Presentation and Diagnosis of Rotator Cuff Tears

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Presentation and diagnosis of rotator cuff tears

Authors: Stephen M Simons, MD, FACSM, J Bryan Dixon, MD, David Kruse, MD
Section Editor: Karl B Fields, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2022. | This topic last updated: Nov 09, 2021.
INTRODUCTION
Shoulder pain is a common presenting complaint to primary care offices and sports medicine
clinics. Estimates of the prevalence of shoulder pain range from 16 to 34 percent in the general
population [1,2]. Rotator cuff pathology is the most common condition of the shoulder for
which patients seek treatment [3]. Estimates published in 2004 by the United States Agency for
Health Care Research and Quality and United States Department of Health and Human Services
show rotator cuff problems accounted for more than 4.5 million clinician visits and
approximately 40,000 surgeries [4].
Despite this burden on patients and health care resources, there remains significant
controversy regarding the etiology of rotator cuff injuries, the role of rotator cuff tears in
generating shoulder pain, and the ability of commonly accepted clinical tests to diagnose rotor
cuff tears.
The etiology, presentation, and diagnosis of rotator cuff tears will be reviewed here. The
treatment of rotator cuff tears, rotator cuff tendinopathy, the shoulder examination, and the
general management of patients with shoulder pain are discussed separately. (See
"Management of rotator cuff tears" and "Rotator cuff tendinopathy" and "Physical examination
of the shoulder" and "Evaluation of the adult with shoulder complaints".)
ANATOMY AND BIOMECHANICS
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The anatomy and biomechanics of the shoulder generally are discussed separately (
figure 1A-C) (see "Evaluation of the adult with shoulder complaints", section on 'Anatomy and
biomechanics'). The biomechanics of the rotator cuff specifically are discussed elsewhere. (See
"Rotator cuff tendinopathy", section on 'Clinical anatomy' and "Rotator cuff tendinopathy",
section on 'Basic biomechanics'.)
MECHANISM OF INJURY
The development of underlying rotator cuff tendinopathy is discussed separately. (See "Rotator
cuff tendinopathy".)
The cause of rotator cuff tears is likely multifactorial. Degeneration, impingement, and overload
may all contribute in varying degrees to the development of rotator cuff tears.
Several theories have developed to explain the cause of rotator cuff injury. In 1934, Codman
theorized that rotator cuff tears developed from intrinsic tissue degeneration [3]. This theory
was bolstered by Rothman and Parke, who suggested in 1965 that a "critical zone" of
hypovascularity in the rotator cuff predisposed the tendon to degeneration. The role of intrinsic
factors was challenged in 1972 by Neer, who suggested that impingement from extrinsic
structures caused rotator cuff tears [3].
Subsequent investigations in throwing athletes suggest that tension overload contributes to

these injuries [5,6]. Tension overload is thought to occur when the ability of the rotator cuff to
compress and maintain the stability of the glenohumeral joint is overwhelmed by the distractive
forces of throwing or by trauma. In other words, rotator cuff muscle weakness allows
subluxation of the glenohumeral joint, leading to impingement, which contributes to the
development of rotator cuff tears.
Most often, rotator cuff lesions begin as partial tears of the undersurface or articular portion of
the supraspinatus tendon ( figure 2) [4]. Over time they can progress to full thickness tears to
include the supraspinatus, infraspinatus, subscapularis and biceps tendons.
RISK FACTORS
Rotator cuff tears are primarily a disease of middle aged and older patients. Observational data
reveals a nearly linear increase in the frequency of rotator cuff tears over time [4,7-14].
However, a sizeable portion of tears in older patients are asymptomatic. (See 'Symptoms'
below.)

