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Clinical Tests for the Diagnosis of Rotator Cuff Disease
Umile Giuseppe Longo, MD, MSc,* Alessandra Berton, MD,*
Philip Michael Ahrens, FRCS (Tr & Orth),w
Nicola Maffulli, MD, MS, PhD, FRCS(Orth),zy and Vincenzo Denaro, MD*
Abstract: Several tests have been described to examine the
shoulder. However, there is a lack of consensus on clinical
assessment of patients with shoulder pain and suspected rotator
cuff pathology. This review reports the diagnostic accuracy of
clinical tests for rotator cuff pathology. Sensitivity, specificity,
positive predictive value, negative predictive value, and accuracy of
21 clinical tests for rotator cuff pathology are reported from the
available literature. Twenty studies investigated supraspinatus
pathology, 12 infraspinatus pathology, and 9 subscapularis
pathology. Most tests for rotator cuff pathology are inaccurate,
and the recent literature shows that there is insufficient evidence to
recommend 1 clinical test over another for diagnosis of rotator cuff
pathology. Poor diagnostic accuracy of clinical tests for rotator cuff
pathology may be related to the close relationships of structures in
the shoulder, to a lack of understanding of anatomical basis of the
tests, or to their lack of reproducibility.
Key Words: shoulder, tests, examination, diagnosis, rotator cuff,
sports
(Sports Med Arthrosc Rev 2011;19:266–278)
Rotator cuff tears are a common cause of shoulder painand occupational disability.1–4 More than 50% of
individuals older than 60 years have at least a partial-
thickness rotator cuff tear,5–7 with significant impact on
patients’ quality of life and marked functional impairment.8
As a large percentage of older individuals maintain a very
active lifestyle, it is important for orthopedic surgeons to be
able to accurately identify and to appropriately manage
patients with rotator cuff tears.9–11 The history and physical
examination of patients with shoulder pain have traditionally
been a cornerstone of the diagnostic process.12–17 A large
number of special tests have been described to examine the
shoulder, and it is not feasible to use all of them at every
examination. They should be used selectively and should be
tailored to the clinical condition suspected.18–24
Classically, the supraspinatus, infraspinatus, and teres
minor tendons have been considered as contiguous but
distinct structures. Later, it has been shown that all the
tendons of the rotator cuff fuse to insert on both
tuberosities of the proximal humerus. The subscapularis
muscle is an internal rotator of the humerus. It arises from
the subscapularis fossa, in the ventral aspect of the scapula,
and inserts on the lesser tuberosity of the humerus. The
supraspinatus muscle arises from the dorsal surface of the
scapula in the supraspinatus fossa and from the fascia
covering the muscle, passing over the top of the shoulder
joint to insert onto the upper aspect of the greater
tuberosity. It is a long, thin muscle. The infraspinatus
muscle arises from its covering fascia and from the
infraspinatus fossa and inserts onto the greater tuberosity
immediately below the insertion of the supraspinatus
muscle. It is a thick triangular muscle, with 3 pennate
origins. The teres minor arises from the upper two-thirds of
the dorsal surface of the lateral border of the scapula and
from the septa between it and the infraspinatus. It inserts
onto the greater tuberosity below the insertion of the
infraspinatus.
The major points to address during physical examina-
tion of patients with suspected rotator cuff pathology
include the loss of active or passive range of motion, painful
range of motion, presence of muscle atrophy, weakness,
swelling, or tenderness. Specific tests can be conducted
during the physical examination to evaluate the functional
status and the strength of the rotator cuff. Many of these
tests are eponymous, and several investigators have
described more than 1 test, leading to confusion regarding
not only the correct way to perform the tests but also the
correct interpretation of the findings. Misquoting or
misinterpretation of the tests by subsequent investigators
has compounded this problem.18
Several studies25–28 have described the accuracy and
reliability of clinical examination, especially in relation to a
pathoanatomical model, with discordant results.29–35
There is a lack of consensus from the available
literature on the diagnostic criteria and concordance in
clinical assessment of patients with shoulder pain and with
suspected rotator cuff pathology.
This study describes the currently available clinical
tests for the diagnosis of rotator cuff pathology.
CLINICAL TESTS FOR DIAGNOSIS OF
ROTATOR CUFF
Table 1 summarizes the clinical tests available for
evaluation of a patient with suspected rotator cuff
pathology, including sensitivity, specificity, positive pre-
dictive value, negative predictive value, and accuracy.
Twenty studies investigated supraspinatus testing, 12
infraspinatus testing, and 9 subscapularis testing.Copyright r 2011 by Lippincott Williams & Wilkins
From the *Department of Orthopaedic and Trauma Surgery, Campus
Bio-Medico University, Trigoria, Rome, Italy; wDepartment of
Orthopaedics, Royal Free Hampstead NHS Trust; zCentre for
Sports and Exercise Medicine, Queen Mary University of London,
Barts; and yThe London School of Medicine and Dentistry, Mile
End Hospital, London, England.
The authors declare no conflict of interest.
Reprints: Nicola Maffulli MD, MS, PhD, FRCS(Orth), Centre Lead
and Sports and Exercise Medicine, Consultant Trauma and
Orthopaedic Surgeon, Centre for Sports and Exercise Medicine,
Barts and The London School of Medicine and Dentistry, Mile End
Hospital, 275 Bancroft Road, London E1 4DG, England
(e-mail: n.maffulli@qmul.ac.uk).
