohumeral arthritis.
Elevation is evaluated while observing the patient from the side and is measured as the angle created between the axis of scapular body and the line extending from the shoulder to the elbow ( Fig. 52.6 A). External rotation is measured with the elbow near the side, rotating the forearm laterally ( Fig. 52.7 A). Internal rotation is measured after instructing the patient to reach up their back, and the most superior spinal segments reached with the thumb is noted ( Fig. 52.8 ). External and internal rotation can also be measured with the arm abducted to 90 degrees. Abduction is tested in the scapular plane (30 degrees internally rotated from the coronal plane), and isolating glenohumeral motion from scapulothoracic motion can be performed by stabilizing the scapula.
Isometric strength testing
Although individual rotator cuff muscles are difficult to isolate given the interdigitation of their tendon insertions, the following isometric tests are reasonably selective. Although patients with full-thickness defects might still retain the ability to actively abduct the arm, significant tendon fiber failure is usually manifested by weakness on manual muscle testing. Rotator cuff muscle testing can also be difficult to perform in patients who experience significant pain that compromises their effort. If the examiner believes pain to be a significant factor in the patient’s weakness, then a subacromial injection of local anesthetic may be used to eliminate pain as a factor. Evaluation should always be performed bilaterally and simultaneously to allow for easier detection of subtle side-by-side differences.
Supraspinatus
Jobe-Yocum test (empty can test).
The Jobe-Yocum test (empty can test) is performed with the arm abducted to 90 degrees in the scapular plane (30-degree forward flexion) so that the muscle-tendon unit is parallel to the floor. The arm is then internally rotated with the elbow fully extended so that the thumb is pointed toward the floor. A downward force is applied to the wrists while the patient is asked to resist ( Fig. 52.9 A). , The test is positive for supraspinatus pathology if accompanied by pain or weakness. Weakness has been shown to be a more accurate predictor of a full-thickness tear than pain, with accuracy of 70% with weakness and 50% with pain. Using electromyography, Malanga et al. reported concomitant activation of the anterior and middle deltoid along with the pectoralis major muscle during peak supraspinatus activity.
Full can test.
Described by Jobe and Moyes, the full can test is similar to the Jobe-Yocum test in that the arm remains 90 degrees abducted in the scapular plane, but the arms are externally rotated so that the thumbs are facing upward. The patient resists a downward force applied to the wrists, and pain or weakness indicates a positive test (see Fig. 52.9 B). Kelly et al. demonstrated through an electromyographic study that this may be a more optimal position to isolate the supraspinatus compared with the Jobe-Yocum test.
Champagne toast position.
Chalmers et al. described the champagne toast position in 2016 in an effort to better isolate and evaluate the supraspinatus from the deltoid. In the scapular plane, the shoulder is placed in 30 degrees of abduction, mild external rotation, 30 degrees of flexion, and 90 degrees of elbow flexion. A downward force is applied at the patient’s elbow, and pain or weakness compared with the contralateral asymptomatic extremity is considered a positive test. The authors performed electromyography analysis of the supraspinatus, anterior head, and middle head of the deltoid and demonstrated that, although the Jobe test resulted in maximal supraspinatus activity at 90 degrees of abduction, it also had the greatest concomitant deltoid activity as evaluated by the ratio of supraspinatus to deltoid activity (0.8 ± 0.6). In contrast, the champagne toast position had the least concomitant deltoid activity of tested positions as demonstrated by the highest ratio of supraspinatus to deltoid activity (4.6 ± 3.4).
Codman sign (drop-arm test).
The drop-arm test was originally described by Codman in 1934 and can be evaluated using two methods. In the first method, the arm is passive elevated to 90 degrees of shoulder abduction and the patient is asked to hold this elevated position for 10 seconds. The second method passively elevates the arm to 160 degrees of shoulder abduction and the patient is subsequently asked to slowly lower the arm to 90 degrees of shoulder abduction, holding this final position for 10 seconds ( Fig. 52.10 ). In both methods, the test was considered positive if the patient was unable to maintain the final position and dropped his or her arm due to pain or weakness.
Whipple test.
The Whipple test was originally described by Savoie et al. and is completed with the patient sitting, passively elevating their shoulder to 90 degrees of flexion and fully extending the elbow. The arm is then adducted until the hand is opposite the contralateral shoulder and a downward force is applied while asking the patient to resist. Pain or inability to maintain arm position indicates a positive test.
Scapular retraction test.
Initially described by Kibler et al., the scapular retraction test positions the arm at 90 degrees of abduction in the scapular plane while the examiner simultaneously stabilizes the medial border of the scapula. A downward force is then applied to the patient’s arm, and the test is considered positive if the measured strength was less than in the traditional empty can position without scapular retraction. It is hypothesized that by stabilizing the scapula in retraction, the external effects from the proximal kinetic chain are minimized and a stable supraspinatus origin base is established, creating a more isometric exam.
