Rotator Cuff Injury

Rotator Cuff Impingement

Pt presents with shoulder pain worse with overhead activity. Exam reveals subacromial tenderness, restricted ROM, pain with abduction/external rotation. Positive Neer, Hawkins test.

  • Obtain shoulder x-ray; consider MRI

  • Start Tylenol/NSAIDs for pain and refer to PT; refer to orthopedics if no improvement in 6-12 weeks

  • Consider corticosteroid injection for temporary relief

  • Severe pain and significant weakness on exam: Refer to orthopedics

  • Pt advised to avoid overhead activity

Rotator Cuff Tear

Pt age > 40 y/o with h/o shoulder trauma presents with diffuse shoulder pain. Pain present at night and worse with overhead activity. Exam reveals muscle atrophy and pain with empty can test, Neer test, and Hawkins-Kennedy tests. Weakness noted with external rotation, internal rotation, and Gerber lift-off test.

  • Diagnosis per physical exam

    • Positive empty can, Hawkins-Kennedy test: Supraspinatus injury

    • Positive Neer test: Subacromial impingement syndrome

    • External rotation weakness: Infraspinatus vs. teres minor injury

    • Internal rotation weakness and positive lift-off test: Subscapularis tear

  • X-ray shows superior humeral head migration/sclerosis, loss of acromial-humeral interval

  • Imaging

    • Consider MRI

    • Consider U/S vs. CT arthrography if MRI contraindicated

  • Start Tylenol/NSAIDs for pain and refer to physical therapy

  • Refer refer to orthopedics if

    • No improvement after 6-12 weeks of physical therapy

    • Severe pain and significant weakness on initial exam

  • Pt advised to avoid overhead activity

 

Note: If the initial exam is concerning enough to warrant MRI, the patient should be referred to orthopedics where an MRI will likely be performed. (In other words, MRIs are rarely ordered by primary care physicians in areas with reasonable access to specialists.)