Current Orthopaedics (2000) 14, 155–160

© 2000 Harcourt Publishers Ltd

doi:10.1054/ cuor.2000.0104, available online at http://www.idealibrary.com on

Mini-symposium: Rotator cuff

(i) Clinical examination of the rotator cuff

M. Pisan, C. Gerber

INTRODUCTION As the symptoms of a rotator cuff lesion are often

Rotator cuff tears are frequent. Cadaver studies have
described a prevalence of full thickness tears of up to
30%,1 and of partial-thickness tears of up to 37%.2
The frequency of rotator cuff tendon defects in
asymptomatic shoulders has been evaluated prospec-
tively with MRI.3 Over a wide age range, an overall
prevalence of 15% of full-thickness and of 20% of
partial-thickness lesions has been found, increasing
significantly with age. In individuals over 60 years of
age the prevalence of full-thickness tears was 28%
and 26% for partial-thickness tears.
Not all rotator cuff tears lead to painful shoulder
dysfunction and the relationship of a morphologic
alteration with the onset of clinical symptoms is not
yet understood. Before clinical examination of the
shoulder, a careful history should be obtained. The
most common clinical manifestations of a rotator
cuff tear are pain and weakness, occasionally stiff-
ness. Usually the patient locates the pain anterolater-
ally or at the level of the deltoid insertion and
commonly complains of aggravation through over-
head use of the arm in a forward flexed position.4
Very often patients suffer from severe night pain.
Associated biceps tendon pathologies can refer the
pain to the level of the elbow. An associated pathol-
ogy of the acromio-clavicular joint usually provokes
pain directly over the joint itself and leads to radia-
tion deep into the supraspinous fossa and in the
upper trapezius. Acromio-clavicular pain can be
aggravated by local pressure on to the joint or
occasionally by active movement of the neck.5
Markus Pisan, MD, Fellow; Christian Gerber, MD, Professor and
Chairman, Department of Orthopaedics, University of Zurich,
Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland.
Correspondence to: Christian Gerber, MD. Fax: + 1386 16 09;
Tel: + 1 386 11 11; E-mail: cgerber@balgrist.unizh.ch
difficult to distinguish from other pathologies, the
shoulder should be examined systematically, includ-
ing the acromio-clavicular and sterno-clavicular
joints and a neurovascular examination of the
involved upper extremity should also be carried out.
THE CLINICAL EXAMINATION OF THE
ROTATOR CUFF
For clinical examination of the rotator cuff the
patient is seated on an examination table with the
back towards the examining physician. The evalua-
tion of the four scapulo-humeral rotator muscles and
their tendons should be performed selectively and
systematically with inspection, palpation, impinge-
ment test, strength test and lag sign:
Inspection: Inspection of the shoulder may
demonstrate muscular wasting. On
the posterior aspect of the shoulder
the supraspinatus and infraspinatus
muscles participate to form the
contour of the shoulder. Atrophy of
these muscles can easily be seen and,
at least in elderly individuals, is most
often the result of a chronic tear of
the corresponding tendon (Fig. 1).
Palpation: The insertion of the subscapularis
tendon on the lesser tuberosity and
of the supraspinatus and
infraspinatus tendons on the greater
tuberosity can directly be palpated.
Tenderness at the insertion indicates
pathology of the tendon.
Impingement: The aetiology of rotator-cuff tears is
still controversial. The causes may be
intrinsic and/or extrinsic disorders of
the tendon. Both may lead to

