Rotator Cuff Strain/ Tendinopathy
Drop Arm Sign
R/C Isolated Strength Test Cluster
R/C Isolated Strength Test Cluster
Rotator Tear Diagnostic Cluster
External Rotation Lag Sign
STM Teres Minor
Mobilization Glenohumeral joint
YTWL Scapular Depression
Glenohumeral Internal Rotation
Corner Pectoral Stretch
Eccentric Scapular Stabilizers
Eccentric Shoulder External Rotation
Introduction & Etiology
The shoulder is a ball-and-socket joint that is afforded great mobility at the sacrifice of structural stability. The rotator cuff is the synthesis of the tendons of the supraspinatus, infraspinatus, teres minor and subscapularis into the capsule of the glenohumeral joint. The supraspinatus, infraspinatus, and teres minor insert on the superior, middle and inferior facets of the greater tuberosity, respectively. The subscapularis is the largest and strongest muscle of the group and inserts on the lesser tuberosity. Collectively, the primary function of the rotator cuff is to stabilize the shoulder while the larger muscles move it (i.e. force couple- the powerful deltoid abducts the arm while the rotator cuff compresses the humeral head into the glenoid to thwart superior translation). The supraspinatus is also called upon to eccentrically decelerate an athlete’s arm after ball release, tennis serve, etc.
Rotator cuff injury is the most common problem to affect the shoulder, accounting for 4.5 million physician office visits per year. (1) Injuries range from a mild strain of a single tendon to complete rupture of multiple tendons. Strains of the rotator cuff can occur abruptly from a solitary insult (falling, pushing, pulling, throwing or lifting), but more commonly (>90%) develop from multiple factors, including repetitive injury and age-related attrition. (2,3,4,31,33) Damage often begins at the undersurface of the supraspinatus tendon, 13-17mm posterior to the biceps tendon (near the junction of the supraspinatus and infraspinatus), and progresses from a partial to a full thickness tear. (54,56,57) A “full thickness tear” is sometimes termed a “complete tear” and is not a rupture, but rather a hole or a slit in the tendon much like what would be created by running a knife lengthwise down the center of a rope. Most tears begin in the supraspinatus but may progress to involve the infraspinatus and subscapularis. (3)
The rotator cuff is predisposed to damage by a multitude of factors including obesity, hypercholesterolemia, genetics, diabetes, or a history of corticosteroid injection (5-10,98). Impingement and hypovascularity may produce recurring damage and impair the cuff’s ability to recover. In 1934, Codman described a “critical zone” of relative hypovascularity, 10–15mm proximal to the insertion of the supraspinatus tendon. (49) This hypovascularity was more pronounced on the “articular” undersurface and was thought to help explain the increased incidence of “articular” surface tears as compared to “bursal” tears.
More recently, Goodmurphy and Brooks (50,51) have refuted the existence of a “critical zone” with research that showed no significant diminution in blood flow to the area. New data suggests that areas closest to the tendon tear are not hypovascular at all. In fact, some researchers have actually reported relative hyper-perfusion within the critical zone. (52) Current technology including laser Doppler flow studies shows a hyper-vascular response at the edge of the tears. (53) Goodmurphy affirmed that the avascularity of the critical zone identified during prior cadaveric studies could have been an artifact of techniques – most notably keeping the cadaveric arm abducted during perfusion.
This research challenges the notion of a simple anatomical origin of hypovascularity at rest. It does not however, refute the concept of functionally diminished blood flow during overhead activity or via traction ischemia. Shoulder abduction is thought to impede blood flow by compressing or “wringing out” this critical zone. As we age, the natural vascularity of our tissue decreases while degenerative spurring increases, thereby advancing the age-related progression of degenerative cuff tendon failure. (11,98) Smoking diminishes blood flow and is another known risk factor for the development of rotator cuff pathology.