Sports and occupations requiring overhead activity produce a high frequency of rotator cuff
tears. In these patients, tears may present at a younger age and are frequently associated with
labral pathology [3,5].
A number of medical conditions have been associated with rotator cuff tears, but whether they
contribute directly to such injuries or are confounders is unclear. A meta-analysis of 26 studies
reported an association between symptomatic rotator cuff tears and diabetes, hypertension,
higher body mass index (BMI), and smoking [15]. A prospective cohort study confirmed an
association with older age and higher BMI but did not report an association with diabetes,
hypertension, or smoking [15]. In an observational study of 180 subjects with a symptomatic
rotator cuff tear, an asymptomatic contralateral rotator cuff tear was identified with ultrasound
in 69 individuals [16]. The prevalence of an asymptomatic lesion was greater among individuals
with diabetes, obesity, hypercholesterolemia, and hypertension and among those who smoked
or engaged in heavy repetitive labor involving the shoulder.
Genetics and familial predisposition may play a role in rotator cuff pathology. Several
haplotypes have been implicated [17]. It remains unclear if genetics exerts its effects through
anatomy that predisposes to injury (eg, distance between acromion and humeral head),
intrinsic tendon weakness, or some combination of factors.
Trauma can cause rotator cuff tears. One study found that 58 percent of patients presenting to
the emergency department with acute shoulder trauma and normal radiographs who were
unable to abduct above 90 degrees had acute traumatic tears of the rotator cuff [12]. Tears
were diagnosed by ultrasound during follow-up evaluations performed a median of 13 days
following the injury.
CLINICAL PRESENTATION
Symptoms — Pain and weakness may be the presenting complaints of the patient with rotator
cuff tear. Classically, rotator cuff tears are associated with pain [18,19]. Pain is said to develop
over the lateral deltoid and is exacerbated by overhead activities and at night (possibly when
the patients lies on the shoulder).
This classic description may be inaccurate. Several observational studies suggest that pain
associated with rotator cuff tears, when present, is nonspecific and may be due to associated
subacromial bursitis, not the tear itself [7,20]. Other observational studies suggest a large
portion of rotator cuff tears are asymptomatic [7-9,21]. Although some degeneration of the

rotator cuff may be inevitable in most individuals beyond the fifth decade of life, these
degenerative changes do not necessarily cause significant functional impairment.
To confuse matters further, some researchers find that increasing tear size correlates with more
severe symptoms [7,10], while others do not [22]. Some researchers maintain that partial
thickness tears create significantly more pain and disability than full thickness tears [23,24].
The understanding of the relationship between rotator cuff tears and shoulder pain is evolving.
Clinicians should not allow the presence or absence of pain to play too significant a role in
diagnosis.
Weakness is another frequently cited symptom of rotator cuff tears and in large or full
thickness tears represents an integral part of the diagnosis. Weakness may be apparent in
otherwise asymptomatic individuals [25-27]. However, using the physical examination to isolate
rotator cuff weakness can be problematic. In addition, pain from bursitis, impingement, or
trauma can lead to reflex muscle inhibition and weakness unrelated to rotator cuff injury.
Distinguishing between reflex muscle inhibition and true weakness is the rationale behind
using a diagnostic injection of lidocaine as part of the clinical evaluation for rotator cuff tears.
(See "Rotator cuff tendinopathy".)
Physical examination — We use a combination of three tests to determine the likelihood of a

rotator cuff tear and the need for further work-up:
● Active painful arc test ( picture 1)

● Drop arm test (failure to smoothly control shoulder adduction)
● Weakness in external rotation ( picture 2)
Performance of these and other examination techniques for the shoulder is discussed
separately. (See "Physical examination of the shoulder", section on 'Examination for rotator cuff
pathology'.)
Although many textbooks and clinicians have long advocated for using the physical
examination to determine the presence of rotator cuff pathology, well-performed studies to
support particular examination techniques or approaches are scarce. Variations in methodology
among studies are partially to blame. Definitions of a positive test vary. Some use pain, others
use weakness, and still others use both. Diagnostic gold standards also vary and may include
advanced imaging or arthroscopic and surgical findings.
Our approach to the examination is based primarily upon our clinical experience and the results
of a prospective observational study of 552 patients who were systematically evaluated using

