What are the exam findings and management for a suspected supraspinatus rotator cuff injury?

Exam Findings and Management for Suspected Supraspinatus Rotator Cuff Injury

For suspected supraspinatus rotator cuff injuries, physical examination should focus on identifying focal weakness with decreased range of motion during abduction with external or internal rotation, followed by MRI or ultrasound imaging for confirmation, and initial management with rest and rehabilitation targeting rotator cuff and scapular stabilizer strengthening. 1

Physical Examination Findings

Key Clinical Signs

• Pain and weakness are the most common symptoms 1
• Pain typically occurs during throwing release and phases of deceleration/follow-through in athletes 1
• Pain often radiates down the upper arm and is present at night 2
• Decreased velocity and precision in throwing athletes 1

Specific Examination Tests

1. Range of Motion Testing:

   • Focal weakness with decreased range of motion during abduction with external or internal rotation 1
   • Limited passive range of motion 2

2. Strength Testing:

   • Weakness on abduction and external rotation 2
   • The External Rotation Lag Sign at 90 Degrees has the highest diagnostic accuracy (DOR 12.70) for rotator cuff tears 3
   • Internal Rotation Lag Sign also shows moderate to high diagnostic accuracy 3

3. Visual Inspection:

   • Deltoid and rotator cuff atrophy may be present 2
   • Scapular dyskinesis (abnormal scapular movement) may contribute to injury 1

Diagnostic Imaging

Initial Imaging

• Radiographs should be the initial imaging study 1, 4
• May show:
  • Degenerative changes of the acromion or acromioclavicular joint
  • Cysts, sclerosis, and spurs of the greater tuberosity
  • Calcific deposits within the supraspinatus tendon 2

Advanced Imaging

• MRI: Generally considered the best modality for assessing soft-tissue injuries 1

  • High sensitivity and specificity for full-thickness tears
  • Lower sensitivity for partial-thickness tears compared to MR arthrography 1

• Ultrasound: Alternative to MRI 1

  • High sensitivity and specificity for full-thickness tears
  • More variable accuracy for partial-thickness tears 1
  • More operator-dependent than MRI

• MR Arthrography: Preferred for assessing intra-articular pathology 1

  • Increased sensitivity for partial-thickness articular surface tears compared to conventional MRI 1

Management Algorithm

1. Initial Conservative Management (0-6 weeks)

• Complete rest from throwing/overhead activities until asymptomatic 1
• NSAIDs for pain management 4, 2
  • Ibuprofen 1.2-2.4g daily or naproxen 500mg twice daily
  • May be combined with acetaminophen (up to 4g daily) for enhanced pain relief 4

2. Rehabilitation Program (Weeks 2-12)

• Early Phase (2-4 weeks):

  • Rotator cuff and scapular stabilizer strengthening 1
  • Re-establishing proper mechanics of the shoulder and spine 1
  • Restoring range of motion 1

• Intermediate Phase (4-8 weeks):

  • Progressive strengthening exercises
  • Eccentric training 4

• Advanced Phase (8-12 weeks):

  • Sport or occupation-specific training
  • Functional exercises 4

3. Return to Activity

• For athletes: Initiate a throwing program emphasizing proper mechanics once pain-free motion and strength are achieved (1-3 months depending on injury severity) 1
• Return to competition allowed after completing a functional, progressive throwing program without symptoms 1
• Return criteria: complete resolution of pain, full range of motion, strength symmetry >90% compared to uninjured side 4

4. Indications for Surgical Referral

• Failure of conservative therapy after 6-12 weeks 2
• Persistent pain despite 3-6 months of well-managed conservative treatment 4
• Full-thickness tears, especially in younger, active patients 1

Special Considerations

Associated Conditions to Evaluate

• Secondary shoulder impingement syndrome 1
• Scapular dyskinesis 1
• Possible suprascapular neuropathy in massive tears 5
  • May present with denervation of supraspinatus/infraspinatus muscles
  • Severe limitation of active motion

Pitfalls to Avoid

1. Prolonged immobilization beyond 4 weeks (leads to quadriceps atrophy and worse outcomes) 4
2. Inadequate rehabilitation or missed associated injuries (increases recurrence risk) 4
3. Delayed referral for surgical evaluation when conservative measures fail 4
4. Overlooking associated nerve involvement in massive tears 5

Prognosis

• Strong evidence supports that patient-reported outcomes improve with physical therapy in symptomatic patients with full-thickness rotator cuff tears 1
• However, tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management 1
• Healed rotator cuff repairs show improved outcomes compared to physical therapy and unhealed repairs 1