What physical exams are used to differentiate rotator cuff issues?

Physical Examination Tests to Differentiate Rotator Cuff Pathology

The External Rotation Lag Sign at 90 Degrees is the single most accurate physical examination test for ruling in rotator cuff tears, followed by the Internal Rotation Lag Sign, while the Empty Can Test specifically indicates supraspinatus involvement. 1

Highest Yield Physical Examination Tests for Rotator Cuff Tears

Most Accurate Tests (Ranked by Diagnostic Performance)

• External Rotation Lag Sign at 90 Degrees has the highest diagnostic accuracy for rotator cuff tears (DOR 12.70), making it the most powerful test for ruling in the diagnosis 1

• Internal Rotation Lag Sign demonstrates moderate to high diagnostic accuracy for rotator cuff pathology 1

• Empty Can Test (Supraspinatus Test) is positive in supraspinatus involvement and indicates full-thickness rotator cuff tears 2

• Neer's Test has 88% sensitivity but only 33% specificity, making it useful for screening but not confirmation 3

• Hawkins' Test has 92% sensitivity but only 25% specificity, similarly useful for screening but poor for ruling in disease 3

Clinical Findings That Support Full-Thickness Tears

• Severe night pain is characteristic of full-thickness rotator cuff tears and helps differentiate from partial tears 2, 4

• Positive "shrug sign" (inability to actively elevate the arm without shrugging the shoulder) indicates significant rotator cuff pathology 4

• Focal weakness in the affected shoulder occurs in 75% of rotator cuff injuries 3

• Decreased range of motion particularly during abduction with external or internal rotation is common 3

Physical Examination Tests for Subacromial Impingement Syndrome

Most Accurate Tests for Impingement

• Yergason's Test has the highest diagnostic accuracy for subacromial impingement syndrome (DOR 4.71) 1

• Neer's and Hawkins' tests are positive in impingement but have low specificity 3

• Pain in anterior or anterolateral shoulder worsening with overhead activities has 88% sensitivity for impingement 3

Differentiating Primary vs. Secondary Rotator Cuff Pathology

Primary Impingement Pattern

• Middle-aged or older athletes with chronic shoulder pain associated with overhand activities suggest primary impingement 4

• Positive impingement signs with limited strength in elevation and external rotation indicate primary impingement 4

Secondary Impingement from Instability

• Young overhand athletes with pain and decreased throwing velocity suggest secondary impingement from subtle anterior instability 4

• Positive relocation test indicates underlying glenohumeral instability causing secondary rotator cuff pathology 4

• Pain during specific throwing phases (arm cocking and acceleration) is common in secondary impingement 3

Critical Examination Pitfalls to Avoid

• Clinical examination alone has 100% sensitivity but only 73.8% specificity for rotator cuff tears, meaning it can rule out disease but cannot definitively rule it in without imaging 5

• Overlap of clinical signs and symptoms between different rotator cuff pathologies limits diagnostic accuracy of examination alone 5

• Examiner bias significantly affects clinical examination findings, making standardized testing protocols essential 5

• Failure to distinguish between primary and secondary impingement leads to inappropriate treatment, as secondary impingement from instability requires capsulolabral repair rather than acromioplasty 4

Algorithmic Approach to Physical Examination

Step 1: Screen with High-Sensitivity Tests

• Perform Hawkins' Test (92% sensitive) and Neer's Test (88% sensitive) to screen for rotator cuff pathology 3
• If both negative, rotator cuff tear is unlikely

Step 2: Confirm with High-Specificity Tests

• Perform External Rotation Lag Sign at 90 Degrees to rule in rotator cuff tears 1
• Perform Internal Rotation Lag Sign for additional confirmation 1
• Perform Empty Can Test to assess supraspinatus specifically 2

Step 3: Differentiate Tear Type and Etiology

• Assess for severe night pain and shrug sign to identify full-thickness tears 2, 4
• Perform relocation test in young athletes to identify secondary impingement from instability 4
• Evaluate for scapular dyskinesis and muscular imbalance patterns 3

Step 4: Proceed to Imaging

• MRI without contrast is mandatory to confirm diagnosis, characterize tear extent, assess tendon retraction, muscle atrophy, and fatty infiltration for treatment planning 2, 3
• Clinical examination findings guide but cannot replace advanced imaging for definitive diagnosis 5