APPROACH TO

McGill Journal of Medicine

Rotator Cuff Pathology

Courtenay Wood1

1 McGill University
ABSTRACT

Correspondence Shoulder pain is a common problem and the third most common
Courtenay Wood
musculoskeletal symptom for which patients seek medical care. Rotator
Email: [email protected]
cuff tendinosis is a frequent cause of this pain and can be diagnosed clin-
Publication Date
ically with a careful history and physical exam. Treatment consists of a
December 6, 2022
trial of pain management and physiotherapy and imaging modalities are
MJM 2022 (21) 10
often not required. However, imaging can be highly valuable for other
https://doi.org/10.26443/mjm.v21i1.957
pathologies. This article guides the reader through key elements to in-

clude in a history and physical exam of the shoulder, and how and when

to select an appropriate imaging modality.

www.mjmmed.com KEYWORDS
Rotator cuff tendinopathy, Shoulder pain, Imaging, Best practice

This work is licensed under a Creative

Commons BY-NC-SA 4.0 International
License.

1 | QUESTION unremarkable. He has a body mass index of 29 and has

been diagnosed with hypertension and diabetes melli-
You are a family medicine resident in a clinic. Your next tus type 2 which are well-managed with Enalapril and
patient is Mr. D, a 54-year-old accountant who enjoys metformin. Mr. D is otherwise in good health, and de-
playing baseball as a left-handed pitcher. He comes in nies smoking, drinking or drug use.
with a 3-month history of insidious onset left shoulder In your physical exam, you do not note any asymme-
pain. try, swelling, erythema, atrophy or deformities in your
He rubs the supero-lateral aspect of his deltoid as he thorough inspection and palpation of the shoulder. Mr.
describes a 5/10 diffuse pain that worsens with pitch- D has full active and passive range of motion of the
ing, lifting objects, starting the lawn mower, and lying shoulder. There is some tenderness in the musculature
on that side. He has not tried any treatment for the around the greater tubercle of the humerus and below
pain. Mr. D denies weakness or limited range of mo- the scapular spine.
tion. He denies shoulder injury and has had no previous You then perform a series of special orthopedic tests
surgeries or shoulder problems. His review of systems is including the external and internal rotation resistance

1
2 Wood

tests and the drop arm test. Mr. D does not demonstrate humerus, and acts to abduct the shoulder. The in-
weakness when performing these tests but reports that fraspinatus and teres minor originate from the in-
it is painful to perform resisted external rotation. fraspinous fossa and inferior lateral border of the
What is the next best step in managing this patient? scapula, respectively, and both insert on the greater tu-
A) Plain radiographs of the shoulder bercle of the humerus. These muscles act to externally
B) Ultrasound (US) rotate the shoulder. Finally, the subscapularis originates
C) Magnetic resonance imaging (MRI) from the subscapular fossa and inserts on the lesser tu-
D) Magnetic resonance arthrography (MRA) bercle of the humerus, acting to internally rotate the
E) 6-week trial of pain management physiotherapy shoulder. See Figure 1 for the anatomy.(5)

