Spectrum from subacromial impingement and tendinopathy to partial and full-thickness rotator cuff tears.
Also known as: rotator cuff tear, rotator cuff tendinopathy, subacromial impingement, supraspinatus tear
Overview
Disorders of the four rotator cuff muscles and tendons (supraspinatus, infraspinatus, teres minor, subscapularis) that surround the glenohumeral joint. Includes tendinopathy, subacromial impingement, partial-thickness tears, and full-thickness tears.
Epidemiology
Most common cause of shoulder pain in adults. Prevalence of asymptomatic full-thickness tears rises with age (>50% by age 80). Symptomatic tears most common in patients 40-65.
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Question 1MusculoskeletalMedium
A 50-year-old male has progressive shoulder pain and weakness with overhead activities. Physical exam shows weakness in abduction and external rotation. Drop arm test is positive. Which of the following structures is most likely injured?
AAcromioclavicular joint capsule
BSupraspinatus tendon
CLong head of biceps tendon
DGlenoid labrum
EInfraspinatus tendon
Reveal answer & full explanation
Correct answer: B — Supraspinatus tendon
AAcromioclavicular joint capsule
BSupraspinatus tendon✓
CLong head of biceps tendon
DGlenoid labrum
EInfraspinatus tendon
Why Supraspinatus tendon is correct
The supraspinatus is the most commonly injured rotator cuff tendon (subacromial impingement is the usual mechanism)
Weakness in abduction and external rotation, combined with a positive drop arm test, localizes the injury to the supraspinatus
Drop arm test: patient cannot maintain the arm abducted at 90 degrees, indicating a full-thickness tear
Other supraspinatus tests: empty can/Jobe test (supraspinatus weakness in 90° abduction with thumbs down) and Hawkins-Kennedy test (impingement)
MRI confirms the diagnosis; acute traumatic and chronic degenerative tears are both recognized
Treatment: physical therapy first; surgical repair indicated if young, active, or full-thickness tear with significant weakness
Why the others are wrong
Long head of biceps tendon — Biceps tendinopathy presents with anterior shoulder pain; Speed test is the relevant provocative test, not the drop arm test
Acromioclavicular joint capsule — AC joint pathology typically presents with pain at the superior shoulder/AC joint, not weakness in abduction/external rotation or a positive drop arm test
Glenoid labrum — A superior labrum anterior posterior (SLAP) tear affects the superior labrum, is common in throwing athletes, and is associated with a positive O'Brien test
Infraspinatus tendon — the infraspinatus is the main external rotator of the shoulder, so the external rotation weakness is tempting, but an infraspinatus lesion does not explain the abduction weakness or the positive drop arm test, which point to the supraspinatus; the supraspinatus is the most commonly torn rotator cuff tendon and contributes to external rotation as well as abduction, and the infraspinatus is usually involved only when a supraspinatus tear enlarges posteriorly, so the supraspinatus is the structure most likely injured
Question 2MusculoskeletalMedium
A 45-year-old painter presents with shoulder pain that worsens with overhead activity and at night. He has positive Neer and Hawkins-Kennedy tests, with weakness of shoulder abduction. Which structure is most likely injured?
ATeres major tendon
BLong head of biceps tendon
CSubscapularis tendon
DInfraspinatus tendon
ESupraspinatus tendon
Reveal answer & full explanation
Correct answer: E — Supraspinatus tendon
ATeres major tendon
BLong head of biceps tendon
CSubscapularis tendon
DInfraspinatus tendon
ESupraspinatus tendon✓
Why Supraspinatus tendon is correct
Supraspinatus is the most commonly injured rotator cuff tendon, particularly with subacromial impingement
Positive Neer and Hawkins-Kennedy tests indicate impingement; the empty can test (Jobe's test) isolates supraspinatus weakness
Subscapularis tendon — Subscapularis is tested with the lift-off and belly press tests; it primarily internally rotates
Long head of biceps tendon — Long head biceps tendinitis presents with bicipital groove tenderness and positive Speed/Yergason tests
Teres major tendon — Teres major adducts and internally rotates the humerus, lies outside the rotator cuff, and is not compressed in the subacromial space
Infraspinatus tendon — the rotator cuff tendon just posterior to the supraspinatus can be involved when a cuff tear extends posteriorly, but this muscle primarily externally rotates the humerus and is tested with external rotation strength; impingement signs with weak abduction point to the supraspinatus
Additional high-yield points
Infraspinatus and teres minor primarily externally rotate and are tested with external rotation strength testing
The supraspinatus initiates abduction and is isolated by the empty can (Jobe's) test
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Trauma — fall on outstretched hand, lifting injury
Acromial morphology (type III hooked acromion)
Smoking
Diabetes mellitus, hypercholesterolemia
Prior shoulder surgery or steroid injection (chronic)
Pathophysiology
The supraspinatus tendon passes under the acromion through the subacromial space — a narrow conduit prone to mechanical and degenerative injury. Repetitive impingement, age-related tendon degeneration, and a relatively poor vascular zone in the supraspinatus combine to produce tendinopathy, partial tears, and eventually full-thickness tears.
