**Diagnosis (Clinical Examination)**

*Strong evidence supports that clinical examination can be useful to diagnose or stratify patients with rotator cuff tears; however, combination of tests will increase diagnostic accuracy.*

Management of Rotator Cuff Injuries

Endorsed by: AANA, ASES, AOSSM, ASSET, APTA

Rationale

Evidence from 8 high quality studies (Liu 2016, Lin 2015, Castoldi 2009, Park 2005, Litaker 2000, Villafane 2015, Holtby 2004, Gillooly 2010) indicate that the following tests are useful to diagnosis full-thickness rotator cuff tear: bear hug test, belly press test, empty can test, external rotator lag sign, external rotation resistance test, full can test, Hawkins test, Hug up test, internal rotation lag sign (IRLS) test, internal rotation resistance test (IRRT) test, Internal rotation resistance test at maximal 90 degrees of abduction and maximal external rotation (IRRTM) test, Jobe Test, Lateral Jobe Test, Lift off test, NEER test, Patte Test, and Yocum test. Generally, these tests are better to diagnose (rule in), than screening (rule out) full thickness rotator cuff tears.

Bear hug test summary

Combined full/partial thickness tears:

One high quality study evaluated the bear hug test to diagnose any rotator cuff tear (Lin 2015). The test results produce a small but sometimes important change in probability of rotator cuff tears (positive LR=3.49, negative LR=0.37).

Belly press test summary

Combined full/partial thickness tears:

One high quality study evaluated the belly press test to diagnose any rotator cuff tear (Lin 2015). The test results produce a small, but sometimes important change in the probability of a tear (positive LR=3.18, negative LR=0.45).

Empty can test summary

Combined full/partial thickness tears:

One high quality study evaluated the empty can test for diagnosing any rotator cuff tear (Liu 2016). The test results produce a small, but sometimes important change in the probability of a tear (positive LR=3.30, negative LR=0.21).

External rotator lag sign summary

Partial Thickness Tears:

One high quality study evaluated the external rotator lag sign test to diagnose partial thickness tears(Castoldi 2009). A positive test resulted in a moderate sized increase in probability of a partial thickness tear (positive likelihood ratio(LR)= 6.44). However, the test was poor for ruling out partial thickness tears, with a negative test producing a very small decrease in probability of a partial thickness tear(negative LR=0.89).

External Rotation Resistance Test (Resisted ER).

One high quality (Park 2005) and one low quality (Litaker 2000) evaluated External Rotation Resistance Test.

Full thickness tear:

Park found that resisted ER maybe useful for ruling in full thickness tears (positive LR=3.16), but was poor at ruling them out (negative LR=0.59).

Partial Thickness Tear:

Park found resisted ER to be poor at ruling in and ruling out partial tears (positive LR=0.63 negative LR=1.17).

Combined partial and full thickness:

Litaker found resisted ER to be a poor rule-in test(positive LR=1.78) in diagnosing combined full/partial thickness tears, but may be somewhat useful for ruling out tears Negative LR=0.42).

Full Can Test summary

Combined full/partial thickness tears:

One high quality study evaluated the full can test to diagnose any rotator cuff tear (Liu 2016). The test results produce a small, but sometimes important change in the probability of a tear (positive LR=4.10, negative LR=0.27).

Hawkins Test summary

Two high quality studies and one low quality study evaluated the Hawkins test (Liu 2016,Villafane 2015, Park 2005).

Combined full/partial thickness tears:

Liu used the test to diagnose any rotator cuff tear, and found a positive test produced a small, but sometimes important increase in probability of a tear with a positive test (positive LR=2.82). However, the same study found it was a poor test for ruling out a tear (negative LR=0.73).

Full Thickness Tears:

A moderate quality study by Park(2005) found the Hawkins test to be poor at ruling in and ruling out full thickness tears (Positive LR=1.33, negative LR=0.65).

Partial Thickness Tears:

The Villafane (2015) study used the test to diagnose partial tears.. A positive test produced a large and conclusive increase in probability of a partial tear (positive LR=10.25), and a negative test produced a moderate decrease in probability of a partial tear(negative LR=0.20). However, a moderate quality study by Park (2005) found the test to be poor at both ruling in and ruling out a partial tear (positive LR=1.36, negative LR=0.55).

Hug up test summary

Combined full/partial thickness tears:

One high quality study evaluated the hug up test for diagnosis of any rotator cuff tear (Liu 2016). A positive test produced a small, but sometimes important increase in probability of a tear (positive LR=4.02), and a negative test produced a large decrease in probability of a tear (negative LR=0.08).