155
156 Current Orthopaedics
structural changes in the tendon.
Extrinsic causes produce a
mechanical conflict either between
the bursal side of the suraspinatus
tendon and the acromion, or between
the articular side of the supraspinatus
or subscapularis and the glenoid rim.
The clinical manifestation of such
impingement is pain. Specific
impingement tests are established for
the supraspinatus and the
subscapularis tendons.
Strength test: Isolated strength testing is possible
for the subscapularis and the
supraspinatus muscle. Strength
testing of the the infraspinatus and
teres minor muscle is also possible,
but it is less selective.
Lag sign: A lag sign is based on the observation
that weakness of a muscle is most
easily demonstrated at the limit of the
amplitude of contraction of a muscle.
A difference between the maximal
active and the maximal passive range
of motion of the joint in any given
plane is called a lag. These lags have
been used for a long time in the
diagnosis of tendon tears under
names such as ‘drop sign’, ‘dropping
sign’, ‘hornblower’s sign’, ‘lift-off test’
etc. The magnitude of the lag
corresponds with the extent of the
lesion of the musculotendinous unit
causing the active movement. If
however, for example, passive
external rotation of the arm is
increased due to rupture of the
subscapularis, an external rotation lag
may be mimicked and does not
identify an infraspinatus lesion.
Before proceeding with examination of the individual
musculotendinous units, mobility of the neck is tested
to detect pain provoked by a cervical pathology which
is, however, rather rare. The acromio-clavicular joint is
then palpated to ascertain that the pain does not arise
in this joint. It is then of crucial importance to check
that the passive range of motion of the gleno-humeral
joint is normal. This is done by testing passive internal
and external rotation of the arm at the side fixing
the scapula on the thorax and preventing scapulo-
thoracic motion. Passive abduction is then tested to
make sure that abduction of the gleno-humeral joint
is also free. To test abduction the scapula must be
controlled and fixed on the thorax. It is critical to
remember that almost all impingement tests are
painful if passive range of motion is limited and that
they lose their diagnostic value if range of motion is
not free.
Fig. 1 A 44 year old patient with a chronic, posttraumatic rotator
cuff tear and consequent atrophy of the supraspinatus and
infraspinatus muscles.
SUPRASPINATUS
Palpation
The tendon of the supraspinatus inserts on the superior
facet and the superior half of the middle facet of the
greater tuberosity. By rotating the shoulder internally
(lift-off position) the insertion of the supraspinatus ten-
don can be palpated approximately 1 cm distally and
ventrally to the lateral rim of the acromion. Tenderness
of the insertion indicates a tear of the tendon. By gently
rotating the shoulder out of this position a full thick-
ness tear can be palpated as a ‘hole’ in the cuff.
Impingement
Neer,6 described the ‘impingement lesion’ of the
supraspinatus as caused by a mechanical conflict
between the tendon and the antero-inferior aspect of
the acromion. The ‘impingement sign’ of Neer is
elicited with the patient seated and the examiner
standing. Scapular rotation is prevented with one
hand while the other hand raises the arm in forced for-
ward elevation, allegedly causing the greater tuberos-
ity to impinge against the acromion. This manoeuvre
causes pain in patients with pathology of the
supraspinatus tendon and if it does so, this test is con-
sidered to be positive. If the pain is due to subacro-
mial pathology, such as a cuff tear, the pain can be
completely eliminated by infiltration of 5–10 ml of
Lignocaine into the subacromial space. The pain relief
after such infiltration of local anaesthetic corresponds
to a positive ‘impingement test’.
Another way of demonstrating the mechanical
conflict between the supraspinatus tendon and the
acromion is the modified impingement test described
by Hawkins et al.7 This test is performed by position-
ing the arm in 90° of flexion and then forcibly inter-
nally rotating the shoulder. The test is positive if this
manoeuvre provokes pain. After subacromial infiltra-
tion with a local anaesthetic, one can also expect
significant pain relief. A positive impingement test
together with a positive Hawkins test is highly
suspicious for a tear of the supraspinatus tendon.

