Wednesday, August 31, 2011

Rotator Cuff 6 - Clinical examination for a rotator cuff tear

Today, we'll consider how the physical examination of a shoulder can help discern if a rotator cuff problem may be present

Inspection can reveal atrophy, as well as incisions and scars indicating previous surgery and penetration. The physical examination may reveal subacromial roughness from hypertrophic bursa or from the superior edges of torn tendon rubbing against the coracoacromial arch that can be felt by a hand placed over the acromion as the shoulder is rotated.

Palpation can reveal gaps in the cuff tendon as shown in the figures below.

The range of motion examination can reveal restrictions due to contracture surrounding the area of injury or scarring in the humeroscapular motion interface. Limited range of motion is particularly common in the presence of partial thickness tears of the rotator cuff. The most common partial thickness tear is that of the supraspinatus tendon. In this situation it is characteristic to have loss of the motions that places this tendon under tension – internal rotation with the arm at the side

 internal rotation of the arm in 90 degrees of abduction

 and cross body movement

While, in the past, pain on these maneuvers has been attributed to ‘impingement,’ it is now recognized as being due to the pull on the partially torn tendon attachment which is analogous to the pain experienced on stretching the origin of the extensor carpal radialis brevis in tennis elbow.

Cuff strength is conveniently examined using manual tests of isometric torque. Isometric testing removes potential interference from pain on motion, from crepitance, or from stiffness. These tests examine the integrity of the supraspinatus

 the infraspinatus

and the subscapularis

Pain or weakness on these maneuvers constitutes an abnormal tendon sign for the specified tendon-muscle unit. These tests are relatively specific to each muscle, but are not specific to the cause of weakness; for example, a suprascapular nerve lesion or a cuff tear may each produce abnormal supraspinatus and infraspinatus tendon signs. 

Using these simple tests, the examiner can assess crepitance, loss of range of motion and pain or weakness on examination of specific tendons.


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