Tendon matrix degradation results from a combination of tensile and compressive overload. During early arm elevation, the supraspinatus tendon is subject to both; with the bursal fibers enduring more tensile load while the articular fibers are subject to greater compression. Since most damage occurs on the articular surface, compression would seem to be a greater threat than tension. (90)
Neer suggested that 95% of chronic rotator cuff tears are associated with impingement. (32) Repetitive overhead activity predisposes a patient to impingement related injury- particularly sports like baseball, swimming, volleyball, tennis, rowing, weightlifting and archery and jobs including carpentry, painting, wallpaper hanging, cleaning windows and washing/ waxing cars. (98) The unilateral nature of these tasks makes rotator cuff injury more common in the dominant arm. (12) Patients with scapular dyskinesis or upper crossed syndrome are highly predisposed to rotator cuff damage from repetitive impingement. A detailed discussion of rotator cuff tendinopathy from impingement can be found in the ChiroUp protocol “Shoulder anterior impingement syndrome”.
Like tendinopathies affecting other areas of the body, the etiology of rotator cuff maladies is now considered more “degenerative” than “inflammatory”- wherein a classic inflammatory reaction is histologically absent in lieu of thinning, degenerated and disorganized collagen fibers and other signs associated with a failed healing response. (58-65) Some authors hypothesize that rotator cuff tendon degeneration may actually precede impingement in a self-perpetuating cycle of dysfunction. The process starts when an insult damages the tendon and leads to tendon degeneration. This weakens the tendon and diminishes its ability to oppose superior shearing force produced by the deltoid during arm abduction. The tendon becomes impinged, producing further insult. (55,56) As tendon fibers fail, the enduring fibers remain under tension, thereby increasing load and the likelihood of failure. (56)
The clinical presentation for rotator cuff injury differs significantly between acute and chronic tears. Acute injuries, resulting from falls, throws or other powerful movements, begin as a “tearing” or “snapping” feeling accompanied by severe pain and weakness, particularly shoulder abduction. Whereas chronic or degenerative tears usually begin silently with widely variable symptoms becoming more evident as the tear progresses. (13) Patients often report gradual onset pain and weakness accompanied by crepitus. Pain may be localized to the anterolateral aspect of the shoulder but can radiate down the arm. Early symptoms are provoked by overhead activity and may progress to the point that the patient has difficulty raising their arm overhead. Pain is often worse at night, particularly when lying on the affected shoulder. (36) Symptoms may be objectively tracked with the Disabilities of the Arm Shoulder and Hand. (DASH)
Clinical evaluation of the rotator cuff begins with observation and palpation for possible atrophy involving the deltoid, infraspinatus or supraspinatus (Rent sign). Palpation below the acromion may demonstrate crepitus on movement. Shoulder range of motion testing will likely demonstrate limited passive internal rotation and decreased active elevation and abduction. (14-16) Internal rotation may be assessed by having the patient reach behind their back and slide their extended thumb as high on the spine as possible (Apply’s inferior scratch test). Slightly diminished ROM on the patient’s dominant shoulder is common. Substantial limitation in passive forward flexion and passive abduction may suggest the onset of adhesive capsulitis.
Clinicians should perform isolated strength testing of each rotator cuff muscle to asses for pain or weakness. The supraspinatus functions in elevation and can be isolated for testing with the arm outstretched in the scapular plane, thumb down (Empty can test/ Jobe test). (17,78) The “Full can test” is an alternate assessment for the supraspinatus. (38,78) The infraspinatus and teres minor function in external rotation and may be isolated in 90 degrees of forward flexion, in the scapular plane, with the elbow flexed to 90 degrees, forearm pointing upward (Hornblower’s Sign/ Patte Test). (39,78) The subscapularis is an internal rotator and can be assessed using the “Lift off test” with the patient’s arm behind their back, palm facing outward while pressing their palm away from their back against resistance. (37) The “Bear Hug test” and “Belly Press test” are alternate ways to assess the integrity of the subscapularis. (40)
A Drop arm test can help detect weakness related to tendon tear. (37) The test is performed by passively abducting the patient’s shoulder to 90 degrees then and asking the patient to slowly lower their arm to their side. The External Rotation Lag Sign (ERLS) has shown utility in detecting rotator cuff tears. (47,48,78) In particular, the ERLS demonstrated high specificity (98%) and acceptable sensitivity (56%) for detecting full-thickness tears of the supraspinatus tendon. (77) The test is performed by flexing the seated patient’s elbow to 90 degrees with 20 degrees of shoulder abduction. The clinician then passively takes the patient’s shoulder into a position of maximal external rotation. The patient is then instructed to hold that position. The test is positive if the patient cannot maintain this position- as evidenced by retreating into internal rotation. Clinicians should assess for signs of shoulder anterior impingement syndrome including a positive painful arc, positive Neer’s test and positive Hawkins test. Biceps tendon tears frequently accompany rotator cuff injury and should be investigated. (35)
