ACC Review: Rotator cuff disorders Part 1 –
Diagnosis
Issue 13 October 2004
General points

Rotator cuff disorders are the most common source of shoulder pain in people
over the age of 35 years, ranging from tendinosis to a significant tear

Tendinosis usually develops from repetitive activity at or above shoulder
height and is characterised by a painful arc due to impingement

Tears are usually a result of trauma. Full thickness and massive tears are
characterised by weakness

If a significant rotator cuff tear is suspected, refer for diagnostic ultrasound

Active and physiologically young people with a full thickness tear require early
specialist referral (within 4-6 weeks)

Massive tears require immediate referral to a specialist for evaluation.
Background
Rotator cuff disorders are the most common source of shoulder pain in people
over 35 years of age. They range from mild strains to massive tears and are
common in athletes, workers with repetitive overhead activities, and the elderly,
due to years of use. Tears usually occur as a result of trauma.
The diagnosis of shoulder injuries is challenging as pathologies and their clinical
manifestations vary widely with each person and more than one pathology may
exist.
Recently ACC published a Guideline on the diagnosis and management of soft
tissue shoulder injuries.1 The Guideline’s recommendations for the diagnosis of
rotator cuff disorders associated with trauma are summarised below.
Clinical Diagnosis
The following are the commonly described trauma-related rotator cuff disorders:

Tendinosis – caused by collagen fibre failure (degeneration) due to ageing,
vascular compromise, or microtrauma associated with repetitive activity at or
above shoulder height.

Partial tears – occur on the bursal or articular side of the tendon. These are
more common than full thickness tears.

Full thickness tears – extend through the full thickness of the tendon.

Massive tears - are large (>5 cm) involving 2 or more tendons (usually
supraspinatus and infraspinatus or supraspinatus and subscapularis).
No clinical test or group of tests is both reliable and valid for diagnosing these
tears. [DSR++] However, a recent study2 [D+] suggests that the supraspinatus
test (Jobe’s test) may be useful in diagnosing large and massive tears. A clinical
examination by a specialist may rule out, but is less effective at detecting, a
rotator cuff tear. [DSR++]
Differential diagnosis
The differential diagnosis includes cervical spine and nerve disorders,
inflammatory disorders and related shoulder disorders including acromioclavicular
joint problems and calcific tendonitis. Labral tears and associated instability
should be considered in younger people with a history of dislocation.
Specific Diagnosis
Tendinosis and partial tears
A painful arc is the classic clinical manifestation of impingement. Activity-related
pain and night pain are also characteristic. Pain is typically felt around the lateral
deltoid or point of the shoulder and may be referred to the elbow. Active
movement may be limited, but full range passive movement can be achieved.
Paradoxically, a younger person may be more symptomatic than an older person
with a larger tear.
Full thickness and massive tears
The primary indicator for these tears is weakness in abduction and external
rotation. Weakness of internal rotation, associated with significant trauma,
suggests a major tear of the subscapularis.
Weakness from pain inhibition can be misleading. A subacromial injection of local
anaesthetic may enable the cause of the weakness to be clarified.
These tears require early specialist referral (4-6 weeks) in the active and
physiologically young as surgery may be required to achieve optimal functional
outcomes. With increasing age, full thickness tears may be asymptomatic,
compatible with normal functional activity, and of little clinical significance. Tears
may be present in greater than 50% of those aged 70-80 years.
Traumatic cuff tears in the older age groups are commonly associated with
dislocation and usually require additional investigation.
Refer people with massive tears to a specialist immediately. A delay in repair may
result in severe loss of function.
Imaging

Diagnostic ultrasound – this is a valid tool for diagnosing full thickness
tears in a secondary care setting. [DSR++] There is no conclusive evidence
for the validity of diagnostic ultrasound in the diagnosis of partial tears.
[DSR++] Where there is a suspicion of a significant tear, referral for
diagnostic ultrasound is recommended.

Magnetic resonance imaging (MRI) – this can rule out a full thickness
tear, but the evidence for ruling in rotator cuff tears has yet to be established.
[DSR++]
MR arthrography may be accurate in detecting full thickness tears, and more
accurate than MRI and diagnostic ultrasound in detecting partial tears. [DSR++]
Summary
In active and young individuals, a full thickness tear requires early referral to a
specialist to evaluate the need for surgery. For individuals with a massive tear,
immediate specialist referral is recommended. Diagnostic ultrasound is
recommended for a full thickness tear and on suspicion of a large or massive
tear.
References
1. Accident Compensation Corporation and New Zealand Guidelines Group. The
Diagnosis and Management of Soft Tissue Shoulder Injuries and Related
Disorders. Wellington: ACC, 2004.
2. Holtby R, Razmjou H. Validity of the supraspinatus test as a single clinical test
in diagnosing patients with rotator cuff pathology. Orthop & Sports Phys Ther
2004;34:194-200.
Evidence Scales (as in the Guide (1))
Single Diagnostic Studies
D+ Fair: One or two of the four criteria not met
(D++ Good, all four criteria met; D- Poor, no criteria met)
Diagnostic Systematic Reviews
DSR++ High quality meta-analysis or systematic review of diagnostic studies
(DSR+ Fair quality; DSR- Poor quality)
© ACC2004 • Printed October 2004