REVIEW ARTICLE
266 | www.sportsmedarthro.com Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011
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Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011 Diagnosis of Rotator Cuff Disease
r 2011 Lippincott Williams & Wilkins www.sportsmedarthro.com | 267
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a
k
er
et
a
l4
8
4
4
8
5
7
D
o
u
b
le
-c
o
n
tr
as
t
ar
th
ro
gr
ap
h
y
N
o
t
st
a
te
d
3
0
7
8
7
3
.6
3
5
.6
A
b
d
u
ct
io
n
—
w
ea
k
n
es
s
K
el
ly
et
a
l4
1
3
4
5
7
(4
4
-6
3
)
U
lt
ra
so
u
n
d
A
n
y
d
eg
re
e
o
f
S
IS
3
7
.9
5
0
3
9
.4
F
T
T
6
5
3
0
.8
5
1
.5
P
T
T
7
5
1
4
.3
5
0
S
D
B
6
5
3
8
.5
5
4
.5
A
b
d
u
ct
io
n
—
p
a
in
K
el
ly
et
a
l4
1
3
4
5
7
(4
4
-6
3
)
U
lt
ra
so
u
n
d
A
n
y
d
eg
re
e
o
f
S
IS
5
5
.2
7
5
5
7
.6
F
T
T
7
5
4
1
.2
5
7
.6
P
T
T
6
8
.8
1
1
.1
3
8
.2
S
D
B
6
8
.8
4
1
.2
5
4
.5
R
es
is
ta
n
ce
te
st
o
r
G
u
m
-T
u
rn
te
st
)
G
u
m
in
a
et
a
l5
2
5
3
6
4
.2
(4
6
-7
9
)
A
rt
h
ro
sc
o
p
y
N
o
t
st
a
te
d
5
5
9
8
9
7
6
8
7
6
D
ro
p
-a
rm
te
st
fo
r
su
p
ra
sp
in
at
u
s
C
a
li
s
et
a
l5
3
1
2
0
5
1
.6
(1
8
-7
0
)
M
R
I
R
eg
a
rd
le
ss
7
.8
9
7
.2
8
7
.5
2
9
.9
3
3
.6
Z
la
tk
in
st
a
g
e
1
4
.4
1
0
0
Z
la
tk
in
st
a
g
e
2
6
.2
9
6
.1
Z
la
tk
in
st
a
g
e
3
1
5
1
0
0
P
a
rk
et
a
l4
4
5
5
2
N
R
A
rt
h
ro
sc
o
p
y
A
n
y
se
v
er
it
y
2
6
8
8
8
1
3
9
.7
4
8
.6
P
T
T
1
4
.3
7
7
.5
8
8
6
.8
6
9
.9
F
T
T
3
4
.9
8
7
.5
6
5
6
6
.8
6
6
.5
M
u
rr
el
l
a
n
d
W
a
lt
o
n
5
4
4
0
0
N
R
O
p
er
a
ti
o
n
N
o
t
st
a
te
d
1
0
9
8
B
a
k
et
a
l4
9
1
0
4
1
8
-7
5
U
lt
ra
so
u
n
d
a
n
d
a
rt
h
ro
sc
o
p
y
in
2
9
p
a
ti
en
ts
;
U
lt
ra
so
u
n
d
in
7
5
p
a
ti
en
ts
F
T
T
4
1
8
3
7
5
5
3
6
0
M
il
le
r
et
a
l5
5
3
7
5
5
.5
(2
0
-8
6
)
U
lt
ra
so
u
n
d
N
o
t
st
a
te
d
7
3
7
7
6
1
8
5
P
a
in
fu
l
a
rc
si
g
n
P
a
rk
et
a
l4
4
5
5
2
N
R
A
rt
h
ro
sc
o
p
y
A
n
y
se
v
er
it
y
7
3
.5
8
1
.1
0
8
8
.2
6
1
.5
P
T
T
6
7
.4
4
7
1
4
.9
9
1
.3
4
9
.4
F
T
T
7
5
.8
6
1
.8
6
1
7
6
.4
6
8
C
a
li
s
et
a
l5
3
1
2
0
5
1
.6
(1
8
-7
0
)
M
R
I
Z
la
tk
in
st
a
g
e
1
9
.5
8
8
.4
4
0
5
4
.7
5
3
.1
Z
la
tk
in
st
a
g
e
2
3
7
.5
7
3
7
2
3
8
.7
5
0
Z
la
tk
in
st
a
g
e
3
4
5
7
8
.5
7
5
5
0
5
8
.8
K
el
ly
et
a
l4
8
3
4
5
7
(4
4
-6
3
)
U
lt
ra
so
u
n
d
A
n
y
d
eg
re
e
o
f
S
IS
2
9
.6
5
0
3
1
F
T
T
7
0
4
4
6
2
.1
P
T
T
7
5
2
0
5
6
.7
S
D
B
5
5
2
2
.2
4
4
.8
L
it
a
k
er
et
a
l4
8
4
4
8
5
7
D
o
u
b
le
-c
o
n
tr
a
st
a
rt
h
ro
g
ra
p
h
y
N
o
t
st
a
te
d
9
7
.5
9
.9
6
6
.6
6
8
.8
In
fr
a
sp
in
a
tu
s
te
st
s
E
x
te
rn
a
l
ro
ta
ti
o
n
st
re
n
g
th
te
st
It
o
i
et
a
l3
8
1
4
9
5
3
A
rt
h
ro
sc
o
p
y
N
o
t
st
a
te
d
8
4
5
3
o
r
P
a
tt
e
te
st
—
w
ea
k
n
es
s
K
el
ly
et
a
l4
8
3
4
5
7
(4
4
-6
3
)
U
lt
ra
so
u
n
d
A
n
y
d
eg
re
e
o
f
S
IS
5
1
.9
6
6
.7
5
3
.3
F
T
T
6
4
.3
3
1
.6
4
5
.5
P
T
T
7
1
.4
1
5
3
8
.2
S
D
B
6
4
.3
3
6
.8
4
8
.5
L
er
o
u
x
et
a
l3
9
5
5
5
1
O
p
er
a
ti
o
n
N
o
t
st
a
te
d
8
3
6
1
2
1
9
7
E
x
te
rn
a
l
ro
ta
ti
o
n
st
re
n
g
th
te
st
It
o
i
et
a
l3
8
1
4
9
5
3
A
rt
h
ro
sc
o
p
y
N
o
t
st
a
te
d
5
4
5
4
o
r
P
a
tt
e
te
st
—
p
a
in
K
el
ly
et
a
l4
1
3
4
5
7
(4
4
-6
3
)
U
lt
ra
so
u
n
d
A
n
y
d
eg
re
e
o
f
S
IS
3
4
.5
1
0
0
4
2
.4
F
T
T
6
5
.2
3
0
5
4
.6
P
T
T
7
8
.3
1
8
.2
1
5
8
.8
S
D
B
6
9
.6
5
0
6
3
.6
(c
o
n
ti
n
u
ed
)
Longo et al Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011
268 | www.sportsmedarthro.com r 2011 Lippincott Williams & Wilkins
L
er
o
u
x
et
a
l3
9
5
5
5
1
O
p
er
a
ti
o
n
T
en
d
o
n
it
is
9
2
3
0
2
9
9
3
E
x
te
rn
a
l
ro
ta
ti
o
n
st
re
n
g
th
te
st
L
it
a
k
er
et
a
l4
8
4
4
8
5
7
D
o
u
b
le
-c
o
n
tr
a
st
a
rt
h
ro
g
ra
p
h
y
N
o
t
st
a
te
d
7
6