Clinical presentation
Symptoms
Anterolateral shoulder pain, often radiating to the deltoid
Worse with overhead activity, reaching behind back
Night pain, inability to sleep on affected side
Weakness on lifting (more prominent with tear)
Acute traumatic tear: sudden weakness after a fall or lifting injury
Signs / physical exam
Painful arc 60-120° of abduction (impingement)
Positive Neer impingement test (forced forward flexion with internal rotation)
Positive Hawkins-Kennedy test (90° forward flexion + passive internal rotation)
Weakness on resisted abduction (empty/full can test for supraspinatus)
Acute MI (especially women) — Left arm/shoulder pain with diaphoresis, dyspnea — ECG and troponin if any doubt
Diagnostic workup
Labs
Not routinely indicated
Imaging
Plain radiographs — AP, scapular Y, axillary views; assess for AC arthrosis, acromial morphology, calcific deposits, glenohumeral OA, superior migration of humeral head (chronic large tear)
MRI — best for tear size, location, retraction, muscle atrophy, fatty infiltration (Goutallier grading); guides surgical decision-making
Ultrasound — accurate and dynamic; operator-dependent; alternative to MRI
Diagnostic algorithm
Test
Finding
Suggests
Neer
Pain with forced forward flexion + IR
Subacromial impingement
Hawkins-Kennedy
Pain with 90° flexion + passive IR
Subacromial impingement
Empty can (Jobe)
Weakness in 90° abduction, 30° forward, thumbs down
Supraspinatus tear/weakness
External rotation lag
Inability to maintain ER at 0°
Infraspinatus tear
Drop-arm
Sudden drop from abducted position
Full-thickness supraspinatus tear
Lift-off / belly-press
Weakness in internal rotation
Subscapularis tear
Painful arc
Pain 60-120° abduction
Impingement / partial tear
Key bedside rotator cuff tests.
Treatment
First-line
Activity modification — avoid overhead and provocative activities
NSAIDs — ibuprofen, naproxen, meloxicam — for pain and inflammation
Subacromial corticosteroid injection — short-term pain relief; limit to 2-3 per year and avoid in suspected large tears (may impair tendon healing)
Second-line / adjunct
Surgical referral indications: full-thickness tear in active patient, persistent symptoms despite ≥3-6 months of conservative care, acute traumatic tear in younger patient
Arthroscopic rotator cuff repair — most common
Subacromial decompression (acromioplasty) — not routinely recommended; sham-controlled trials show no benefit over placebo surgery for subacromial pain, and AAOS does not suggest routine acromioplasty with cuff repair
Tendon transfer or reverse total shoulder arthroplasty — for irreparable massive tears with pseudoparalysis
Complications
Progression from tendinopathy to partial then full-thickness tear
Tear extension and retraction over time
Rotator cuff arthropathy — chronic massive tear leads to glenohumeral arthritis with superior migration
Adhesive capsulitis after prolonged immobilization
Postoperative re-tear (especially with large tears or poor tissue quality)
PANCE pearls
Passive range of motion is preserved in rotator cuff disease; loss of passive ROM should redirect you to adhesive capsulitis or arthritis.
Asymptomatic rotator cuff tears are common over age 60 — imaging findings should be correlated with exam.
Acute traumatic full-thickness tears in younger patients deserve earlier surgical consideration than degenerative tears.
Steroid injections may help symptoms but can weaken tendon — limit frequency.
Drop-arm test highly specific for full-thickness supraspinatus tear.
References
AAOS 2025 — American Academy of Orthopaedic Surgeons. Management of Rotator Cuff Injuries Evidence-Based Clinical Practice Guideline (updated August 2025).
MOON Shoulder Group 2013 — Kuhn JE, Dunn WR, Sanders R, et al; MOON Shoulder Group. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371-1379.
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