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Make the Diagnosis: Rotator Cuff Disease

Prior Probability of Rotator Cuff Disease

Rotator cuff disease (RCD) includes tendinopathy of 1 or more of the 4 muscles of the rotator cuff, tears of those muscles, or subacromial bursitis. The impingement syndrome occurs when one of these disorders causes shoulder discomfort during abduction of the arm between 60° and 120°. At any given time, up to 25% of adults may experience shoulder discomfort.1 Rotator cuff disease is the most common cause, occurring in about 2.8% of those older than 30 years and in 15% of those older than 70 years.2,3 Because most patients do not require surgery, many of them are seen by primary care physicians. Among those referred to orthopedists, the probability of RCD is greater than 30%.

Population in Whom Rotator Cuff Disease Should Be Considered

The shoulder joint has the widest range of motion of all joints in the body. Any patient with shoulder discomfort (especially with overhead activity) should be examined to assess for RCD. However, cervical spine pain can create pain referred to the shoulder, and intrinsic glenohumeral joint disorders (instability, osteoarthritis, or adhesive capsulitis) may also cause the discomfort.

Assessing the Likelihood of Rotator Cuff Disease in Patients With Shoulder Pain

Tests for RCD are categorized as pain provocation tests (positive when causing pain), strength tests (positive when causing weakness), or combination tests (positive when causing weakness or pain). The best findings and tests are shown in Table 93-1. Neither the commonly performed Hawkins test nor Neer test worked as well as the findings and tests shown in Table 93-1. Table 93-3 lists all clinical tests for RCD and Figure 93-2 shows the recommended clinical tests for the evaluation of RCD.

Table 93-1Useful Findings for Assessing the Likelihood of Rotator Cuff Disease in Patients With Shoulder Pain

All studies of tests and findings useful in diagnosing RCD have been done in specialty practices where the prevalence of disease is high. Patients in orthopedic clinics may be more likely to have severe rotator cuff disease or to have failed conservative treatments. This creates verification bias that leads to overestimation of sensitivity and underestimation of specificity. Thus, an increased number of positive findings ...

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