2 | ANSWER 2.1.3 | Etiology of RC Pathology

Multiple factors including over- or under-loading, age

E. Mr. D’s case is typical of a rotator cuff tendinosis
over 40 years, genetics, vascular changes, and an im-
which usually does not require any imaging for diagno-
pinging acromion may lead to cumulative injury and de-
sis. In fact, there is a weak correlation between posi-
generation which contribute to RC disease.(1, 6, 7, 9)
tive imaging findings and the presence of symptoms. (1)
A distinction must be made between RC tendinosis
Management should include a 6-12 week trial of pain
and RC tears as they may require different treatment.
management, relative rest, and physiotherapy. (1, 2,
Tendinosis is treated with pain management and physi-
16) If symptoms do not improve after this trial, imaging
cal therapy.(1) However, in the case of a traumatic full-
modalities can then be considered and selected accord-
thickness RC tear, it is important to treat early with
ing to the patient’s history and physical exam findings.
surgery. Untreated full-thickness tears may enlarge and
the muscle may atrophy, predisposing the individual to
2.1 | Background recurrent tears.(3) Furthermore, if the tear becomes too
large or is left too long without repair, intrinsic changes
2.1.1 | Problem
to the tendon may make it inoperable at a later date.(3)
Shoulder pain is a common problem with a self-reported
prevalence of 16-26% in the general population. It is
2.2 | History
the third most common musculoskeletal symptom for
which patients seek medical care, followed by low back When taking the patient’s history, it is first important to
and knee pain.(3) Shoulder injury is associated with a de- determine whether there was any trauma to the shoul-
lay in return to work and an increased frequency of sick der as this will influence further management.(3, 12)
leave.(4) Among the many etiologies of shoulder pain, Once trauma is ruled out, the physician must then ascer-
rotator cuff (RC) disease - which includes tendinosis, im- tain whether the issue is indeed musculoskeletal in ori-
pingement, and tears - is the most common.(5) gin by doing a review of systems to rule out referred pain
from other areas including the neck, diaphragm, gallblad-
der, and heart.
2.1.2 | Anatomy
A detailed history on the nature and location of the
The RC includes the supraspinatus, infraspinatus, teres pain will then help narrow down the diagnosis. RC tendi-
minor and subscapularis muscles. These muscles act nosis usually presents as atraumatic shoulder pain at the
as dynamic stabilizers of the glenohumeral joint.(5) The tip of the shoulder and supero-lateral aspect of the del-
supraspinatus originates in the supraspinous fossa of toid. The pain may worsen with activities such as reach-
the scapula, inserts on the greater tubercle of the ing, punching, pulling, lifting, or lying on that side.(10)
Wood 3

The presentation of a RC tear differs in that there may active and passive range of motion.(12)
be weakness (e.g., with external rotation or abduction of Special orthopedic tests should then be employed
the shoulder) in the affected muscle.(1, 10) Other exam- to narrow down the diagnosis. Examples of these
ples of causes of non-traumatic shoulder pain include tests include the belly press test (sensitivity 28%, speci-
adhesive capsulitis, glenohumeral osteoarthritis, labral ficity 94%) and lift off test (sensitivity 19%, speci-
tears, biceps tendinopathy, avascular necrosis, and bone ficity 95%) for the subscapularis; Hornblower (sensi-
tumors.(8, 10) tivity 17%, specificity 96%) for the infraspinatus; and
Attention to risk factors for these shoulder patholo- Jobe’s test (sensitivity 88%, specificity 62%) and full
gies should also be investigated. Risk factors that in- can tests (sensitivity 7-% and sensitivity 81%), for the
crease the likelihood of RC disease include: age, tis- supraspinatus.(10, 12, 13) However, a combination of
sue over- or under-loading, an occupation or sport with special orthopedic tests must be used to increase diag-
overhead activity, diabetes mellitus, hypertension, high nostic accuracy (17) as none of these tests alone reliably
body mass index, and smoking.(1, 6) isolate separate structures given their close proximity to
one another.(1) Normal strength in a series of tests may
point the physician toward a tendinosis whereas weak-
2.3 | Physical Examination ness may allow the physician to diagnose a RC tear.(1,
12, 14)
The physician should begin with observation of the pa-
tient.(12) They should note their posture, arm position,
and the use of compensating accessory muscles. The 2.4 | Treatment for RC Tendinosis
physician should then inspect for swelling, erythema, at-
2.4.1 | Pain management
rophy, deformities, and any asymmetries between the
shoulders and scapulae.(12) The physician should then Adequate pain management and a prompt return to
proceed to palpate for any pain or deformities in the work are important components of the recovery pro-
bony and muscular structures of the shoulder and sur- cess.(2, 15) Non-pharmacological measures such as
rounding joints. Next, they should assess the patient’s ice, heat, and massage as well as pharmacological

FIGURE 1 Anatomy of the rotator cuff.(10)