Internal Rotation Lag Sign (IRLS) test summary

Combined full/partial thickness tears:

One high quality study evaluated the IRLS test to diagnose any rotator cuff tear(Lin 2015). A positive test produced a small, but sometimes important increase in probability of a tear(positive LR=4.21). The test was poor for ruling out a tear, with a negative test producing a very small decrease in probability of a tear(negative LR=0.74).

Internal rotation resistance test (IRRT) test summary

Combined full/partial thickness tears:

One high quality study (Lin 2015) evaluated the IRRT test to diagnose any rotator cuff tear. A positive test produced a small, but sometimes important increase in probability of a tear (Positive LR=2.59). However, it was a poor rule out test (negative LR=0.51).

Internal rotation resistance test at maximal 90 degrees of abduction and maximal external rotation (IRRTM) test summary

Combined full/partial thickness tears:

One high quality study evaluated the IRRTM test to diagnose any rotator cuff tear (Lin 2015). Both positive and negative test results produced a small, but sometimes important change in probability of any rotator cuff tear (positive LR=3.91, negative LR=0.29).

Jobe Test summary

Two high quality studies evaluated the Jobe test (Holtby 2004,Villafane 2015) for FTT and PTT tears.

Full-Thickness Tears : Holtby(2004) was the only study to specifically evaluate full thickness tears. The study found the test results produced a very low change in probability of a full-thickness tear(positive LR=1.36, negative LR=0.84).

Partial-Thickness Tears: Two studies evaluated the Jobe test for diagnosing a partial tear (Holtby 2004,Villafane 2015). The results were varied between the two studies. The rule in test strength ranged from poor (positive LR=1.34, Holtby 2004) to moderately strong (positive LR=9.50, Villafane 2015). The Villafane study found that a negative test produced a small, but sometimes important decrease in probability of a partial tear(negative LR=0.26). However, the Holtby study found the test to be poor at ruling out a partial tear (negative LR=0.71).

Lateral Jobe Test Summary

Combined full/partial thickness tears:

Gillooly(2010) found the Lateral Jobe test to be moderately good at ruling in any tear (positive LR=7.43), and a negative test produced a small but sometimes important decrease in probability of a tear(negative LR=0.21). The same study evaluated the Lateral Jobe test when combined with other physical exams, and found the test results produced a small but sometimes important change in probability of a tear(positive LR=4.69, negative LR= 0.48).

Lift off test summary

Combined full/partial thickness tears:

Lin(2015, high quality) evaluated the lift off test for diagnosing any rotator cuff tear. The test was poor at ruling in and ruling out a tear (positive LR=1.92, negative LR=0.58).

NEER test summary

Three high quality studies and one moderate quality study evaluated the Neer test (Liu 2016,Villafane 2015, Park 2005). Liu tested for any rotator cuff tear, Villafane tested for partial tears, and Park stratified by tear size.

Combined full/partial thickness tears:

Liu found the test to be moderately strong at ruling in any tear (positive LR=5.90), and may be useful for ruling out any tear (negative LR=0.42).

Full Thickness Tear:

Park evaluated the tests ability to diagnose full thickness tears. The study found the test was poor at both ruling in and ruling out full tears (positive LR=1.12, negative LR=0.86).

Partial Thickness Tears:

The Villafane and Park studies evaluated the neer test for diagnosing partial tears. As a rule in test, the results were inconsistent between studies. Villafane found the test to be moderately strong at ruling in partial tears (positive LR=7.00), but Park found it to be poor at ruling in a tear (positive LR=1.44). Both studies showed the test to be poor at ruling out partial tears (negative LR range=0.52-0.75).

Patte Test summary

Partial Thickness Tears:

One high quality study evaluated the Patte test to diagnose a partial tear (Villafane 2015). A positive test result produced a large and conclusive increase in probability of a partial tear(positive LR=19.0). However, it was a poor rule out test (negative LR=0.63).

Yocum test summary

Partial Thickness Tears:

One high quality study evaluated the Yocum test for partial tears (Villafane 2015). A positive test result produced a large and conclusive increase in probability of a partial tear (positive LR=19.5). A negative test produced a small, but sometimes important decrease in probability of a partial tear (negative lr=0.23).

There is no known harm to patients by implementing this recommendation, but there could potentially be a slightly higher reoperation rate on patients who did not undergo the concomitant procedures.

Future research could be performed to elucidate risk factors for reoperation rates in certain groups who did not undergo concomitant procedures.