We have recently documented,8 that this manoeu-
vre can also provoke a mechanical conflict between
the subscapularis tendon and the antero-superior
aspect of the anterior glenoid rim. It can well be that
this manoeuvre identifies an undersurface lesion of
the subscapularis rather than a bursal lesion of the
supraspinatus. If subacromial infiltration does not
relieve pain in the modified impingement test, local
anaesthetic should be injected into the gleno-humeral
joint. If pain is then relieved, intra-articular impinge-
ment of the subscapularis is the most likely cause.
Recently Walch et al.9 described intra-articular
impingement of the deep surface of the supraspinatus
tendon on the postero-superior glenoid rim causing a
partial articular side tear of the tendon often associ-
ated with a lesion of the postero-superior labrum
(Walch syndrome). The typical pain can be repro-
duced when the arm is held in full external rotation
and then moved between 90° and 150° of adduction
e.g. in the apprehension position.
Strength testing
The two main functions of the supraspinatus muscle
are active abduction of the arm synergistic with the
deltoid muscle and dynamic stabilisation of the
humeral head in the glenoid fossa. This function helps
to keep the center of rotation of the gleno-humeral
joint stabilized during elevation and counteracts the
superior shear forces of the deltoid. A tear of the
supraspinatus tendon causes a decrease in the com-
pressive forces and an increase in the shear forces at
the gleno-humeral joint, resulting in slight superior
subluxation of the humeral head during active eleva-
tion.10 The clinical expression of this is loss of
strength. The strength of the supraspinatus should
therefore be tested in line with the supraspinatus fossa
with the arm slightly elevated. Jobe described how to
test the strength of the supraspinatus.11 This ‘Jobe
test’ is performed by positioning the arm in 90° eleva-
tion in the scapular plane and the forearm rotated into
pronation, so that the thumb points towards the
ground. The test is considered negative if the patient is
able to maintain the affected shoulder in this position
against a force applied by the examiner. A painful test
is not positive, but often associated with partial
lesions of the cuff. The ‘Jobe test’ is positive if the
strength of the tested arm is diminished. It should be
noted that normal strength testing is not sensitive at
all. If differences of more than 10% (which are signif-
icant) but less than about 30–40% are to be detected,
instrumented measurement of strength is mandatory.
We prefer to modify the supraspinatus test of Jobe
thus: as the proportional contribution to abductor
strength of supraspinatus and deltoid changes
through abduction, we test strength of abduction
at 60° because the relative contribution of the
supraspinatus is larger than at 90° of abduction and
Clinical examination of the rotator cuff 157
sensitivity for supraspinatus pathology is thereby
increased.
Lag signs
The Lag sign for the supraspinatus and infraspinatus
musculotendinous units is the external rotation lag
sign (ERLS) described by Hertel et al.12 The test is
performed by elevating the arm 20° with the elbow
passively flexed to 90° and the shoulder in near maxi-
mal external rotation. The patient is then asked to
maintain the position of external rotation as the
examiner releases the wrist while maintaining support
of the arm at the elbow. The test is considered positive
if the patient is not able to maintain the external
rotation and a lag occurs.
INFRASPINATUS/TERES MINOR
Palpation
The tendon of the infraspinatus attaches to the entire
middle facet of the greater tuberosity of the humeral
head and can be palpated there. Therefore the arm of
the patient should be placed in 90° of flexion and
slight external rotation. The insertion can then be
palpated 1 cm distal to the dorso-lateral rim of the
acromion. Tenderness at the insertion indicates a
lesion of the tendon.
Strength tests
The main function of the infraspinatus is active exter-
nal rotation of the shoulder with the arm at the side.
This function of the infraspinatus is supported by the
posterior fibres of the deltoid and the teres minor.
There is probably no position of the arm that isolates
the activity of the infraspinatus completely from the
teres minor muscle, but electromyographic studies
have documented that 45° internal rotation with the
arm at the side is the optimal manual muscle testing
position for the infraspinatus.13 Weakness of external
rotation from this position indicates a tear of the
infraspinatus. Because shortening weakens the muscle,
we prefer to test external rotator strength with the
elbow at the side and the arm fully externally rotated.
Relevant weakness in this position proves infraspina-
tus involvement.
The hornblower’s sign is a very sensitive and spe-
cific sign to document a lesion of the teres minor.14
This sign was described in obstetric brachial plexus
palsy,15 and relies on the difficulty in raising the hand
to the mouth in the absence of external rotator power
of the shoulder without abduction of the affected
arm. The corresponding strength test is performed by
supporting the involved arm at 90° of elevation with
the elbow flexed to 90° and the shoulder in maximal
external rotation. The patient is then asked to rotate
158 Current Orthopaedics

the forearm against the resistance of the examiner’s

hand.