4 Wood

agents including acetaminophen or nonsteroidal anti- 3 | BEYOND THE INITIAL AP-

inflammatory drugs should be employed for pain re- PROACH
lief.(2, 15) If these pain management measures plus ex-
ercise programs are not effective in relieving pain, cor- 3.1 | Imaging
tisone or local anesthetic injections may provide some
temporary analgesia.(1, 2, 17) Although imaging can be a critical diagnostic tool for
shoulder pathologies, it must be used wisely and the
modality must be chosen carefully based on the pa-
tient’s history and physical exam findings.(3) With RC
tendinosis in particular, there is a very weak associa-
2.4.2 | Physical Therapy tion between symptoms and structural changes found
on imaging, which challenges the validity of using imag-
ing to justify that structural abnormalities lead to pain
in RC tendinosis.(1) See Flow Chart 1 for a decision tree
Fortunately, RC tendinosis can be managed with phys- regarding selection of imaging modalities.
ical therapy which has a 75% success rate.(16) These
exercise programs include three stages: shoulder mo-
3.1.1 | Utility of Plain Radiographs
bility, building strength and flexibility, and integration
towards sports or occupation-specific activities such as Although plain radiographs of the shoulder may not be
a return-to-work program.(15, 18) Pain and function necessary in the initial investigation of non-traumatic
usually improve after just 6 to 12 weeks of a rehabili- shoulder pain, they should be the first imaging modal-
tation exercise program.(16) Treatment should involve ity in acute trauma, especially given their ease of ac-
relative rest from or modification of painful activities, cess and low cost.(19) X-rays can provide information
adjusting posture, avoiding sleeping on the sore shoul- about pathologies such as fractures, osteoarthritis, ma-
der, controlled reloading, sustained isometric contrac- lignancy, dislocation, Hills-Sachs lesions, and Bennett
tions, and progression from simple to complex shoul- Lesions to name a few.(3, 9, 14, 19) Although plain radio-
der movements.(1, 2) Compared with surgery, this reha- graphs can also detect abnormalities related to impinge-
bilitative approach brings the additional benefit of im- ment, such as osteophyte formation or a down slop-
plementing exercise, minimizing sick leave with a faster ing acromion, these findings are commonly present in
return to work, and reducing costs to the healthcare asymptomatic patients as well and must be interpreted
system.(1) Likewise, for non-traumatic partial thickness with caution.(9, 14)
tears, surgery has no better outcome than an exercise
program.(1, 17) In fact, exercise programs are beneficial
even in large inoperable RC tears.(1, 17) 3.1.2 | Utility of US, MRI, and MRA

Since chronic partial RC tears and tendinosis are treated

similarly, whereas acute traumatic full thickness tears
However, despite the benefits of exercise, surgery may require timely surgery for the best prognosis, it is
may still be warranted in traumatic, full-thickness tears most important to choose a modality that can accurately
as there is a risk that the size of the tear, fatty infiltra- detect a full-thickness tear in a timely manner.(3, 11)
tion and muscle atrophy may all increase over time(3,6). US, MRI, and MRA perform equally well in the detec-
Without prompt surgery on these acute tears, the tissue tion of full-thickness tears.(3, 11) Ultrasound should be
may be inoperable and unable to recover with conserva- the first-line imaging of choice over MRI or MRA given
tive management.(3) its low cost, portability, availability, real-time imaging,
Wood 5

FLOWCHART 1 Decision tree for selecting an imaging modality for shoulder pain.

short scan times, and greater patient satisfaction. Fur- ten be diagnosed clinically with a history and physical
thermore, MRI and MRA have contraindications such exam.(1) In the case of traumatic full thickness tears,
as metal implants or claustrophobia, which ultrasound prompt surgery is recommended.(3) For tendinosis, if
avoids.(3, 9, 11, 19) If ultrasound imaging remains incon- symptoms do not improve after a 6-12 week (16) course
clusive, the patient should then undergo MRI or MRA.(3) of conservative treatment, imaging may be indicated.

Although ultrasound carries the above benefits, it The modality of choice should be carefully selected

does have some shortcomings. One major disadvantage based on the suspected etiology according to the pa-

of ultrasound is the necessity of personnel trained in ul- tient’s presentation. In general, plain radiographs are

trasound imaging of the RC.(19) When it comes to evalu- best used to assess bone and joint pathology, ultrasound

ating partial thickness tears, MRA may be the best imag- is best for RC or bursal pathology, and MRI or MRA are

ing modality for this pathology given its superior sen- best for labral pathology.(20)

sitivity compared to US or MRI.(11) Finally, ultrasound

has a limited ability to provide information about labrum,
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