5
7
7
8
5
4
o
r
P
a
tt
e
te
st
—
w
ea
k
n
es
o
r
P
a
rk
et
a
l4
4
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2
N
R
A
rt
h
ro
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A
n
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v
er
it
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4
1
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9
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9
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4
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8
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p
a
in
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r
b
o
th
P
T
T
1
9
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6
9
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1
0
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4
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F
T
T
5
0
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8
4
6
9
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7
0
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7
0
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W
a
lc
h
et
a
l5
6
4
3
9
7
9
6
7
S
a
la
ffi
et
a
l4
2
2
0
3
5
8
(2
3
-8
1
)
U
lt
ra
so
u
n
d
N
o
t
st
a
te
d
6
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1
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l
ro
ta
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n
la
g
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g
n
H
er
te
l
et
a
l4
5
1
0
0
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1
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p
er
a
ti
o
n
N
o
t
st
a
te
d
7
0
1
0
0
1
0
0
5
6
7
8
(E
R
L
S
)
(w
ea
k
n
es
s
in
a
ct
iv
e
C
a
st
o
ld
i
et
a
l5
7
4
0
1
5
0
A
rt
h
ro
sc
o
p
y
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r
o
p
en
su
rg
er
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Is
o
la
te
d
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T
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1
2
9
8
7
3
7
3
7
3
ex
te
rn
a
l
ro
ta
ti
o
n
a
rm
P
T
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T
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n
e
1,
2
1
4
9
6
6
3
7
2
7
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in
2
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o
f
a
b
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ct
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n
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Is
o
la
te
d
F
T
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n
e
3
1
3
9
8
2
5
7
3
9
4
F
T
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n
e
3
/
1
,
2
3
2
9
3
3
0
9
4
8
8
S
u
p
ra
sp
in
a
tu
s
F
T
T
(3
,
4
)
5
6
9
8
8
6
9
2
9
1
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T
T
in
zo
n
e
3
,
4
/
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a
rs
1
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2
6
2
9
3
6
4
9
3
8
8
F
T
T
zo
n
e
5
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3
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4
,
1
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2
,
P
T
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6
5
9
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6
2
9
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9
F
T
T
5
,
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3
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4
,
1
,
2
,
P
T
T
9
7
9
3
6
6
9
9
9
3
W
a
lc
h
et
a
l5
8
5
4
O
p
er
a
ti
o
n
S
u
p
ra
sp
in
at
u
s
an
d
in
fr
a
sp
in
a
tu
s
te
n
d
o
n
s
te
ar
b
et
w
ee
n
2.
5
an
d
5.
