Rotator cuff tear: physical examination and conservative treatment

Abstract

Rotator cuff tear is one of the most common shoulder diseases. It is interesting that some rotator cuff tears are symptomatic, whereas others are asymptomatic. Pain is the most common symptom of patients with a tear. Even in patients with an asymptomatic tear, it may become symptomatic with an increase in tear size. Physical examination is extremely important to evaluate the presence, location, and extent of a tear. It also helps us to understand the mechanism of pain. Conservative treatment often works. Patients with well-preserved function of the supraspinatus and infraspinatus are the best candidates for conservative treatment. After a successful conservative treatment, the symptom once disappeared may come back again. This recurrence of symptoms is related to tear expansion. Those with high risk of tear expansion and those with less functional rotator cuff muscles are less likely to respond to conservative treatment. They may need a surgical treatment.

Fig. 1

Atrophy of the shoulder musculature. The right infraspinatus muscle is atrophic, and the infraspinous fossa is dented (arrow)

Fig. 2

Winging of the scapula. The medial boarder of the right scapula (arrows) is prominent because of subacromial impingement

Fig. 3

Palpation of a delle (defect) of the cuff tendon. A delle or defect of the tendon may be palpated just anterior to the anterior margin of the acromion

Fig. 4

Neer impingement sign. While holding the scapula with one hand to avoid scapular rotation, apply elevation force to the arm that is in internal rotation. This procedure causes pain if there is a subacromial impingement

Fig. 5

Hawkins impingement sign. With the arm in flexion, apply internal rotation force, which causes pain if there is a subacromial impingement

Fig. 6

Modified Neer sign. Applying elevation force with the arm in external rotation is a modification of original Neer sign

Fig. 7

Modified Hawkins sign. Keeping the arm in abduction, apply internal rotation force, which causes pain

Fig. 8

Supraspinatus test (empty-can test). Apply downward force to the arm in 90° scaption and in internal rotation (thumb down). If there is a supraspinatus tear, the patient cannot resist this force because of muscle weakness

Fig. 9

Supraspinatus test (full-can test). Apply downward force with the arm in 90° scaption and in external rotation (thumb up). If there is a supraspinatus tear, the patient cannot resist this force and the arm will be depressed

Fig. 10

Dropping sign or external rotation lag sign. The patient is asked to keep the arm in external rotation. On the intact side (a), the patient can keep the arm in external rotation position when the examiner lets the arm go. On the involved side (b), the patient cannot keep the arm in external rotation, and the arm comes back to the neutral rotation after the examiner lets the arm go

Fig. 11

Hornblower’s sign. The patient is asked to bring the hands to the mouth. He can do it, but only with the elbow in a high position and the wrist in extension on the affected side (right arm). On the intact side (left arm), the patient can reach the mouth without bringing the elbow high

Fig. 12

Lift-off test. A patient can lift off the hand from the back at the lumbar level with the intact subscapularis (a). If it is torn, the patient cannot lift off the hand from the back (b)

Fig. 13

Belly-press test. With the intact subscapularis, a patient can press the belly with the hand, wrist, and elbow straight (a). If the subscapularis is torn, the patient cannot keep the hand, wrist, and elbow straight to press the belly (b). Due to weakness, the patient flexes the wrist and brings the elbow backward in order to press the belly