eight common shoulder examination tests and then underwent diagnostic arthroscopy [28].
Logistic regression analysis found that the combination of a positive painful arc sign, positive
drop arm test, and weakness in external rotation accurately predicted full-thickness rotator cuff
tear (LR 15.6), while a combination of three negative tests made the diagnosis unlikely (LR 0.16).
This study is among the few well-performed trials to assess shoulder examination techniques
that include a sufficient number of patients to draw meaningful conclusions [29].
A similar study assessed the accuracy of 23 clinical tests in 400 patients who subsequently
underwent arthroscopic surgery [11]. According to this study, patients with shoulder pain who
demonstrated supraspinatus and infraspinatus weakness and a positive impingement sign had
a 98 percent chance of having a full thickness tear. Among patients 60 years or older with
positive findings of any two of these three tests, there was again a 98 percent chance of tear.
The study did not include descriptions of the techniques used for clinical testing, making it
difficult to replicate the protocol. We have included descriptions of the most commonly used
tests for the signs they describe ( picture 2 and picture 3 and picture 4 and picture 5).
A prospective observational study of 208 patients with shoulder pain reported that the
“Hornblower Sign,” which involves resisted external rotation while the shoulder is held in 90
degrees of abduction, is specific for infraspinatus tear, but additional study is needed [30].
If one assumes a pretest probability for rotator cuff tear of 30 to 70 percent, the combination of
clinical tests described in either of these two large, prospective studies would effectively rule in
full thickness tears if all were positive. If all were negative, the latter study's combination would
rule out full thickness rotator cuff tear [11] while the former study's combination would rule out
full thickness tear in patients over 60 years of age [28].
Systematic reviews of studies assessing clinical tests for the shoulder report a wide range of
approaches and methodologic quality, thereby precluding meaningful meta-analysis of tests for
rotator cuff integrity [31,32]. In addition, individual analyses of the 15 available studies in one
review showed that only 8 studies met quality criteria and none of the individual clinical tests
included among these studies was consistently diagnostic [31]. This highlights the difficulty in
recommending evidence-based clinical tests for rotator cuff tears and the importance of
continued research. The results of another systematic review of five relatively high quality
studies of maneuvers to detect rotator cuff injury reinforces the limitations of studies
performed to date and the potential for both type 1 and type 2 errors when clinicians attempt
to detect rotator cuff tears based upon a single maneuver [32]. Accurate diagnosis of partial
thickness tears or tears of specific rotator cuff muscles and tendons through clinical testing
remains challenging, and our review of the literature did not yield sufficient high quality
evidence to determine whether any particular test or combination of tests is best for
diagnosing these conditions. We believe that rotator cuff tears should be suspected or ruled out
on the basis of the history and a combination of examination tests, and prefer the combination
listed at the beginning of this section.
As studies of rotator cuff examination maneuvers accumulate, two consistent findings are
noteworthy:
● No single examination maneuver can accurately diagnose a rotator cuff tear.

● Several different combinations of examination tests can be useful for diagnosis.
Alternative test combinations advocated by clinical researchers include the following:
● The empty can, full can, and zero-degree abduction tests to diagnose supraspinatus tears;
the drop sign and resisted external rotation test to diagnose infraspinatus tears [33,34].
● The Jobe and full can tests to diagnose supraspinatus tears; the lag and Hornblower tests
to diagnose infraspinatus tears [30]. In this study, 15 tests were assessed using expert
examination and magnetic resonance imaging (MRI) as the diagnostic gold standard.
● In a select group of patients presenting with a history suggesting rotator cuff tear but
negative results for traditional examination maneuvers, the Dynamic Isotonic
Manipulation examination (DIME) was used to determine the need for MRI [35]. A negative
DIME test, following negative traditional testing, effectively ruled out rotator cuff tear and
made MRI unnecessary.
The concept of muscle lag provides the basis for several published tests of rotator cuff integrity.
These tests require further study and are discussed separately. (See "Physical examination of
the shoulder", section on 'Testing for rotator cuff tear'.)
We do not routinely use injections of an anesthetic (eg, lidocaine) specifically to help diagnosis
rotator cuff tear. Selective anesthetic injection at discrete locations (eg, acromioclavicular joint,
proximal biceps tendon) can help to determine the cause of shoulder pain in some cases.
Subacromial injection of an anesthetic and glucocorticoid can help to relieve symptoms in some
patients. The use of such injections is discussed separately. (See "Rotator cuff tendinopathy",
section on 'Adjunct treatments' and "Acromioclavicular joint disorders" and "Biceps
tendinopathy and tendon rupture", section on 'Glucocorticoid injection for tendinopathy' and
"Frozen shoulder (adhesive capsulitis)", section on 'Glucocorticoid injection'.)
IMAGING STUDIES

Plain radiographs — Although usually normal, anterior-posterior, lateral, and outlet views of
the shoulder can be of value in assessing large, chronic rotator cuff tears. These studies can
help to confirm the diagnosis by showing whether the humeral head is migrating relative to the
glenoid and acromion. The clinician can expect larger rotator cuff tears (>1.75 cm) and probable
involvement of both the supraspinatus and the infraspinatus among individuals with a
symptomatic shoulder and humeral migration on plain radiographs [36]. Plain films also allow
for the evaluation of some concomitant or alternative shoulder pathology.
Musculoskeletal ultrasound — Musculoskeletal ultrasound (MSK US) is an accurate tool for