Lag sign
Neer described a functional lag of the infraspinatus
musculotendinous unit and called it the ‘dropping
sign’.16 This sign is elicited by supporting the forearm
and hand of the patient in the externally rotated posi-
tion and the elbow bent to 90°. The patient is then
asked to maintain this position. If the infraspinatus is
non-functioning the arm falls against the side of the
body.
Hertel et al.12 described the ‘drop’ sign, which is dif-
ferent from the ‘dropping sign’ of Neer,16 and is also
designed to assess the function of the infraspinatus.
The affected arm is held at 90° of elevation and at
almost full external rotation and the elbow is flexed at
90°. The drop sign is positive if the patient is not able
Fig. 2 The modified impingement test (8) can provoke a
to maintain the position and a lag occurs. A drop sign mechanical conflict between the superior part of the subscapularis
is the same as the previously described hornblower’s tendon and the anterior glenoid rim. In cases with a partial
sign. thickness tear of the deep surface of the subscapularis, this
manoeuvre reproduces typical pain.

SUBSCAPULARIS
Palpation
The tendon of the subscapularis muscle inserts into
the lesser tuberosity of the humeral head and is sup-
plemented inferiorly by direct muscular insertion
along the surgical neck of the humerus. The insertion
of the tendon can easily be palpated about 1 cm distal
to the anterior rim of the acromion with the arm in
a 0° neutral position. Tenderness of the insertion
increases by gentle passive rotation of the shoulder
into slight external rotation and indicates a tear of the
tendon.
Impingement
Corresponding to the impingement of the supraspina-
tus tendon on the postero-superior glenoid rim
(Walch syndrome) an anterior impingement of the
superior part of the subscapularis tendon on the ante-
rior glenoid rim can occasionally be observed. It leads
to a partial tear of the deep surface of the tendon.8
The typical pain can be reproduced when the arm is
positioned in elevation of 80–110°, forcefully inter-
nally rotated and adducted (Fig. 2A & B). Neer’s
impingement sign is usually negative. We considered
an anterior impingement as positive if this manoeuvre
remains positive even after subacromial infiltration of
local anaesthetic (negative ‘impingement test’), but
becomes negative after intra-articular injection of
local anaesthetic.
Strength test
The subscapularis is a strong internal rotator of the
shoulder and limits passive external rotation. An
increased, asymmetric passive external rotation indi-
cates a tear of the tendon of the subscapularis and is
often associated with apprehension-like discomfort.
The functional deficiency resulting from a tear is
weakness of internal rotation compared to the oppo-
site side and the inability to lift the hand off the spine
when tested with the ‘lift-off’ test described by the
senior author in 1991,17 (compare Lag sign). If the
passive range of motion of the affected shoulder is
limited and the arm cannot be brought behind the
body, the ‘belly-press’ test is an appropriate substi-
tute.18 In this test, the patient presses the hand on his
(her) abdomen. If the subscapularis is intact and
active internal rotation is strong, the elbow remains in
front of the trunk and the wrist is not flexed while
pressure is exerted. If the strength of the subscapu-
laris is impaired the patient cannot maintain maximal
internal rotation. The elbow drops back behind the
body and the wrist will be flexed. In this position the
patient exerts pressure on the abdomen by extending
the shoulder.
Lag sign
The ‘lift-off’ test17 is a sensitive and specific examina-
tion for a subscapularis tear. The test is performed by
bringing the arm passively behind the body into max-
imum internal rotation. The test is considered normal
if the patient maintains maximum internal rotation
after the examiner releases the patient’s hand. If pas-
sive maximum internal rotation cannot be actively
maintained and the hand drops straight back (internal
rotation lag sign)12 the test is considered positive
(Fig. 3A & B). The result is considered as weak if
there is small internal rotator lag but the hand does