0
cm
9
8
9
8
N
/A
B
a
k
et
a
l4
9
1
0
4
1
8
-7
5
U
lt
ra
so
u
n
d
a
n
d
a
rt
h
ro
sc
o
p
y
in
2
9
p
a
ti
en
ts
;
u
lt
ra
so
u
n
d
in
7
5
p
a
ti
en
ts
F
T
T
4
5
9
1
8
7
5
7
6
5
M
il
le
r
et
a
l5
5
3
7
5
5
.5
(2
0
-8
6
)
U
lt
ra
so
u
n
d
N
o
t
st
a
te
d
4
6
9
4
7
7
7
8
D
ro
p
si
g
n
(w
ea
k
n
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s
in
a
ct
iv
e
H
er
te
l
et
a
l4
5
1
0
0
5
1
O
p
er
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ti
o
n
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o
t
st
a
te
d
2
1
1
0
0
1
9
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2
4
3
ex
te
rn
a
l
ro
ta
ti
o
n
a
rm
in
9
0
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eg
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o
f
a
b
d
u
ct
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n
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B
a
k
et
a
l4
9
1
0
4
1
8
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5
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lt
ra
so
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n
d
a
n
d
a
rt
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ro
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p
y
in
2
9
p
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ti
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;
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lt
ra
so
u
n
d
in
7
5
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a
ti
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ts
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T
T
4
5
7
0
6
5
5
0
5
6
M
il
le
r
et
a
l5
5
3
7
5
5
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(2
0
-8
6
)
U
lt
ra
so
u
n
d
N
o
t
st
a
te
d
7
3
7
7
6
1
8
5
M
u
sc
le
a
tr
o
p
h
y
in
fr
a
sp
in
a
tu
s
L
it
a
k
er
et
a
l4
8
4
4
8
5
7
D
o
u
b
le
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o
n
tr
as
t
ar
th
ro
gr
ap
h
y
N
o
t
st
a
te
d
5
5
7
3
8
1
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4
3
.4
P
a
ss
iv
e
ex
te
rn
a
l
ro
ta
ti
o
n
L
it
a
k
er
et
a
l4
8
4
4
8
5
7
D
o
u
b
le
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o
n
tr
as
t
ar
th
ro
gr
ap
h
y
N
o
t
st
a
te
d
1
9
8
3
7
0
3
3
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D
ro
p
p
in
g
si
g
n
W
a
lc
h
et
a
l5
8
5
4
O
p
er
a
ti
o
n
S
u
p
ra
sp
in
at
u
s
an
d
in
fr
a
sp
in
a
tu
s
te
n
d
o
n
s
te
ar
b
et
w
ee
n
2.
5
an
d
5.
0
cm
1
0
0
1
0
0
S
u
b
sc
a
p
u
la
ri
s
te
st
s
L
if
t
o
ff
te
st
—
w
ea
k
n
es
s
It
o
i
et
a
l3
8
1
4
9
5
3
7
9
5
9
L
er
o
u
x
et
a
l3
9
5
5
5
1
O
p
er
a
ti
o
n
0
6
1
0
8
8
B
a
rt
h
et
a
l5
9
6
8
O
p
er
a
ti
o
n
N
o
t
st
a
te
d
1
7
.6
1
0
0
1
0
0
7
6
.7
7
7
.8
L
if
t
o
ff
te
st
—
p
a
in
It
o
i
et
a
l3
8
1
4
9
5
3
N
o
t
st
a
te
d
4
6
6
9
L
if
t
o
ff
te
st
—
w
ea
k
n
es
s
W
a
lc
h
et
a
l5
6
4
3
9
5
9
8
5
o
r
p
a
in
o
r
b
o
th
H
er
te
l
et
a
l4
5
1
0
0
5
1
O
p
er
a
ti
o
n
N
o
t
st
a
te
d
6
2
1
0
0
1
0
0
6
9
7
9
S
ch
ei
b
el
et
a
l6
0
1
2
5
5
.3
(2
6
-8
3
)
O
p
er
a
ti
o
n
a
n
d
M
R
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Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011 Diagnosis of Rotator Cuff Disease
r 2011 Lippincott Williams & Wilkins www.sportsmedarthro.com | 269
The reference standard was magnetic resonance imaging in
2 studies, ultrasound in 4 studies, double-contrast arthro-
graphy in 1 study, operation in 10 studies, arthroscopy in 8
studies, and a combined approach in 4 studies.
The number of participants in the studies ranged from
552 to 12, with a mean sample size of 158. The age of the
participants ranged from 16 to 86 years. Seventeen studies
evaluated participants with subacromial impingement
syndrome, subacromial/subdeltoid bursitis, partial-thick-
ness rotator cuff tear, and full-thickness rotator cuff tear.
Ten studies did not state the degree of tendon tear. Twenty-
one clinical tests were evaluated in 27 studies. The majority
of the studies included in this review were level IV studies.
DIAGNOSTIC ACCURACY OF THE
CLINICAL TESTS
Supraspinatus Tendon
Empty Can Test
The empty can test,63 also known as the supraspinatus
test or the Jobe test, is performed placing patient arms in 90
degrees abduction and 30 degrees horizontal abduction (in
the plane of the scapula) with thumbs pointing downward
to produce medial rotation of the shoulder. The examiner
then pushes the patient’s arms downward while asking the
patient to resist the pressure. Pain or weakness is indicative
of a positive test (Fig. 1).
In the assessment of supraspinatus tendon tears, the
empty can test had a sensitivity greater than 80% in 2
evaluations across 2 studies36,38 when assessed by muscle
weakness, in 2 evaluations across 2 studies39,40 when
assessing the provocation of pain as positive, and in 7
evaluations across 6 studies37,40,43,45–47 using weakness or
pain or both. Specificity of the empty can test was greater
than 80% only in 1 evaluation40 when assessed by muscle
weakness, and in 2 evaluations, both in Park et al44 study,
T
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e.