Bear hug test summary

Combined full/partial thickness tears:

One high quality study evaluated the bear hug test to diagnose any rotator cuff tear (Lin 2015). The test results produce a small but sometimes important change in probability of rotator cuff tears (positive LR=3.49, negative LR=0.37).

Belly press test summary

Combined full/partial thickness tears:

One high quality study evaluated the belly press test to diagnose any rotator cuff tear (Lin 2015). The test results produce a small, but sometimes important change in the probability of a tear (positive LR=3.18, negative LR=0.45).

Empty can test summary

Combined full/partial thickness tears:

One high quality study evaluated the empty can test for diagnosing any rotator cuff tear (Liu 2016). The test results produce a small, but sometimes important change in the probability of a tear (positive LR=3.30, negative LR=0.21).

External rotator lag sign summary

Partial Thickness Tears:

One high quality study evaluated the external rotator lag sign test to diagnose partial thickness tears(Castoldi 2009). A positive test resulted in a moderate sized increase in probability of a partial thickness tear (positive likelihood ratio(LR)= 6.44). However, the test was poor for ruling out partial thickness tears, with a negative test producing a very small decrease in probability of a partial thickness tear(negative LR=0.89).

External Rotation Resistance Test (Resisted ER).

One high quality (Park 2005) and one low quality (Litaker 2000) evaluated External Rotation Resistance Test.

Full thickness tear:

Park found that resisted ER maybe useful for ruling in full thickness tears (positive LR=3.16), but was poor at ruling them out (negative LR=0.59).

Partial Thickness Tear:

Park found resisted ER to be poor at ruling in and ruling out partial tears (positive LR=0.63 negative LR=1.17).

Combined partial and full thickness:

Litaker found resisted ER to be a poor rule-in test(positive LR=1.78) in diagnosing combined full/partial thickness tears, but may be somewhat useful for ruling out tears Negative LR=0.42).

Full Can Test summary

Combined full/partial thickness tears:

One high quality study evaluated the full can test to diagnose any rotator cuff tear (Liu 2016). The test results produce a small, but sometimes important change in the probability of a tear (positive LR=4.10, negative LR=0.27).

Hawkins Test summary

Two high quality studies and one low quality study evaluated the Hawkins test (Liu 2016,Villafane 2015, Park 2005).

Combined full/partial thickness tears:

Liu used the test to diagnose any rotator cuff tear, and found a positive test produced a small, but sometimes important increase in probability of a tear with a positive test (positive LR=2.82). However, the same study found it was a poor test for ruling out a tear (negative LR=0.73).

Full Thickness Tears:

A moderate quality study by Park(2005) found the Hawkins test to be poor at ruling in and ruling out full thickness tears (Positive LR=1.33, negative LR=0.65).

Partial Thickness Tears:

The Villafane (2015) study used the test to diagnose partial tears.. A positive test produced a large and conclusive increase in probability of a partial tear (positive LR=10.25), and a negative test produced a moderate decrease in probability of a partial tear(negative LR=0.20). However, a moderate quality study by Park (2005) found the test to be poor at both ruling in and ruling out a partial tear (positive LR=1.36, negative LR=0.55).

Hug up test summary

Combined full/partial thickness tears:

One high quality study evaluated the hug up test for diagnosis of any rotator cuff tear (Liu 2016). A positive test produced a small, but sometimes important increase in probability of a tear (positive LR=4.02), and a negative test produced a large decrease in probability of a tear (negative LR=0.08).

Internal Rotation Lag Sign (IRLS) test summary

Combined full/partial thickness tears:

One high quality study evaluated the IRLS test to diagnose any rotator cuff tear(Lin 2015). A positive test produced a small, but sometimes important increase in probability of a tear(positive LR=4.21). The test was poor for ruling out a tear, with a negative test producing a very small decrease in probability of a tear(negative LR=0.74).

Internal rotation resistance test (IRRT) test summary

Combined full/partial thickness tears:

One high quality study (Lin 2015) evaluated the IRRT test to diagnose any rotator cuff tear. A positive test produced a small, but sometimes important increase in probability of a tear (Positive LR=2.59). However, it was a poor rule out test (negative LR=0.51).

Internal rotation resistance test at maximal 90 degrees of abduction and maximal external rotation (IRRTM) test summary

Combined full/partial thickness tears:

One high quality study evaluated the IRRTM test to diagnose any rotator cuff tear (Lin 2015). Both positive and negative test results produced a small, but sometimes important change in probability of any rotator cuff tear (positive LR=3.91, negative LR=0.29).