External rotation (infraspinatus and teres minor)
The infraspinatus and teres minor form the posterior rotator cuff and are the primary shoulder external rotators. These tendons are more easily isolated because the deltoid has very limited ability to externally rotate the humerus and so any external rotation weakness can be attributed to an abnormality in these muscles.
Resisted external rotation test.
The infraspinatus is examined with the arm adducted to the side of the body in neutral rotation with the 90-degree elbow flexed; the patient then externally rotates the shoulder against the examiner’s resistance. The teres minor is subsequently isolated with the arm abducted to 90 degrees with the shoulder in neutral rotation, again externally rotating against resistance ( Fig. 52.11 ). Pain or weakness is indicative of possible posterior rotator cuff injury.
External rotation lag sign.
Patients with large or massive rotator cuff tears involving the infraspinatus often demonstrate an external rotation lag sign. The arm is placed at the patient’s side, with the elbow 90 degrees flexed, and passive terminal external rotation is performed. The examiner then releases the arm and instructs the patient to maintain the maximally rotated position ( Fig. 52.12 ). The test is positive if the patient is unable to maintain this arm position and internally rotates at least 10 degrees. The difference in the two positions should be documented in degrees. For instance, if a patient has passive external rotation to 45 degrees but can hold the arm externally rotated to only 20 degrees, then the patient has a 25-degree external rotation lag sign. Of note, concomitant massive subscapularis tears may result in excessive passive external rotation and should be considered when interpreting this test in the setting of large anterosuperior tears.
Hornblower’s sign.
The hornblower’s sign was originally described in the evaluation of brachial plexus injuries when Walch et al. later adapted the maneuver to examine teres minor function. , The elbow is 90 degrees flexed, and the arm is placed at 90 degrees’ abduction in the scapular plane, with the shoulder at terminal external rotation. The examiner then releases the arm and instructs the patient to maintain the rotated position ( Fig. 52.13 ). The test is positive if the arm is unable to maintain its position and falls into internal rotation, potentially indicating a massive tear involving the teres minor.
Drop sign.
Initially described by Hertel et al., the drop sign is performed by passively elevating the arm to 90 degrees in the scapular plane, with the examiner supporting the 90-degree flexed elbow with one hand and placing the shoulder into maximal external rotation the with the other. The arm is released while supporting the elbow, and the patient is instructed to maintain position for 10 seconds. The test is positive if the arm internally rotates, or “drops,” from the final position by at least 5 degrees, and the magnitude of internal rotation is recorded in degrees. Maintaining the final position is mainly a function of the infraspinatus.
Patte sign.
Patte et al. originally described this test with the examiner moving the arm to 90 degrees of elevation in the scapular plane and 90 degrees’ external rotation with elbow flexed 90 degrees. The patient’s attempts to further externally rotate arm against resistance and weakness indicate an infraspinatus or teres minor tear.
Sgroi et al. evaluated the diagnostic value of various clinical tests for infraspinatus tendon tears in 91 patients and found that the drop sign and the resisted external rotation test in isolation were most able to accurately diagnose tears of the infraspinatus tendon, and only muscle weakness should be considered when interpreting the resisted external rotation test. In addition, the combination of the Patte sign and resisted external rotation test led to significantly improved diagnostic value.
Collin et al. assessed the best clinical test for the assessment of teres minor injury in massive rotator cuff tears and found that an external rotation lag sign greater than 40 degrees was more specific (92%) than an external rotation lag sign greater than 10 degrees (51%, P < .001) and a Patte sign (72%, P < .001) but was not more specific than the drop sign (88%, P < .47). An external rotation lag sign of greater than 40 degrees was also determined to be the most accurate test because it demonstrated a sensitivity of 100% in addition to a specificity of 92%.
Subscapularis
The subscapularis is difficult to isolate with a single specific test because several muscle groups contribute to internal rotation of the shoulder. Tokish et al. found that different arm positions are correlated with the selective activation of different subscapularis muscle regions. Presuming no injury in the other contributing internal rotation muscle groups, the following tests are reasonable for evaluating the subscapularis.
Lift-off test.
The lift-off test was originally described by Gerber and Krushell and has been confirmed by electromyography to isolate the subscapularis. The patient first places the hand of the symptomatic extremity behind the back at the level of the waist and is then instructed to push the hand away from the body, internally rotating the shoulder. The examiner should ensure that the elbow is not moving during this maneuver. The ability to perform the test indicates that at least a partially functional subscapularis is present ( Fig. 52.14 ). If the patient cannot initially perform the maneuver due to perceived weakness, the examiner can alternatively position the hand away from the waist and instruct the patient to hold the hand in that position. This test can be used only if no shoulder contractures are present preventing the initial passive positioning of the hand behind the waist. Yoon et al. evaluated several different tests used to evaluate subscapularis deficiency and found the lift-off test to be the most specific for identifying both partial- and full-thickness tears of the subscapularis.
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