Rotator Cuff Evaluation

[Peppin Kishore]

Inexamining a patient with a painful shoulder we should start with a general inspection, looking for musculoskeletal abnormalities and any associated functional deficits. Then, we can carry on some specialized tests that will help us uncover any lesions of the muscular or ligamentous structures of the joint.

Once the patient has uncovered the upper trunk and extremities we can move to a general inspection of the front, the side and the back of each shoulder. Our goal is to identify any abnormalities in the muscle bulk or any asymmetrical bony defects.

Before proceeding with the examination of the shoulder it is very important to complete a full examination of the cervical spine to make sure that no spinal pathologies are contributing to the presentation. We should at the very least check for cervical spinal tenderness, by palpating the cervical spinous processes, and the range of motion of the neck in flexion, extension and rotation.

Have the patient flexing the upper extremity forward to 90. From this position, ask the patient to maximally adduct the shoulder by moving the arm horizontally all the way to the other side. Make sure to test one side at a time.

First ask the patient to flex the elbows at approximately 45 with the fists clenched and the thumbs up, then ask to position both hands behind the back until the thumb touches the apex of the homolateral shoulder. This maneuver tests for the functional integrity of the internal rotation of the shoulder.

Before completing the inspection of the shoulder it is good practice to repeat all the maneuvers that test for range of motion while observing the movement of the scapulae. Any asymmetries in the rhytm of scapular movement would indicate pathology in the anterior aspect of the shoulder.

The exam of the shoulder has to be completed by some specialized tests and provocative maneuvers that are specific for different shoulder lesions and pathologies. These tests will help us confirm or exclude the presence of a specific shoulder condition, that we may only suspect after the inspection and the assessment of the full range of motion.

Rotator cuff injuries are among the most common causes of shoulder pain. These can manifest as bursitis, tendonitis or tendon tears. The patients usually complain of pain and reduced function of the affected shoulder. In young patients a rotator cuff tear is usually traumatic in etiology and the symptoms show an acute onset. In older patients, instead, a tendon tear is usually caused by a chronic degenerative process related to aging, and the pain is more gradual in onset.

The supraspinatus tendon is the most frequently injured tendon of the rotator cuff. To test for integrity of the supraspinatus we can ask the patient to abduct both arms to 90 and then to bring them anteriorly with a 30 forward flexion. From this position, we will ask the patient to push both arms upwards against our resistance. Any pain or reduced strength, especially if unilateral, will be indicative of a supraspinatus tendon injury.

To check for the integrity of both infraspinatus and teres minor tendons we need to apply resistance to the external rotation of the shoulder. To do this, we will ask the patient to flex the forearms at 90 with the palms supinated. From this position we will have the patient to externally rotate the shoulders by moving the forearms laterally, against our resistance. Any pain and/or weakness will indicate an injury in one of these tendons.

To test for the presence of a subscapularis tendon tear, first have the patient to bring the hand on the back at the level of the lumbar region. Then, passively separate the hand from the back until full internal rotation of the shoulder is achieved. At this point ask the patient to actively keep the hand away from the back. If the patient is unable to do so, this is evidence of a subscapularis tendon tear and it is called positive internal rotation lag sign.

Ask the patient to internally rotate the shoulder by bringing the hand behind the back at the lumbar region with the dorsum of the hand facing the lumbar spine. Then, ask the patient to move the hand away from the back against your resistance. If pain or weakness is elicited, the test is considered positive for a subscapularis tendon tear.

To perform this test both the elbow and the shoulder should be flexed at 90. The examiner must support the arm of the patient at the level of the elbow so that the upper extremity can be as much relaxed as possible. Then the examiner has to internally rotate the shoulder while at the same time perform a cross-body adduction of the arm. The test is positive if pain is elicited.

Patients with shoulder impingement may also have tenderness upon palpation of the anterior joint line. To expose the subacromial and subdeltoid spaces ask the patient to internally rotate the shoulder by placing the hand against the back.

