Friday, May 2, 2014

Diagnosing rotator cuff tears on physical examination

Rotator cuff crepitus: could Codman really feel a cuff tear?

It is, therefore, refreshing to read a paper in which the authors assess the accuracy of physical findings to diagnose rotator cuff tears. 

These authors describe the 'crepitus' test as the use of the fingers to directly palpate the cuff insertion to the greater tuberosity deep to the deltoid, just inferior to the anterolateral acromion while the arm is held in slight extension and passively rotated. A test result is considered positive in the presence of any reproducible palpable crepitus. 

They evaluated 63 patients who presented with shoulder pain and no previous imaging or surgery. The results were compared to findings on MRI. 

They found that the crepitus test had a sensitivity for full-thickness or high-grade partial tears of 82% and 73%, respectively; the PPV and NPV were 77% and 79%.

Comment: In our experience the diagnosis of rotator cuff tear can usually be made on history and physical examination as detailed in this publication and as shown in the figures below from a previous post.

Crepitus on passive rotation

Palpation of a defect at the supraspinatus insertion

Location of the defect in relation to the bicipital groove

Increasing exposure by passive extension of the humerus.

With practice, surgeons can gain confidence in their ability to diagnose cuff tears on examination, avoiding spending dollars on imaging unless it will change the management of the patient.

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