Episode 5
Rotator Cuff Tears
Listen to Episode:
Objectives:
After listening to this episode, we hope that you can:
- Describe the anatomy of the rotator cuff.
- Understand the biomechanics of the shoulder.
- Describe the prevalence of rotator cuff tears.
- Describe tests for each rotator cuff muscle.
Show Notes
Episode 5: Rotator Cuff Tears
Accurate assessment of rotator cuff pathology requires a structured approach that integrates targeted physical examination maneuvers, imaging-based classification systems, and an understanding of surgical options when primary repair is not feasible. Each rotator cuff muscle contributes uniquely to shoulder motion and stability, allowing specific exam findings to be mapped directly to the injured structure. Imaging further refines diagnosis by characterizing tear size, chronicity, and muscle quality, all of which influence prognosis and management.
The sections below provide a high-yield summary of rotator cuff physical exam tests organized by muscle, followed by key imaging classifications that predict reparability and healing potential. We conclude with an overview of tendon transfer and superior capsular reconstruction techniques, which may be considered for massive or irreparable tears in select patient populations.
Rotator Cuff Physical Exams – High Yield Summary
| Muscle | Function | Tests | How | Positive |
|---|---|---|---|---|
| Supraspinatus | Initiates abduction (0–15°); assists deltoid | #1 – Empty Can #2 – Painful Arc #3 – Drop Arm | Resisted abduction in scapular plane How: Arm abducted to 90° in scapular plane, thumb down; resist downward pressure Patient actively abducts arm from 0–180° Inability to slowly lower abducted arm How: Passively abduct arm to 90°, patient slowly lowers | Pain and weakness Pain from 60–120° abduction Arm moves fast |
| Infraspinatus | ER at side | ER Lag sign | Cannot maintain passive ER How: Elbow at 90°, arm at side; passively place in ER and ask patient to hold | Arm drifts into IR |
| Teres Minor | ER in abduction | Hornblower’s Test aka res | Hornblower’s Test ER against resistance at 90° abduction How: Arm abducted to 90°, elbow flexed; resist external rotation | Cannot maintain position |
| Subscapularis | IR Anterior stability | Lift off test | Hand on lower back, patient lifts hand away | Cannot lift hand off back |
| Belly off test | Patient presses palm into abdomen, keeping elbow forward | Elbow drifts posteriorly |
Imaging Classification
Goutallier Classification:
This grading system looks at how much fat has replaced muscle in the rotator cuff on imaging (usually CT or MRI).
- Grade 0: normal muscle, no fat
- Grade 1: some fatty streaks
- Grade 2: fat < muscle
- Grade 3: fat = muscle
- Grade 4: fat > muscle
Higher grades (3–4) mean poor healing potential after repair.
Cuff Tear Size Classification:
Rotator cuff tears are often described by size of the defect (AP length):
- Small: <1 cm
- Medium: 1–3 cm
- Large: 3–5 cm
- Massive: >5 cm or involving ≥2 tendons
Larger tears are harder to repair and more likely to fail.
More on tendon transfer and SCR
If the injury is not acute or cannot be repaired, tendon transfers can be considered.
- If the subscapularis tendon is deficient, the pectoralis major tendon can be moved and placed under the conjoined tendon to better mimic the normal pull of the subscapularis. After surgery, the arm must be kept completely still in a brace for 4–6 weeks. The goal is to restore some strength and stability in the front of the shoulder.
- If there are large tears of the supraspinatus and infraspinatus in younger, active patients (like labourers) latissimus dorsi transfer is possible. The latissimus tendon is attached to the rotator cuff area to help with external rotation and lifting. The arm is braced in abduction and external rotation for 6 weeks after surgery. This choice does bring some risk of nerve injury specifically to the radial nerve (during tendon release) and the posterior branch of the axillary nerve (as the tendon is passed under the deltoid).
Superior capsular reconstruction (SCR) is a newer option for massive, irreparable cuff tears, using grafts to stabilize the shoulder joint. Different graft types include xenografts (from animals), allografts (from human tissue), and synthetic patches. Early studies show some improvement in function, but results vary depending on the graft used. Long-term and large human studies are still limited, so its role is still being defined.
