Physical examination for rotator cuff disorders

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During a physical examination for a rotator cuff disorder, your health professional will look at your shoulder for signs of swelling, discoloration, muscle deterioration (atrophy), deformities, or abnormal appearance. He or she also will press around your shoulder and arm to check for any tenderness, swelling, or warmth.

Your health professional will examine your range of motion, stability, strength, blood flow, reflexes, and sensation in both the injured and uninjured arms. Moving the arms in specific ways can provide information about the condition of the rotator cuff tendons and the shoulder joint.

If your shoulder is too painful for an adequate examination, your health professional may inject a shot of anesthetic into your shoulder (subacromial space injection) to help determine whether the limited movement is due to pain or weakness. If the anesthetic relieves the pain and allows you to move your shoulder normally, the diagnosis is most likely some form of rotator cuff disease. Your health professional may then inject corticosteroids into the area to reduce inflammation. But if your shoulder is still weak after the injection of anesthetic, the problem may be a rotator cuff tear.

Your health professional may conduct tests to determine whether you have subacromial impingement or a tear in the rotator cuff.

Tests for subacromial impingement

Tests for rubbing of the tendon on the bone (impingement) are based on whether certain movements cause pain and discomfort. To test for impingement, your health professional may have you:

1. Raise your arm straight out in front to shoulder height (forward flexion).
2. Raise your arm out to your side (abduction).
3. Do either step 1 or step 2 and ask you to rotate your arm or rotate your arm for you.
4. Do either step 1 or step 2 and apply resistance to your arm.

Your health professional will consider how painful these movements are to you and, if there was pain, what position your shoulder was in.

Another test involves injecting a pain reliever (such as lidocaine) into the bursa and near the rotator cuff tendons of your shoulder (subacromial space injection). If this relieves your pain, then you probably have rotator cuff abrasion or subacromial bursitis.

Tests for a rotator cuff tear

The main symptoms of a complete rotator cuff tear are pain and weakness. Tests for rotator cuff tears include the following:

• Drop arm test: Hold your arm straight out to your side (90 degrees) with your thumb down. Lower your arm slowly. If it drops suddenly, you probably have a rotator cuff tear.
• Hold your arm straight out to the side, level with your shoulder, with your palm facing down (hand in a fist). Your health professional will press your arm down to determine your strength in this position.
• Raise your arm straight in front about shoulder height (90 degrees) and turn your wrist so your thumb points toward the floor. Your health professional tries to push your arm down against your resistance. If your rotator cuff is weak or torn, you will not be able to hold your arm steady as your health professional pushes down on it.
• Raise your arm straight in front about shoulder height (90 degrees) and turn your palm up toward the ceiling. Your health professional will try to force your hand downward against your resistance. If your rotator cuff is weak or torn, you will not be able to hold your arm steady as your health professional pushes down on it. If you have more pain or weakness in this position, you may also have bicep tendon damage.
• Hold your arm at your side, bend your elbow, and turn your wrist so your thumb points toward the ceiling. Your health professional will try to force your hand in toward your stomach as you resist by trying to rotate your arm outward. If your rotator cuff is weak or torn, you will not be able to hold your arm steady as your health professional pushes on it.
• The touchdown test: Raise your arms alongside your ears, with your palms facing inward. Your doctor will stand behind you and push your arms forward. If you have trouble resisting this, you may have a rotator cuff tear.

The specific movements that cause pain or weakness are clues to the location of a rotator cuff tear.

A physical examination is always done for shoulder pain.

If your health professional thinks your shoulder may be broken or dislocated, X-rays may be done before a physical examination.

In rotator cuff tendinitis, tests usually cause some pain or discomfort.

• If tests are completely normal (negative), you may have mild tendinitis or bursitis.
• Nonsurgical treatment may be started even if the tests are just barely positive.
• If an injection of anesthetic into your shoulder relieves pain during the impingement tests, you are more likely to have a rotator cuff problem.

For a torn rotator cuff, weakness with or without pain is the key diagnostic sign.

• If you have a complete tear, you may be unable to raise your arm straight to the side or to hold your arm in that position if your health professional moves it there.
• Rupture of the long head of the biceps tendon, which is often minimally painful, may be apparent as the muscle rolls into a ball down near the elbow. This also can be a marker for a rotator cuff tear.
• If you have a torn rotator cuff, many tests may be abnormal (positive).
• Injecting an anesthetic into your shoulder may relieve pain but will not restore strength if you have a torn rotator cuff.
• It may be hard to tell the difference between partial tears of the rotator cuff and rotator cuff tendinitis or bursitis.

You may have a rotator cuff tear but still have normal shoulder motion and strength. In these cases, the tear is usually mild.

More extensive and costly diagnostic studies can help determine the cause of shoulder pain or weakness. Your medical history and overall health status, symptoms, age, and occupation or activity level are things your health professional will consider when recommending whether you should have any of these tests.

For example, a professional athlete or a person who hangs wallpaper for a living may warrant more tests earlier than a relatively inactive older adult. A more complete diagnosis is important if you need a strong shoulder or if you may continue activities that will further damage your shoulder.

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Other Works Consulted

• Krishnan SG, Hawkins RJ (2003). Rotator cuff and impingement lesions in adult and adolescent athletes. In JC DeLee, D Drez Jr., eds., DeLee and Drez's Orthopaedic Sports Medicine, Principles and Practice, 2nd ed., vol. 1, pp. 1065–1095. Philadelphia: W.B. Saunders.