the evaluation of superficial tendon and muscle lesions, as well as bursitis, of the shoulder, and
enables dynamic examination at the bedside. Its role in the evaluation of the rotator cuff and
performance of the shoulder ultrasound examination are discussed separately. (See "Rotator
cuff tendinopathy", section on 'Musculoskeletal ultrasound' and "Musculoskeletal ultrasound of
the shoulder".)
Magnetic resonance imaging (MRI) — MRI accurately diagnoses full thickness rotator cuff
tears and many partial tears ( figure 2), although its sensitivity for detecting partial tears is
much lower ( image 1) [37-40]. The accuracy of MRI for detecting tears may also be limited in
patients with severe glenohumeral osteoarthritis [41]. MRI often provides information about
the degree of tear, tendon retraction, and muscle atrophy, all of which is critical in preoperative
planning for rotator cuff repair. Conversely, MRI may reveal tears that are not amenable to
operative management, such as chronic retracted tendon tears. (See "Management of rotator
cuff tears".)
The MRI "cuff" protocol, designed specifically to identify supraspinatus pathology, may improve
sensitivity particularly for the non-radiologist, but further study is needed [42]. According to a
meta-analysis of 14 studies involving imaging of over 1800 shoulders, MRI is sensitive and
specific for identifying full-thickness subscapularis tendon tears but has only modest sensitivity
and specificity for partial-thickness subscapularis tears [43].
Interpretation of the MRI must be clinically correlated due to the high rate of asymptomatic
tears. An observational study of MRI performed in 96 asymptomatic individuals showed rotator
cuff tears in 34 percent of subjects, and nearly 54 percent of those over 60 years of age [21].
MRI can be used if the diagnosis remains unclear after initial evaluation or if definitive
confirmation of the diagnosis is needed for guidance about surgery or return to sport.
Rotator cuff tears are diagnosed on MRI based upon discontinuity of the tendon on T-1
weighted images and a fluid signal on T-2 weighted images. Ancillary findings include fluid in
the subacromial space on T-2 images, loss of the subacromial fat plane on T-1 images, and

proliferative spur formation of the acromion or acromioclavicular joint. Large chronic tears may
be associated with cephalad migration of the humeral head and fatty atrophy of the
supraspinatus and infraspinatus muscle bellies [44]. In addition to rotator cuff pathology, MRI
allows visualization of periarticular soft tissues, including the capsulolabral complex and biceps
tendon.
Arthrography with MRI or CT — Magnetic resonance arthrography (MRI-A) is more sensitive

and specific for diagnosing partial thickness rotator cuff tears than standard MRI, but it too has
limited accuracy, especially for certain types of tears [37,38,45-48]. According to a meta-analysis
of 12 studies, MRI-A is as accurate as MRI for identifying bursal-sided, partial-thickness tears
[49]. MRI-A is not typically obtained as part of the diagnostic workup for rotator cuff tears and is
usually reserved for cases when a labral injury is suspected.
According to small prospective studies using findings at arthroscopy as the gold standard, the
diagnostic performance of arthrography with computed tomography (CT) is similar to that of
MRI-A for detecting rotator cuff tears [46]. CT arthrography may be useful in patients requiring
more sophisticated imaging to assess the rotator cuff but who cannot undergo MRI-A (eg, body
metal, pacemaker). The role of arthrography with MR or CT to assess the shoulder is reviewed
separately. (See "Radiologic evaluation of the painful shoulder in adults", section on
'Arthrography'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Shoulder soft tissue
injuries (including rotator cuff)".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Rotator cuff injury (The Basics)")
● Beyond the Basics topic (see "Patient education: Rotator cuff tendinitis and tear (Beyond
the Basics)")
SUMMARY AND RECOMMENDATIONS
● Mechanism and risk factors – Rotator cuff tears are common, particularly in older adults.
(See 'Mechanism of injury' above and 'Risk factors' above.)
The etiology of rotator cuff tears is multifactorial. Chronic tears likely represent the
culmination of degeneration and impingement. Trauma can produce acute tears. (See
'Mechanism of injury' above.)
● Clinical presentation – Many rotator cuff tears are asymptomatic. Patients with
symptoms may complain of shoulder pain, weakness, and difficulty with overhead or
reaching activities. (See 'Clinical presentation' above.)
● Physical examination – The use of three clinical tests (painful arc, drop arm sign, and
weakness on external rotation) can accurately diagnose full thickness rotator cuff tears in
patients older than 60 years of age. (See 'Physical examination' above.)
● Diagnostic imaging – The identification of partial tears of the rotator cuff and tears of
individual rotator cuff tendons remains a clinical challenge and the use of clinically
correlated imaging is needed to make the diagnosis. Musculoskeletal ultrasound and MRI
can accurately make the diagnosis of most rotator cuff tears. (See 'Imaging studies'
above.)
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Topic 241 Version 24.0

GRAPHICS
Anterior view of shoulder anatomy
Graphic 72709 Version 3.0

Lateral view of shoulder anatomy

Posterior view of shoulder anatomy

Rotator cuff tear classification
Classification from: Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop
Relat Res 1990; 254:64.
Illustration modified from: Funk L. Partial thickness rotator cuff tears: Arthroscopic classification.
Rotator cuff classifications. ShoulderDoc, 2015.

