Rotator Cuff Testing: Identifying Shoulder Pathology with Precision
Technique
The rotator cuff is essential for shoulder stability and function, yet injuries to this structure are common, particularly in athletes, older adults, and those engaged in repetitive overhead activities. An accurate assessment of the rotator cuff is crucial for proper diagnosis and treatment planning. Clinicians rely on a combination of special tests, clinical reasoning, and imaging when necessary to differentiate between strains, tears, and impingements.
Rotator cuff tears increase with age, with studies estimating prevalence rates of 22% in individuals over 65 and up to 54% in those over 80.¹ This highlights the importance of early detection and intervention, as untreated tears can lead to progressive weakness, compensatory movement patterns, and further joint degeneration.
🔬 What the Science Says
The combination of multiple special tests improves diagnostic accuracy, with the full-can test, external rotation lag sign, and drop arm test demonstrating high sensitivity and specificity for identifying supraspinatus and infraspinatus pathology.² Ultrasound and MRI remain gold standards for diagnosing full-thickness tears but may not always be necessary for partial-thickness injuries if clinical tests strongly indicate dysfunction.³
🎯 Key Rotator Cuff Tests by Muscle
Supraspinatus
Full-Can and Empty-Can Tests: Assess supraspinatus integrity. Pain or weakness in the empty-can position suggests supraspinatus involvement⁴.
How to Perform: The patient abducts the arms to 90 degrees in the scapular plane with thumbs up (full-can) or thumbs down (empty-can). The examiner applies downward pressure while the patient resists.
Drop Arm Test: Evaluates for significant rotator cuff tears by assessing controlled arm lowering⁵.
How to Perform: The patient abducts the arm to 90 degrees and slowly lowers it. Inability to control the descent indicates a positive test.
Infraspinatus
External Rotation Lag Sign (ERLS): Identifies infraspinatus and supraspinatus dysfunction⁶.
How to Perform: With the patient's elbow flexed at 90 degrees and the arm at the side, the examiner passively externally rotates the shoulder to near end-range and asks the patient to maintain the position. A lag or inability to hold indicates a positive test.
Resisted External Rotation Test: Assesses weakness and pain in the infraspinatus muscle⁷.
How to Perform: The patient flexes the elbow to 90 degrees with the arm adducted. The examiner applies resistance as the patient externally rotates the arm. Pain or weakness suggests infraspinatus pathology.
Subscapularis
Lift-Off and Belly Press Tests: Examine subscapularis function⁸.
Lift-Off Test: The patient places the dorsum of the hand on the lower back and attempts to lift it off against resistance. Inability indicates subscapularis weakness.
Belly Press Test: The patient presses the palm against the abdomen while attempting to keep the elbow forward. Weakness or elbow dropping indicates subscapularis dysfunction.
Bear Hug Test: Assesses internal rotation strength and subscapularis involvement⁹.
How to Perform: The patient places the palm of the affected side on the opposite shoulder with fingers extended and elbow anterior to the body. The examiner applies an external rotation force perpendicular to the forearm while the patient resists by performing internal rotation. Inability to maintain position indicates a positive test.
Teres Minor
Hornblower’s Sign: Detects teres minor weakness by assessing the ability to maintain external rotation in 90-degree abduction¹⁰.
How to Perform: With the patient seated, the examiner elevates the patient's arm to 90 degrees in the scapular plane and flexes the elbow to 90 degrees. The patient is asked to externally rotate against resistance. Inability indicates teres minor pathology.
➡️ Advanced Testing Methods
MRI and CT Scans: Provide detailed imaging to assess the extent of rotator cuff tears, tendinopathy, and other structural abnormalities.
Diagnostic Ultrasound: A real-time, cost-effective alternative to MRI for detecting tears and structural abnormalities.
💡 The Therapist’s Role
Perform a comprehensive shoulder assessment integrating history, functional tests, and palpation.
Determine if pain is mechanical, inflammatory, or related to compensatory movement patterns.
Educate patients on proper movement mechanics and injury prevention strategies.
Integrate manual therapy, strengthening, and mobility work based on assessment findings.
🚧 Common Challenges and Solutions
False Positives in Testing: Combine multiple tests to improve diagnostic accuracy rather than relying on a single test.
Distinguishing Rotator Cuff Injury from Other Shoulder Pathologies: Use a cluster of tests and clinical reasoning to differentiate from labral injuries or nerve involvement.
Patients Hesitant to Undergo Imaging: Educate on the benefits and limitations of imaging and emphasize functional assessment findings. PROVIDE MORE; ELABORATE.
📊 Assessments & Measurements
Rotator Cuff Strength Testing: Using handheld dynamometry or manual muscle testing.
Shoulder Range of Motion (ROM): Active and passive measurements to identify limitations.
Special Test Clusters: Combining ERLS, Drop Arm, and Full-Can tests for increased diagnostic confidence.
Pain Provocation Tests: Hawkins-Kennedy and Neer to assess for impingement-related dysfunction.
🌀 My Take
Rotator cuff injuries are often overlooked because many people simply learn to live with the impairment, as there’s often no correlated pain. Instead, they compensate with altered movement patterns, leading to progressive weakness and further dysfunction.
Rotator cuff injuries can be tricky to pinpoint without a solid assessment strategy. The best approach is to use a cluster of special tests, consider patient history, and integrate imaging when necessary. I’ve found that early detection and tailored interventions lead to the best outcomes. Whether managing a high-performance athlete or a desk worker with chronic shoulder pain, precision in rotator cuff testing is the first step toward effective treatment and long-term recovery.
References
Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The Demographic and Morphological Features of Rotator Cuff Disease: A Comparison of Asymptomatic and Symptomatic Shoulders. J Bone Joint Surg Am. 2006;88(8):1699-1704.
Hegedus EJ, Goode AP, Cook CE, et al. Scapular Positioning in Patients with Shoulder Pain: A Meta-Analysis. J Orthop Sports Phys Ther. 2009;39(10):635-648.
Roy JS, Braën C, Leblond J, et al. Diagnostic Accuracy of Ultrasonography, MRI, and MR Arthrography in the Characterization of Rotator Cuff Disorders: A Meta-Analysis. J Bone Joint Surg Am. 2015;97(17):1517-1525.
Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Arch Phys Med Rehabil. 2009;90(11):1898-1903.
Park HB, Yokota A, Gill HS, et al. Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. J Bone Joint Surg Am. 2005;87(7):1446-1455.