Rotator cuff tear: physical exam predicts tear size and reparability!

Accuracy of infraspinatus isometric testing in predicting tear size and tendon reparability:comparison with imaging and arthroscopy

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 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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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Diagnosing rotator cuff tears on physical examination

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

As we've pointed out before,  many precious health care dollars are spent in evaluating patients for rotator cuff pathology. On the other hand, as we've emphasized previously rotator cuff tears can usually be diagnosed from history and physical examination alone.

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.

These findings are combined with examination for stiffness and weakness as explained here.

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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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

To see other similar posts, click on the label of interest below.

The Power of the Human Touch, the iPatient, and the role of ritual in future of medicine.

The Ethiopian born surgeon Abraham Verghese and author of the wonderful book, Cutting for Stone, has provided us with a mind-bending TED talk, called "A doctor's touch". To see it click here. This is 11 minute program is of importance for every doctor, every patient, and everyone.

 I am grateful to my close friend, Gene Peterson, for calling this YouTube to my attention.

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To learn more about shoulder arthritis and what can be done about it, see the Shoulder Arthritis Book.

To learn more about the rotator cuff, see the Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, androtator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Rotator cuff disease - clinical signs

Does This Patient With Shoulder Pain Have Rotator Cuff Disease? The Rational Clinical Examination Systematic Review

These authors remind us that rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians. They performed a meta-analysis to identify the most accurate clinical examination
findings for RCD. They located 28 studies that assessed the examination of referred patients by specialists. Only 5 of the studies reached Rational Clinical Examination quality scores of level 1-2. These included from 30 to 203 shoulders with the prevalence of RCD ranging from 33%to 81%. 

They found that among pain provocation tests, a positive painful arc test result was the only finding with a positive likelihood ratio (LR) greater than 2.0 for RCD (3.7 [95%CI, 1.9-7.0]) and a
normal painful arc test result had the lowest negative LR (0.36 [95%CI, 0.23-0.54]). 

Among strength tests, they found that a positive external rotation lag test (LR, 7.2 [95%CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95%CI, 2.6-12]) were the most accurate findings for full-thickness
tears.  A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95%CI, 0.0-0.58]). 

We observe that the tricky thing about cuff disease is that, addition to pain, it can present with (1) weakness (usually on supraspinatus testing, but also on infraspinatus and subscapularis testing), (2) subacromial crepitance on active or passive motion of the shoulder, (3) stiffness (limitation of range of motion, especially internal rotation), and (4) instability.

Our examination for patients suspected of having cuff problems is shown here.

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Rotator Cuff 5 - Can the rotator cuff tear be repaired?

Yesterday's post covered some of the key factors bearing on the repairability of a rotator cuff tear.


Below are listed findings that have been shown to be encouraging or discouraging about the prospect of the shoulder having a durably reparable cuff tear. It is of interest that many of these factors can be determined without advanced testing.

ENCOURAGING                                          DISCOURAGING

History
    Age less than 55                                             Age over 65
    Acute traumatic onset                                     Insidious, atraumatic onset
    No relation to work                                        Attribution of tear to work
    Short duration of weakness                            Weakness over 6 weeks
    No history of smoking                                    Many smoking pack-years
    No steroid injections                                       Repeated steroid injections
    No major medications                                     Steroids/antimetabolites
    No concurrent disease                                     Inflammatory joint disease
    No infections                                                   History of previous infection
    No previous shoulder surgery                          Previous cuff surgery
    Benign surgical history                                    History of failed tissue repairs

Physical Examination
   Good nutrition                                                  Poor nutrition/obesity
   Mild weakness                                                  Severe weakness
   No spinatus atrophy                                          Severe spinatus atrophy
   Stable shoulder                                                 Anterior superior instability
   Intact acromion                                                 Previous acromioplasty
   No stiffness                                                       Stiffness

Radiographs
   Normal radiographs                                          Upwards head displacement
                                                                              Cuff tear arthropathy

MRI or Ultrasound                                            
  Good tendon quality                                         Thin tendon

  One tendon tear                                                 Multiple tendon involvement

  Small gap to close                                             Severe retraction

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).