(A)
Fig. 3 A 41 year old patient with a traumatic subscapularis tear and a positive lift-off test. He is not able to maintain actively the passive
maximum internal rotation (A) and the hand drops straight back after releasing the patient’s hand (B).
not drop all the way to the spine. Such weakness is
normally the expression of a partial tear or of a
superior tear of the subscapularis tendon.
THE ROTATOR INTERVAL
Another important structure is the rotator interval. It
is the anatomical entity closing the space between the
superior border of the subscapularis and the adjacent
supraspinatus. It is formed by thin elastic, membra-
nous tissue strengthened by the coraco-humeral and
the superior gleno-humeral ligaments, as well as the
capsule.19 The functions of the rotator cuff interval
are not yet absolutely clear. Harryman20 suggested
that the interval checks the range of flexion, exten-
sion, adduction and external rotation as well as the
inferior translation of the gleno-humeral joint in the
adducted shoulder and provides stability of the joint
against posterior dislocation. A tear of the rotator
interval leads to an asymmetrically positive sulcus
sign, which does not decrease if tested with the arm in
external rotation.
CONCLUSION
Clinical examination of the rotator cuff is based on
verifying whether the specific functions of the four
rotator cuff musculotendinous units are intact and
painfree. Provocation of pain by testing the musculo-
tendinous unit is usually associated with partial ten-
don tears. Pathological tendons are painful if loaded
under tension (strength testing) or compression
(impingement). The main criterion proving tendon
Clinical examination of the rotator cuff 159
(B)
tear is loss of strength for the specific function of the
specific muscle tested. Accuracy of physical examina-
tion should be greater than 85% for identifying full
thickness tears of any of the four tendons.
REFERENCES
1. Lehman C, Cuomo F, Kummer FJ, Zuckermann JD. The
incidence of full thickness rotator cuff tears in a large
cadaveric population. Bull Hosp Jt Dis 1995; 54: 30–31.
2. DePalma AF. Surgery of the shoulder, 3rd ed. Philadelphia:
JB Lippincott, 1983.
3. Sher JS, Uribe JW, Posada A, Murphy B, Zlatkin MB.
Abnormal findings on Magnetic Resonance Images of
asymptomatic shoulders. J Bone Joint Surg 1995; 77A: 10–15.
4. Miniaci A, Salonen D. Rotator cuff evaluation: imaging and
diagnosis. Orthop Clin North Am 1997; 28: 43–58.
5. Gerber C, Galantay RV, Hersche O. The pattern of pain
produced by irritation of the acromioclavicular joint and the
subacromial space. J Shoulder Elbow Surg 1998; 7:
352–355.
6. Neer CS. Impingement lesions. Clin Orthop 1983; 173:
70–77.
7. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes.
Am J Sports Med 1980; 8: 151–158.
8. Gerber C, Sebesta A. The role of anterosuperior glenoid
impingement in lesions of the subscapularis, the rotator
interval and the tendon of the long head of the biceps. 1999
Submitted.
9. Walch G, Boileau P, Noel E, Donell ST. Impingement of the
deep surface of the supraspinatus tendon on the
posterosuperior glenoid rim: An arthroscopic study. J
Shoulder Elbow Surg 1992; 1: 238–245.
10. Friedman RJ, Knetsche RP. Biomechanics of the rotator cuff.
In: Burkhead WZ Jr (ed). Rotator cuff disorders. Baltimore:
Williams & Wilkins, 1996; 45–56.
11. Jobe FW, Moynes DR. Delineation of diagnostic criteria and
a rehabilitation programm for rotator cuff injuries. Am J
Sports Med 1982; 10: 336–339.
12. Hertel R, Ballmer FT, Lambert SM, Gerber C. Lag signs in
the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg
1996; 5: 307–313.
13. Kelly BT, Kadrmas W, Speer KP. The manual muscle
examination for rotator cuff strength: an electromyographic
investigation. Am J Sports Med 1996; 24: 581–588.
160 Current Orthopaedics
14. Walch G, Boulahia A, Calderone S, Robinson AH. The
‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-
cuff tears. J Bone Joint Surg 1998; 80B: 624–628.
15. Arthuis M. Obstetrical paralysis of the brachial plexus. I.
diagnosis: clinical study of the initial period. Rev Chir Orthop
Reparatrice Appar Mot 1972; 58 (suppl I): 124–136.
16. Neer CS. Shoulder reconstruction. Philadelphia, London,
Toronto, Montreal, Sydney, Tokyo: W.B. Saunders Company,
1990; 1–142.
17. Gerber C, Krushell RJ. Isolated rupture of the tendon of the
subscapularis muscle. J Bone Joint Surg 1991; 73B: 389–394.
18. Gerber C, Hersche O, Farron A. Isolated rupture of the
subscapularis tendon. J Bone Joint Surg 1996; 78A:
1015–1023.
19. Nobuhara K, Ikeda H. Rotator interval lesion. Clin Orthop
1987; 223: 44–50.
20. Harryman DT, Sidles JA, Harris SL, Matsen FA. The role of
the rotator interval capsule in passive motion and stability of
the shoulder. J Bone Joint Surg 1992; 74A: 53–66.