FIGURE 1. The empty can test (or Jobe test) is performed by
placing the patient’s arms in 90 degrees abduction and in 30
degrees horizontal abduction (in the plane of the scapula) with
thumbs pointing downward to produce medial rotation of the
shoulder. The examiner then pushes the patient’s arms down-
ward while asking the patient to resist the pressure. Pain or
weakness is indicative of a positive test.
Longo et al Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011
270 | www.sportsmedarthro.com r 2011 Lippincott Williams & Wilkins
when weakness or pain or both arise. Diagnostic accuracy
has not been showed in a large proportion of the studies.
Full-can Test
The full-can test64 is performed with patient’s arms
abducted in 90 degrees in the horizontal plane and rotated
45 degrees externally, with the thumb pointing upward. The
sign is positive when there is pain or weakness at the
downward pressure applied by the examiner (Fig. 2).
The full-can test showed a lack of diagnostic accuracy
in 19 evaluations, using pain and/or weakness as criteria,
across 4 studies.37,38,40,41
Painful Arc Test
While standing, with the shoulder in external rotation
(palm facing up), the patient is asked to abduct the arm and
to report the occurrence of pain.65 The test is considered
positive if pain is experienced between 60 and 120 degrees,66
above or below which movement is pain free (Fig. 3).
The painful arc test showed a lack of diagnostic
accuracy for supraspinatus pathology in 10 evaluations
across three studies.41,44,53
Palpation of the Supraspinatus
Codman67 first described the palpation of full-thick-
ness rotator cuff tears. He described the ability to palpate a
“sulcus” produced by a rent in the supraspinatus tendon.
The elbow on the affected side is flexed to 90 degrees and is
held in that position. The top of the humeral head is
palpated with the arm rotated into internal and external
rotation and then hyperextended. In external rotation, an
anterior supraspinatus tear can be felt.
The 2 studies investigating palpation of the supraspi-
natus tendon for a tendon rupture both reported high
sensitivity values.50,51 Wolf and Agrawal51 also found high
specificity, thus producing the most accurate result reported
in this review.
Drop-arm Test for Supraspinatus
In the drop-arm sign described by Codman,68 patients
are asked to elevate the arm fully and then to slowly reverse
the motion in the same arc. If the arm dropped suddenly or
the patient experiences severe pain, the test is considered
positive. This test was investigated in 10 evaluations across
5 studies44,49,53–55 reporting good specificity (from 77% to
100%), but poor accuracy.
Supraspinatus Muscular Atrophy
Supraspinatus muscular atrophy48 is present if reduced
muscle mass is observed superior to the supraspinatus
fossa. It is an insensitive marker of rotator cuff tear
(sensitivity <60%), even in expert hands, as supraspinatus
muscular atrophy may frequently be obscured by the close
proximity of the uninvolved musculature (trapezius) and by
overlying adipose tissue.48
Passive Elevation of the Shoulder
Litaker48 analyzed passive elevation of the shoulder.
With the patient supine, the examiner elevates the shoulder
to the maximal distance. Normal elevation is defined as 170
degrees or higher, and comparison with the contralateral
shoulder should not differ by more than 10 degrees.
Sensitivity was 30%, whereas specificity was 78%. Accu-
racy was not reported.
Resistance Test
Resistance test, or the gum-turn test52; is performed in
the standing position with the involved arm at 90 degrees
abduction, 20 to 30 degrees anteposition, and in external
rotation as for the full-can test. The patient is then asked to
trace the path of a spiral drawn on a drawing sheet 20
FIGURE 2. The full-can test is performed with patient’s arms
abducted in 90 degrees in the horizontal plane, and rotated 45
degrees externally, with the thumb pointing upward. The sign is
positive when there is pain or weakness at the downward
pressure applied by the examiner.
FIGURE 3. The painful arc test. While standing, with the
shoulder in external rotation (palm facing up), the patient is
asked to abduct the arm and to report the occurrence of pain. It
is considered positive if pain is experienced between 60 and 120
degrees, above or below which movement is pain free.
Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011 Diagnosis of Rotator Cuff Disease
r 2011 Lippincott Williams & Wilkins www.sportsmedarthro.com | 271
times; 1 turn is from the center to the end of the spiral and
vice versa (spiral width=20 cm).
This test, introduced by Gumina, has not been
evaluated in other studies so far. The original article
concluded that, when the test is negative, there is a high
probability that the patient does not have a large or massive
cuff tear, because the test has a sensitivity of 55% and a
specificity of 98% for supraspinatus tears, with a diagnostic
accuracy of 76%.
Resisted Isometric Abduction
Resisted isometric abduction69 is performed with the
elbow extended, and with the arm in neutral rotation, the
patient abducts the arm to 90 degrees. The patient is asked
to maintain this position as the examiner applied a
downward force to the lateral aspect of the arm, proximal
to the elbow (Fig. 4). Pain or weakness indicated a positive
test.
The most recent study on physical tests for shoulder
dysfunction41 examined, among the others, weakness or
pain on resisted isometric abduction, defining pain on
resisted abduction as the most sensitive test for diagnosing
full-thickness tears (75%).