Jobe Test summary

Two high quality studies evaluated the Jobe test (Holtby 2004,Villafane 2015) for FTT and PTT tears.

Full-Thickness Tears : Holtby(2004) was the only study to specifically evaluate full thickness tears. The study found the test results produced a very low change in probability of a full-thickness tear(positive LR=1.36, negative LR=0.84).

Partial-Thickness Tears: Two studies evaluated the Jobe test for diagnosing a partial tear (Holtby 2004,Villafane 2015). The results were varied between the two studies. The rule in test strength ranged from poor (positive LR=1.34, Holtby 2004) to moderately strong (positive LR=9.50, Villafane 2015). The Villafane study found that a negative test produced a small, but sometimes important decrease in probability of a partial tear(negative LR=0.26). However, the Holtby study found the test to be poor at ruling out a partial tear (negative LR=0.71).

Lateral Jobe Test Summary

Combined full/partial thickness tears:

Gillooly(2010) found the Lateral Jobe test to be moderately good at ruling in any tear (positive LR=7.43), and a negative test produced a small but sometimes important decrease in probability of a tear(negative LR=0.21). The same study evaluated the Lateral Jobe test when combined with other physical exams, and found the test results produced a small but sometimes important change in probability of a tear(positive LR=4.69, negative LR= 0.48).

Lift off test summary

Combined full/partial thickness tears:

Lin(2015, high quality) evaluated the lift off test for diagnosing any rotator cuff tear. The test was poor at ruling in and ruling out a tear (positive LR=1.92, negative LR=0.58).

NEER test summary

Three high quality studies and one moderate quality study evaluated the Neer test (Liu 2016,Villafane 2015, Park 2005). Liu tested for any rotator cuff tear, Villafane tested for partial tears, and Park stratified by tear size.

Combined full/partial thickness tears:

Liu found the test to be moderately strong at ruling in any tear (positive LR=5.90), and may be useful for ruling out any tear (negative LR=0.42).

Full Thickness Tear:

Park evaluated the tests ability to diagnose full thickness tears. The study found the test was poor at both ruling in and ruling out full tears (positive LR=1.12, negative LR=0.86).

Partial Thickness Tears:

The Villafane and Park studies evaluated the neer test for diagnosing partial tears. As a rule in test, the results were inconsistent between studies. Villafane found the test to be moderately strong at ruling in partial tears (positive LR=7.00), but Park found it to be poor at ruling in a tear (positive LR=1.44). Both studies showed the test to be poor at ruling out partial tears (negative LR range=0.52-0.75).

Patte Test summary

Partial Thickness Tears:

One high quality study evaluated the Patte test to diagnose a partial tear (Villafane 2015). A positive test result produced a large and conclusive increase in probability of a partial tear(positive LR=19.0). However, it was a poor rule out test (negative LR=0.63).

Yocum test summary

Partial Thickness Tears:

One high quality study evaluated the Yocum test for partial tears (Villafane 2015). A positive test result produced a large and conclusive increase in probability of a partial tear (positive LR=19.5). A negative test produced a small, but sometimes important decrease in probability of a partial tear (negative lr=0.23).

**Risks and Harms of Implementing this Recommendation**There is no known harm to patients by implementing this recommendation, but there could potentially be a slightly higher reoperation rate on patients who did not undergo the concomitant procedures.

**Future Research**Future research could be performed to elucidate risk factors for reoperation rates in certain groups who did not undergo concomitant procedures.

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- Holtby, R., Razmjou, H. Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. Journal of Orthopaedic & Sports Physical Therapy 2004; 4: 194-200
- Lin, L., Yan, H., Xiao, J., Ao, Y., Cui, G. Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions. Knee Surgery, Sports Traumatology, Arthroscopy 2015; 4: 1247-52
- Litaker, D., Pioro, M., El Bilbeisi, H., Brems, J. Returning to the bedside: using the history and physical examination to identify rotator cuff tears. Journal of the American Geriatrics Society 2000; 12: 1633-7
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- Park, H. B., Yokota, A., Gill, H. S., El Rassi, G., McFarland, E. G. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. Journal of Bone & Joint Surgery - American Volume 2005; 7: 1446-55
- Villafane, J. H., Valdes, K., Anselmi, F., Pirali, C., Negrini, S. The diagnostic accuracy of five tests for diagnosing partial-thickness tears of the supraspinatus tendon: A cohort study. Journal of Hand Therapy 2015; 3: 247-51; quiz 252