The importance of proper scapulohumeral rhythm cannot be overstated. The scapula serves as a functional platform for proper glenohumeral mechanics, and alterations in normal mechanics may lead to pathology. Scapular dyskinesis and upper crossed syndrome are two of the most significant contributors to rotator cuff pathology. Clinicians should assess to ensure that the patient’s glenohumeral to scapulothoracic motion is a 2:1 ratio (i.e., 180 degrees of abduction = 120 degrees glenohumeral + 60 degrees scapulothoracic motion). Clinicians should assess for scapular winging, which may become more pronounced when performing the “Quadruped rock test”. Evaluation of the remainder of the kinetic chain may demonstrate a need to address deficits in hip mobility and core stability as these problems are associated with shoulder injury in throwers. (18,19)
Combining assessments into clusters can improve diagnostic accuracy. Murel and Walton (20) demonstrated a 98% probability of full thickness rotator cuff tear in patients exhibiting at least three of the following four findings: age over 60, supraspinatus weakness, weakness in resisted external rotation and positive signs of impingement.
Diagnostics & Differential
The diagnosis of tendinopathy is based upon clinical findings, and imaging should be reserved for special circumstances. (97) Clinicians should base their decision to image the shoulder on whether the outcome of the study will affect treatment. Acute injury in a young patient suspected of having a rupture may warrant immediate advanced imaging, whereas an 80-year old patient with slow onset shoulder pain and weakness may not. Plain films would include AP (performed with shoulder Internal Rotation), Grashey, aka Neer AP or True AP (performed with shoulder External Rotation), Lateral axillary, and Arch or Rockwood views. Diminished acromial-humeral distances (<7mm) on the AP view, are associated with rotator cuff tears. (21,31) Acromial changes (Type I, II,III) are associated with impingement syndrome, but may not have a direct correlation with rotator cuff tear. (22,93) Sclerosis and spurring of the acromion and greater tuberosity are common in older populations.
In atraumatic tendinopathy cases without significant loss of strength, MRI should not be performed prior to a trial of conservative care. (96) In cases where significant disruption is suspected, or surgery is contemplated, both ultrasound and MRI are highly accurate (90%) in detecting complete rotator cuff tears. (21,23, 79-82) MRI arthrography has long been considered the most sensitive test, particularly for detecting partial tears (34), however, it is not routinely recommended for diagnosing rotator cuff tears as it has a marginal benefit over plain MRI or Ultrasound. (79) The likelihood of finding a rotator cuff tear on advanced imaging is relatively proportionate to the patient’s age. Researchers have shown that asymptomatic rotator cuff defects are present in 10% of those under the age of 20, 50% of people over 70 years of age, and 50-80% of people over 80 years of age. (24,74,76,88) Not all tears are the source of the patient’s symptoms.
In addition to scapular dyskinesis and shoulder anterior impingement syndrome, the differential diagnosis for rotator cuff injury includes cervical radiculopathy, biceps tendonitis, calcific tendonitis, A/C joint injury, labral injury, osteoarthritis, instability, fibromyalgia, adhesive capsulitis, acute bursitis, myofascial pain syndrome, thoracic outlet syndrome, fracture, infection, neoplasm and somatovisceral referral- particularly cardiac.
Although there is no consensus on the most appropriate management for rotator cuff injuries, current research suggests that conservative care should be the first choice for most non-traumatic tears. (25, 45,75,76) The decision to initiate conservative versus surgical management should be based on acuity, tear size, age and loss of function. (5) Bartolozzi (27) identified three factors associated with a poor prognosis for conservative management of rotator cuff injury: full thickness tears greater than 1 cm, symptoms lasting more than one year and functional impairment/weakness. Ruptures and larger tears (> 1 cm) in younger populations may be best addressed surgically before irreversible retraction. (5) Data suggests that conservative management of partial thickness and chronic full-thickness tears yields good outcomes. (5,28,29) Success rates for conservative care vary between 33-92%, and the prognosis seems to be based on the patient’s history, tear size and duration of symptoms. (25) Findings from high-quality research investigations “suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery for; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, partial thickness rotator cuff (RC) tears and atraumatic full-thickness rotator cuff tears.”(75) Long-term non-operative outcomes compare to surgical repairs. (91,95)
The conservative management of rotator cuff injuries should include activity modification, stretching, strengthening, manual therapy, and restoration of scapular mechanics. (86) Patients should avoid painful overhead activity, carrying heavy objects and sleeping on the affected side, especially with the arm stretched overhead. Patients may benefit by sleeping on the unaffected side with a pillow between their affected arm and trunk. Smokers should consider a cessation program. Overweight patients would benefit from a diet and aerobic exercise regimen.