Biceps tendinopathy refers to inflammation or degeneration of the long head of the biceps tendon. It is an important cause of anterior shoulder pain and it is usually seen in association with other shoulder pathologies, such as rotator cuff tears and shoulder impingement.

In this test the patient is asked to first extend the elbow and fully supinate the forearm. Then the patient is asked to flex the shoulder forward against the resistance of the examiner. At the same time, the examiner should palpate the anterior joint line for any tenderness. Any pain elicited by the maneuver would be indicative of biceps tendinopathy.

In adhesive capsulitis the capsule of the shoulder joint becomes inflamed and stiff making every movement very painful and difficult to execute. The initial stage of the disease is carachterized by pain with movement of the shoulder in any directions. In the later stages the pain tends to subside but the ranges of motion are still severely reduced. It is important to remember that both the passive and the active ranges of movement are affected. The first range of motion to be affected is the external rotation. Also, there is usually an associated asymmetry in scapular movement.

With this term are indicated all the pathologies that may affect the acromioclavicular joint such as, degenerative processes or traumatic injuries. Regardless of the cause, the complaints are almost always the same. The patients will report pain localized over the acromionclavicular joint and pain at night triggered by sleeping on the affected side.

In the scarf test the examiner places the hand of the affected side on the contralateral shoulder. Then it forces the cross body adduction of the arm by pushing at the elbow. At the same time the examiner must palpate the AC joint. Any pain or crepitus are indicative of an AC joint injury.

For this test it's preferable that the patient lies supine on the examination table. Then the examiner flexes the elbow at 90 and abducts the shoulder to 90 as well. At this point the examiner applies a downward pressure with one hand at the level of the wrist, while the other fist is placed behind the shoulder. This maneuver creates a dislocation of the humerus that should cause pain or discomfort if instability is present. Then, we must apply a downward pressure on the anterior aspect of the shoulder that makes both the pain and the apprehension disappear if instability is present.

The glenoid labrum is a ring of cartilage that surrounds the margins of the glenoid fossa. It stabilizes the shoulder joint by giving attachment to the ligaments. It is most commonly damaged in its superior portion, that also includes part of the biceps tendon (SLAP lesions). This lesion is usually seen in athletes that do repetitive overhead activities, such as baseball players, or in accidents where the arm is in the overhead position, as a consequence of humeral head dislocation.

Dr. Mark Genovese is a Professor of Medicine and certified in rheumatology. He is actively involved in house staff training at Stanford University. He is involved in research including clinical trials and interventions in rheumatic diseases such as rheumatoid arthritis, psoriatic arthritis, & osteoarthritis.

As with many conditions, single physical examination maneuvers rarely are sensitive enough to rule out disease when absent or specific enough to rule in disease when present. By themselves, these maneuvers increase or decrease the likelihood of disease slightly, and it remains up to the physician to integrate a series of findings into an estimate of the probability of disease.

Clinical decision rules help physicians by integrating the most helpful findings into a single, easy-to-use algorithm, rule, or scoring system. Two systems for the evaluation of patients with shoulder pain are presented in this article. The authors of the first clinical rule1 began by assessing 23 maneuvers for evaluating the shoulder. They defined weakness as any score below 5 (full strength) on a 1 to 5 scale.1 All patients underwent arthros-copy as the reference standard. The authors then identified the first 100 patients with a partial- or full-thickness rotator cuff tear of any size and no other shoulder pathology, and the first 100 patients without a tear. Only three maneuvers distinguished between the two groups: supraspinatus weakness, weakness in external rotation, and a positive impingement sign1 (Figure 1). Next they evaluated these three physical findings in two larger groups of patients with shoulder pain: (1) a group of 200 patients with rotator cuff tear, including some who had additional shoulder pathology and (2) a group of 200 patients without a tear.1

The results of the second evaluation are shown in Table 1,1 stratified by the number of abnormal physical findings and patient age. Older patients were more likely to have a rotator cuff tear than younger patients. The probability of rotator cuff tear was high (98 percent) in patients of any age with all three findings or in patients with any two findings who were at least 60 years of age. The probability was 5 percent in the 97 patients who had none of the three findings.

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