Infraspinatus and Teres Minor Tendons
External Rotation Strength Test or Patte Test
Patte’s maneuver70 compares the strength of lateral
rotation in 90 degrees of forward elevation. With the
examiner supporting the patient’s elbow in 90 degrees of
forward elevation in the plane of the scapula, the patient is
asked to rotate the arm laterally against resistance (Fig. 5).
In 7 studies,38,39,41,42,44,48,56 the test showed poor accuracy.
External Rotation Lag Sign
External rotation lag sign (ERLS)45 is performed with
the patient seated with his or her back to the physician. The
elbow is passively flexed to 90 degrees, and the shoulder is
held at 20 degrees elevation (in the scapular plane) and near
maximal external rotation (ie, maximum external rotation
minus 5 degrees to avoid elastic recoil in the shoulder) by
the physician (Fig. 6). The patient is then asked to actively
maintain the position of external rotation in elevation as
the physician releases the wrist while maintaining support
of the limb at the elbow (Fig. 7). The sign is positive when a
lag, or angular drop, occurs (Fig. 8).
This test showed good specificity (form 91% to 98%)
and better value of diagnostic accuracy than other tests for
infraspinatus tears.45,49,55,57,58
Drop Sign
The drop sign45 is performed with the patient seated
on the examination couch with his or her back to the
physician, who holds the affected arm at 90 degrees of
elevation (in the scapular plane) and at almost full external
FIGURE 4. Resisted isometric abduction is performed with the
elbow extended, and with the arm in neutral rotation, the patient
abducts the arm to 90 degrees. The patient is asked to maintain
this position as the examiner applied a downward force to the
lateral aspect of the arm, proximal to the elbow. Pain or weakness
indicated a positive test.
FIGURE 5. Patte’s maneuver compares the strength of lateral
rotation in 90 degrees of forward elevation. With the examiner
supporting the patient’s elbow in 90 degrees of forward elevation
in the plane of the scapula, the patient is asked to rotate the arm
laterally against resistance.
FIGURE 6. External rotation lag sign is performed with the
patient seated with his or her back to the physician. The elbow is
passively flexed to 90 degrees, and the shoulder is held at 20
degrees elevation (in the scapular plane) and near maximalexternal rotation (ie, maximum external rotation minus 5
degrees to avoid elastic recoil in the shoulder) by the physician.
Longo et al Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011
272 | www.sportsmedarthro.com r 2011 Lippincott Williams & Wilkins
rotation, with the elbow flexed at 90 degrees (Fig. 9). The
patient is asked to actively maintain this position as the
physician releases the wrist while supporting the elbow. The
sign is positive if a lag or “drop” occurs (Fig. 10). This test
is equivalent to the “Hornblower’s sign.”
Hertel et al45 reported a specificity of 100%, but
specificity was lower in other studies.44,49,53–55
Infraspinatus Atrophy
Infraspinatus atrophy48 is present if a concavity in the
infraspinatus fossa is noted in conjunction with prominence
of the scapular spine.
Litaker et al48 found that one of the clinical findings
most closely associated with rotator cuff tear was evidence
of infraspinatus atrophy (P<0.001). However, its sensitiv-
ity and specificity are 55% and 19%, respectively.
Weakness With External Rotation
Weakness in external rotation48 is evaluated with the
patient sitting or standing with the arms alongside the
body. The elbows are flexed to 90 degrees with the thumbs
up, with the shoulders rotated internally 20 degrees. The
examiner places his hands outside those of the patient’s and
directs the patient to resist attempts at pushing the forearm
internally (Fig. 11).
Dropping Sign
The dropping sign58 is performed with the patient
seated; the shoulder is placed in 0 degrees of abduction and
FIGURE 7. External rotation lag sign. The patient is then asked to
actively maintain the position of external rotation in elevation as
the physician releases the wrist while maintaining support of the
limb at the elbow.
FIGURE 8. External rotation lag sign. The sign is positive when a
lag, or angular drop, occurs.
FIGURE 9. The drop sign is performed with the patient seated on
the examination couch with his or her back to the physician, who
holds the affected arm at 90 degrees of elevation (in the scapular
plane) and at almost full external rotation, with the elbow flexed
at 90 degrees. The patient is asked to actively maintain this
position as the physician releases the wrist while supporting the
elbow.
FIGURE 10. The drop sign is positive if a lag or “drop” occurs.
Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011 Diagnosis of Rotator Cuff Disease
r 2011 Lippincott Williams & Wilkins www.sportsmedarthro.com | 273
45 degrees of external rotation with the elbow flexed to 90
degrees. The examiner holds the patient’s forearm in this
position and instructs the patient to maintain it when he lets
go of the forearm. On releasing the forearm, a positive test
is recorded when the patient’s forearm drops back to 0
degrees of external rotation, despite efforts to maintain
external rotation. Walch et al58 reported it to be 100%
sensitive and 100% specific for degeneration of the
infraspinatus.
Subscapularis Tendon
The lift-off, lag sign in internal rotation, bear-hug,
belly-press, belly off, and Napoleon tests are variants of
subscapularis testing, involving active internal rotation of
the shoulder in different positions of shoulder flexion.