Immobilization of injured tendons promotes adhesion and delays recovery; however, clinicians must carefully weigh the balance of aggravating symptoms and encouraging recovery. (66,67) Early interventions should minimize stressful loading of the injured tissues. Stretching and myofascial release techniques may be appropriate for the pectoral muscles, infraspinatus, teres minor, subscapularis, trapezius, levator and posterior capsule. Transverse friction massage or IASTM may be implemented judiciously to enhance remodeling of scar tissue. Modalities may be used initially as adjuncts for pain relief. (97) Low-level laser therapy may be helpful. (86) Shockwave therapy (ESWT) may provide pain relief and functional improvement. (99) The use of elastic therapeutic tape may help to facilitate or inhibit muscular function. Joint mobilization and manipulation are appropriate for restrictions in the scapulothoracic, glenohumeral joint, and cervicothoracic spine. (30) There is evidence to suggest that cervicothoracic and thoracic spine manipulation may help decrease shoulder pain while improving mobility and function. (41-44,73)
“The evidence supports a slowly progressive loading program, rather than complete rest.” (97) The goal of tendinopathy rehab is to carefully balance stimulating a controlled musculotendinous inflammatory response without causing greater injury or exacerbating symptoms. Rehab should begin with moderate effort and low repetitions. Response to tensile loading may be assessed by the patient’s change in night pain. Increases in night pain indicate the current rehab load is excessive. Progression advances when the patient tolerates a given level of tensile load. (89)
Self-managed home exercise programs show similar outcomes to those directed in-office by a physical therapist. (46) Gentle range of motion exercises can begin with Codman pendulum exercises, wall walking and stick or towel exercises. Stretching exercises should focus on restoring adduction, internal rotation, and external rotation. This may be accomplished by a cross body stretch and sleeper stretch. Progressive resistance exercises can be implemented as tolerated for the rotator cuff and periscapular musculature, particularly the external rotators, serratus anterior and lower trapezius. Stabilization exercises will progress from isotonic strengthening to more sport-specific actions, including eccentric strengthening and endurance. Clinicians should address any likely concurrent deficits in scapular mechanics with the implementation of a scapular dyskinesis or upper crossed syndrome rehab protocol. Clinicians should correct deficits of hip mobility or trunk stability in throwers.
The use of NSAIDs should be limited as these drugs inhibit collagen synthesis and may interfere with natural healing. (71,72,79,83,84,85) Although PRP injections have been shown promote tendon healing (68,69), existing literature does not support their use for rotator cuff tendinopathy. (56,70,71,94) Prolotherapy (injecting an irritating solution. i.e. dextrose) may provide benefit for rotator cuff tendinopathy patients. (100) Patients who fail conservative therapy are candidates for orthopedic consult. Rotator cuff surgery patients who undergo concurrent biceps tendon repair demonstrate lower effectiveness and efficiency scores. (87) Arthroscopy patients demonstrate improved functional scores when a post-surgical sling is not utilized. (92)
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* 95% of chronic rotator cuff tears are due to impingement & 100& of impingement patients have scapular dyskinesis.
* Tears begin at the undersurface of the supraspinatus and may progress to involve the infraspinatus and subscapularis.
* Asymptomatic rotator cuff defects are present in 50% of people over 70 years of age and 80% of people over 80 years of age.
* 3 factors associated with a poor prognosis for conservative management of rotator cuff injury: full thickness tears greater than 1 cm, symptoms lasting more than one year and functional impairment/weakness.
* Surgical intervention should be considered for: acute ruptures, full thickness tears greater than 1 cm, symptoms lasting more than one year and functional impairment/weakness