These authors examined the accuracy of external rotation in neutral (0° external position) and in shortened position (45° external position) in relation to rotator cuff tear size, tendon reparability, and other clinical, surgical, and imaging findings (magnetic resonance imaging and arthroscopic surgery).Eighty-five patients (35 female and 50 male, 65 years ±10 years) were found to have the following tear types: sixty patients (71%) had a minor tear (4 small, 56 moderate), and 25 patients
(29%) had a major tear (17 large and 8 massive). Seventy patients (82%) had a full repair, and 15 (18%) patients underwent a partial repair. There were 26 (31%) associated full-thickness tears of the infraspinatus.
The isometric strength testing in both positions had good to excellent accuracy for detecting reparability, tear retraction, infraspinatus atrophic changes observed by the clinician, and infraspinatus fatty infiltration on magnetic resonance images. The shortened position had an overall higher accuracy than the neutral position and was more clinically useful for detecting an infraspinatus fullthickness tear and rotator cuff tear size.
The isometric strength testing in both positions had good to excellent accuracy for detecting reparability, tear retraction, infraspinatus atrophic changes observed by the clinician, and infraspinatus fatty infiltration on magnetic resonance images. The shortened position had an overall higher accuracy than the neutral position and was more clinically useful for detecting an infraspinatus fullthickness tear and rotator cuff tear size.
The authors concluded that the strength of isometric external rotation is an accurate test in diagnosing different aspects of rotator cuff disease and specifically of the infraspinatus muscle. The isometric strength at the shortened position was a better predictor of clinical, surgical, and imaging findings.
Comment: This study again highlights that a good history, physical examination and plain radiographs provide much of the information needed to guide treatment of cuff disease without resorting to more expensive advanced imaging. This cost-effective approach was presented decades ago in Practical Evaluation and Management of the Shoulder (see this link). Here is a chart from that book showing the approach that we used then and still use now
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