Lift-off Test
The lift-off test, described by Gerber and Krushell1 in
1991,61 is performed by placing the hand of the affected arm
on the back (at the position of the midlumbar spine) and by
asking the patient to internally rotate the arm to lift the
hand posteriorly off of the back (Fig. 12). The test is
considered positive if the patient is unable to lift the arm
posteriorly off of the back or if he or she performs the
lifting maneuver by extending the elbow or the shoulder.
The evaluation of diagnostic accuracy for the lift-off
test produced mixed results. Barth et al59 indicated a
sensitivity of 17.6% and a specificity of 100% for the lift-off
test using weakness as a criterion. Therefore, if the lift-off
test is positive, one can be sure that a torn subscapularis
tendon is present. These results were not found by Itoi
et al38 or Leroux et al,39 whereas Hertel et al45 and Rigsby
et al62 confirmed not only good specificity (100%, 99%),
but also good sensitivity (62%, 94%) for the lift-off test
using weakness and/or pain as criteria.
Internal Rotation Lag Sign
The internal rotation lag sign (IRLS)45 is performed
with the patient seated with his or her back to the physician.
The affected arm is held by the physician at almost maximal
internal rotation. The elbow is flexed to 90 degrees, and the
shoulder is held at 20 degrees elevation and 20 degrees
extension. The dorsum of the hand is passively lifted away
from the lumbar region until almost full internal rotation is
reached (Fig. 13). The patient is then asked to actively
maintain this position as the physician releases the wrist,
while maintaining support at the elbow. The sign is positive
when a lag occurs (Fig. 14).
Hertel et al45 and Rigsby et al62 analyzed the IRLS
with similar good results (sensitivity 97% to 98% and
specificity 96% to 94%), as in Miller et al55 (sensitivity
100%, specificity 84%). However, Bak49 found lower
sensitivity (31%) and diagnostic accuracy (56%).
Belly Press
Belly press, described by Gerber et al in 1996,71 is
performed with the arm at the side and with the elbow
flexed to 90 degrees, by having the patient press the palm
into his or her abdomen by internally rotating the shoulder.
The test is considered positive (1) if the patient shows a
weakness in comparison with the opposite shoulder, or (2)
if the patient pushes the hand against the abdomen by
means of elbow extension or shoulder extension, indicating
FIGURE 11. Weakness with external rotation is evaluated with
the patient sitting or standing with the arms alongside the body.
The elbows are flexed to 90 degrees with the thumbs up, with
the shoulders rotated internally 20 degrees. The examiner places
his hands outside those of the patient’s and directs the patient to
resist attempts at pushing the forearm internally.
FIGURE 12. The lift-off test is performed by placing the hand of
the affected arm on the back (at the position of the midlumbar
spine) and by asking the patient to internally rotate the arm to lift
the hand posteriorly off of the back. The test is considered
positive if the patient is unable to lift the arm posteriorly off of the
back or if he or she performs the lifting maneuver by extending
the elbow or the shoulder.
Longo et al Sports Med Arthrosc Rev � Volume 19, Number 3, September 2011
274 | www.sportsmedarthro.com r 2011 Lippincott Williams & Wilkins
an inability to exert a force against the abdomen by active
internal rotation produced by the subscapularis (Fig. 15).
This test seems to be a specific test for showing a
subscapularis muscle tendon tear when positive,59,62 even if
its specificity is lower than the lift-off test.
Bear-hug Test
The bear-hug test, described in 2006 by Barth et al,59
uses resisted internal rotation with the palm held on the
opposite shoulder with the fingers extended, while the elbow
is held in maximal anterior translation anterior to the body.
As for the belly press, the bear hug seems to be
valuable as a specific test to show a subscapularis muscle
tendon tear when positive,59,62 even if its specificity is lower
than the lift-off test.
Napoleon Test
The Napoleon test, first described by Schwamborn and
Imhoff72 and further refined by Burkhart and Tehrany,73 is
a variation of the belly-press test. It is performed by placing
the hand on the belly and pushing the hand against the
stomach with the wrist straight. It is positive if the wrist is
flexed to 90 degrees to push against the stomach.
Its specificity is greater than 80% in 2 evaluations
across 2 studies,59,62 but its sensitivity is greater than 80%
only in one of these evaluations.62
DISCUSSION
The clinical evaluation of rotator-cuff tears is not
straightforward, and even for an intact rotator cuff there is
disagreement on the optimal position for testing individual
muscles.64,74A variety of tests can be used during the
examination of shoulder disorders, but the individual
contribution of each of these tests to the differential
diagnosis of shoulder pain and the most accurate combina-
tion or sequence of tests is unclear. The conclusions of
previous reviews32–34 were included and integrated with
data from more recent studies.41,42,49,52,55,57,62
Previous reviews examined respectively 6,34 12,32 and
1533 of the 27 papers included in this review. Their
conclusions are in agreement with this review that most tests
for rotator cuff pathology are inaccurate. Insufficient
evidence was found in the more recent literature to
recommend any one clinical examination test for diagnosis
of rotator cuff pathology. Most investigators agree that the
structure of the rotator cuff does not allow for individual
tendon examination, and the close relationship of other
structures in the shoulder may make it difficult to identify
specific pathologies with clinical tests. One of the reasons
could be the structural overlap between the tendon fibers and
the glenohumeral joint capsule.75 The 4 tendons of the
rotator cuff join form a common insertion onto the humeral
tuberosities.75 This suggests that no test can selectively detect
a lesion of any one of the rotator cuff tendons, and any result
from muscle testing may implicate a number of structures.