Painful arc sign for rotator cuff pathology
Pain with active abduction beyond 90 degrees (ie, painful arc sign)
suggests rotator cuff tendinopathy. The test is most useful when
combined with other rotator cuff tests, such as the Neer and
Hawkins-Kennedy tests.
Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD.

Testing of shoulder external rotation strength
External rotation of the shoulder is performed primarily by the

infraspinatus. The maneuver shown is used to assess the strength of
the infraspinatus tendon. The patient's elbow is flexed to 90 degrees
and held against the patient's body by the examiner's hand. The
patient actively rotates the arm externally against the resistance of
the examiner's other hand, placed at the wrist.
Courtesy of Bruce C Anderson, MD.

Jobe's test of supraspinatus strength
Jobe's test (or the "empty can" test) assesses supraspinatus function. The
patient places a straight arm in about 90 degrees of abduction and 30
degrees of forward flexion, and then internally rotates the shoulder
completely. The clinician then attempts to adduct the arm while the patient
resists. Pain without weakness suggests tendinopathy; pain with weakness
is consistent with tendon tear.

Hawkins Kennedy test for shoulder impingement
The Hawkins Kennedy test is used to assess shoulder impingement.

In this test the clinician stabilizes the shoulder with one hand and,
with the patient's elbow flexed at 90 degrees, internally rotates the
shoulder using the other hand. Shoulder pain elicited by internal
rotation represents a positive test.

Neer test for shoulder impingement
The "passive painful arc maneuver" shown above involves passively

flexing the glenohumeral joint while simultaneously preventing
shoulder shrugging. The test is often referred to as the Neer test,
and is used to assess shoulder impingement.

Partial rotator cuff tear on magnetic resonance

imaging
The presence of increased signal within the supraspinatus tendon

(arrows) in these oblique coronal T2-weighted fat-
suppressed magnetic resonance images of the right shoulder is
characteristic of a partial tendon tear.
Courtesy of Douglas H Brown, MD.

Contributor Disclosures
Stephen M Simons, MD, FACSM No relevant financial relationship(s) with ineligible companies to
disclose. J Bryan Dixon, MD No relevant financial relationship(s) with ineligible companies to
disclose. David Kruse, MD No relevant financial relationship(s) with ineligible companies to disclose. Karl
B Fields, MD Consultant/Advisory Boards: Allard USA [Sports medicine]. All of the relevant financial
relationships listed have been mitigated. Jonathan Grayzel, MD, FAAEM No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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Presentation and Diagnosis of Rotator Cuff Tears - UpToDate

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20/5/22, 16:45 Presentation and diagnosis of rotator cuff tears - UpToDate

Official reprint from UpToDate®

ANATOMY AND BIOMECHANICS

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Subsequent investigations in throwing athletes suggest that tension overload contributes to

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Physical examination — We use a combination of three tests to determine the likelihood of a

● Active painful arc test ( picture 1)

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● No single examination maneuver can accurately diagnose a rotator cuff tear.

Alternative test combinations advocated by clinical researchers include the following:

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Musculoskeletal ultrasound — Musculoskeletal ultrasound (MSK US) is an accurate tool for

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Arthrography with MRI or CT — Magnetic resonance arthrography (MRI-A) is more sensitive

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

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SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Terms of Use.

1. Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders

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24. Gotoh M, Hamada K, Yamakawa H, et al. Interleukin-1-induced subacromial synovitis and

26. Schibany N, Zehetgruber H, Kainberger F, et al. Rotator cuff tears in asymptomatic

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Anterior view of shoulder anatomy

Graphic 72709 Version 3.0

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Lateral view of shoulder anatomy

Graphic 54102 Version 4.0

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Posterior view of shoulder anatomy

Graphic 69995 Version 7.0

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Rotator cuff tear classification

Graphic 100729 Version 3.0

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Painful arc sign for rotator cuff pathology

Graphic 70787 Version 5.0

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Testing of shoulder external rotation strength

External rotation of the shoulder is performed primarily by the

Courtesy of Bruce C Anderson, MD.

Graphic 77117 Version 3.0

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Jobe's test of supraspinatus strength

Graphic 74738 Version 6.0

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Hawkins Kennedy test for shoulder impingement

The Hawkins Kennedy test is used to assess shoulder impingement.

Graphic 60425 Version 4.0

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Neer test for shoulder impingement

The "passive painful arc maneuver" shown above involves passively