Poor diagnostic accuracy may be also related to a lack
of understanding of the anatomical basis of the test. A
recent systematic review76 yielded 11 papers that had
reported on the anatomical basis for a total of six of 34
clinical tests. Four of these tests had evidence from more
than 1 study of a valid anatomical basis, but only 2 tests
FIGURE 13. The internal rotation lag sign is performed with
patient seated with his or her back to the physician. The affected
arm is held by the physician at almost maximal internal rotation.
The elbow is flexed to 90 degrees, and the shoulder is held at 20
degrees elevation and 20 degrees extension. The dorsum of the
hand is passively lifted away from the lumbar region, until almost
full internal rotation is reached. The patient is then asked to
actively maintain this position as the physician releases the wrist,
while maintaining support at the elbow.
FIGURE 14. The internal rotation lag sign is positive when a lag
occurs.
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r 2011 Lippincott Williams & Wilkins www.sportsmedarthro.com | 275
provided consensus evidence that supported the anatomical
basis provided by the test developer.
Another explanation of the low accuracy of the clinical
tests is the lack of reproducibility.77,78 This may results
from subtle but critical differences in test position, in
evaluation of positivity, and in experience in performing
each clinical test.
Clinical tests for the rotator cuff tended to be either
highly sensitive or highly specific, and very few showed
both high sensitivity and specificity. As a result, few tests
provided convincing evidence of the presence or absence of
disease in the settings in which they were applied.34
Dinnes et al34 included the Jobe test and arc of pain
among tests with sensitivities greater than 80% and the
drop arm test and passive external rotation among tests
with specificity greater than 80%, but concluded that the
small sample sizes did not give conclusive evidence for any
single test that can accurately diagnose rotator cuff
disorders. Hegedus et al33 considered the ERLS as a
specific confirmatory test for any rotator cuff tear and
diagnostic for an infraspinatus tear, whereas the bear-hug
and belly-press tests proved to be valuable in showing a
subscapularis tear.
Hughes et al32 concluded that the suspicion of a
rotator cuff tear may be heightened by positive palpation,
combined painful arc/infraspinatus test, Napoleon test, lift-
off test, belly-press test, or drop-arm test, and it may be
reduced by a negative palpation and an empty can test.
Recent articles included in this review provided
information about ERLS, drop sign, and IRLS, painful
arc of abduction, empty and full-can tests, resisted
isometric shoulder abduction and resisted isometric
shoulder external rotation, Patte test, lift-off test, Napoleon
sign, and bear-hug, lift-off, and belly-press sign. Their
conclusions do not differ from previous reports. Most
investigators agree that clinical tests have limited use in
confirming diagnosis.41 Only Castoldi et al57 stated that the
ERLS is highly specific and acceptably sensitive for
diagnosis of full-thickness tears, even in the case of an
isolated lesion of the supraspinatus tendon. Bak49 stated
that a positive lag sign (ERLS or drop-arm test) is
indicative of a full-thickness supraspinatus tear, but a
negative lag sign does not exclude a tear.
Overall, in patients with suspected acute rotator cuff
tear, clinical tests are not accurate in differentiating rotator
cuff disorders from other causes of shoulder pain. Other
information, such as mechanism of injury, pain behavior,
and location of pain when combined with clinical tests
might provide a more accurate indication of clinical
patterns. A combination of criteria, not just clinical tests,
may prove to be of greater use in the clinic.32 Other
investigators 44,57 proposed that a combination of several
signs, including history and the conventional radiographic
signs, will dramatically improve our diagnostic accuracy,
probably to a level where additional imaging is only
necessary to determine the degree of degeneration of the
tendon and muscular cuff.79
Pathology of the tendon of the long head of the biceps
and impingement is commonly associated with rotator cuff
tears. There is significant crossover between rotator cuff
tears and the long head of the biceps tendon testing.80–86
However, for the purposes of this review we did not include
articles describing tests for the tendon of the long head of
the biceps and impingement.
Investigators’ Preferred Physical Examination
Maneuvers
In clinical practice, it is not always possible to perform
all the tests for shoulder examination, and often the
shoulder is so painful that it is not possible to perform
any test.
Our preferred physical examination maneuvers are the
Jobe test for the supraspinatus tendon, the Patte and the
Hornblower tests for the infraspinatus tendon, and the lift-
off/belly-press, depending on the range of motion, for the
subscapularis tendon.
CONCLUSIONS
In conclusion, poor diagnostic accuracy of clinical
tests for rotator cuff pathology may be related to the close
FIGURE 15. Belly press is performed with the arm at the side and
the elbow flexed to 90 degrees, by having the patient press the
palm into his or her abdomen by internally rotating the shoulder.
The test is considered positive (1) if the patient shows a weakness
in comparison with the opposite shoulder, or (2) if the patient
pushes the hand against the abdomen by means of elbow
extension or shoulder extension, indicating an inability to exert a
force against the abdomen by active internal rotation produced
by the subscapularis.
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relationships of structures in the shoulder, to a lack of
understanding of the anatomical basis of the tests, and to
the lack of their reproducibility. Other information, such as
mechanism of injury, pain behavior, and location of pain,
when combined with conventional radiographic signs,
might provide a more accurate evaluation of clinical
conditions.
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