Rotator Cuff Tear

Upper Limb

Overview

A rotator cuff tear involves partial or complete disruption of one or more of the four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize the glenohumeral joint. Tears can be acute from trauma or chronic from degenerative changes, leading to pain, weakness, and functional limitation of the shoulder. The severity ranges from partial thickness tears to complete rotator cuff tears affecting overhead activities and quality of life.

Pathophysiology

The rotator cuff muscles maintain dynamic stability of the glenohumeral joint against the larger deltoid muscle. Tears disrupt this stabilizing mechanism, allowing abnormal joint mechanics, altered scapulohumeral rhythm, and compensatory overload of remaining structures. This leads to inflammation, secondary impingement, muscle atrophy, and progressive degenerative changes if left untreated. Chronic tears may involve tendon retraction and fatty infiltration of muscle.

Patient Education

Understanding that rotator cuff tears require early intervention to prevent progression; controlled movement within pain-free ranges during healing, combined with progressive strengthening, offers the best outcomes for both conservative and post-surgical management.

Typical Presentation

Site

Anterolateral shoulder, often radiating to lateral upper arm; pain may localize to specific rotator cuff muscles depending on which tendon is affected

Quality

Sharp or aching pain with movement; may feel like clicking, catching, or instability; burning sensation in some cases

Intensity

Mild to severe (6-9/10), often worse with night pain and sleeping on affected side; intensity often increases with overhead activities

Aggravating

Overhead reaching, lifting, throwing, sleeping on affected shoulder, internal rotation, forced external rotation, repetitive shoulder activities

Relieving

Rest, ice, anti-inflammatory medications, immobilization, gentle passive motion, downward pressure on shoulder, abduction to 90 degrees with support

Associated

Weakness with specific movements (positive drop arm test), loss of active range of motion, scapular dyskinesis, shoulder impingement signs, possible audible clicking or clunking

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Supraspinatus Test (Empty Can/Jobe's Test)

Procedure

Patient standing. Arms elevated to 90° in the scapular plane, elbows straight, thumbs pointing down. Apply a downward force at the forearms while the patient resists; compare sides.

Positive Finding

Weakness compared with the other side, or pain.

Sensitivity / Specificity

74%/77%

Reference: Gismervik SØ et al., BMC Musculoskelet Disord 2017; PMID 28122541

Interpretation

Weakness points towards a supraspinatus tear; pain alone is common with tendinopathy. Combine it with the lag signs, drop arm test, age and mechanism of injury. The empty-can (supraspinatus) test pools at 74% sensitivity / 77% specificity for any full-thickness rotator cuff tear (Gismervik 2017 meta-analysis, highest single-test DOR 9.24).

Sources

No accuracy study

Drop Arm Test

Procedure

Patient standing. Passively raise the arm out to the side to about 90–120°, then ask the patient to lower it slowly.

Positive Finding

The arm drops suddenly, or the patient cannot lower it smoothly, usually around 90°.

Interpretation

A positive test suggests a large full-thickness cuff tear. It is usually negative with smaller tears, so a negative test does not rule out a tear. A positive test after an injury warrants prompt imaging and orthopaedic referral. A 2013 JAMA review of the examination for rotator cuff disease (Hermans et al.) found that a positive drop arm test might help identify rotator cuff disease (likelihood ratio 3.3, with a wide confidence interval of 1.0–11). No single sensitivity and specificity pair is shown.

Sources

  • RelatedHermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SM. Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. JAMA. 2013;310(8):837-47.

Further reading

No accuracy study

Infraspinatus Strength Test (Resisted External Rotation)

Procedure

Patient seated, arm at the side, elbow bent to 90°. Ask the patient to push outwards against your hand; compare sides.

Positive Finding

Weakness on resisted external rotation compared with the other side.

Interpretation

Weakness suggests posterior cuff involvement or a larger tear. The crank test is a separate test for labral problems; the name has been corrected. Park (2005) reported the infraspinatus strength test as highly specific (~90%) for rotator cuff disease; sensitivity is lower and a single confirmed pair is not shown.

Sources

No accuracy study

Lift-Off Test (Gerber's Test)

Procedure

Patient standing. Place the back of the hand on the lower back, then ask the patient to lift the hand away from the back. If they can, add gentle resistance.

Positive Finding

Unable to lift the hand off the back, or clear weakness compared with the other side.

Interpretation

Suggests a subscapularis tear. Smaller tears of the upper part of subscapularis are often missed by this test. If the patient cannot reach behind the back, use the belly-press test. Original description Gerber & Krushell 1991 (JBJS Br — the previously cited "Gerber 1992" year was incorrect); no clean diagnostic-accuracy pair.

Sources

No accuracy study

Painful Arc Test

Procedure

Ask the patient to raise the arm slowly out to the side as far as possible and lower it again. Note where pain appears and disappears.

Positive Finding

Pain in the middle of the range (roughly 60–120° of elevation) that eases above and below it.

Interpretation

Fits a subacromial source but does not separate a tear from tendinopathy or bursitis. Weakness and lag signs are more informative for a tear. A 2013 JAMA review of the examination for rotator cuff disease (Hermans et al.; 28 studies, all in patients seen by specialists) found the painful arc the most useful pain-provocation test: a positive arc made rotator cuff disease more likely (likelihood ratio 3.7) and a normal arc made it less likely (0.36). The review reports likelihood ratios rather than one sensitivity and specificity pair, so no figure is shown.

Sources

No accuracy study

Belly-Press Test and Hornblower's Sign

Procedure

Belly-press: the patient presses the palm into the abdomen with the wrist straight, keeping the elbow forward. Hornblower's: support the arm at 90° of abduction in the scapular plane with the elbow bent to 90°, and ask the patient to rotate the forearm upwards (external rotation) against gravity.

Positive Finding

Belly-press: the elbow drops back behind the body or the wrist flexes to press. Hornblower's: the patient cannot externally rotate and the forearm falls.

Interpretation

A positive belly-press suggests a subscapularis tear. A positive hornblower's sign suggests teres minor loss, which occurs with large posterior cuff tears. Either finding warrants imaging and referral. Hertel (1996, J Shoulder Elbow Surg — not JBJS) described the external rotation lag sign as highly specific for rotator cuff rupture; no single confirmed sensitivity/specificity pair is shown.

Sources

⚠ Red Flags

  • •Acute severe trauma with complete loss of function suggesting acute complete tear
  • •Progressive neurological deficit or upper limb nerve compression signs
  • •Signs of septic arthritis (fever, warmth, erythema, severe swelling)
  • •Shoulder dislocation or significant fracture on imaging
  • •Severe night pain unresponsive to conservative treatment for >6 weeks
  • •Symptoms of cervical myelopathy or brachial plexus injury

⚡ Yellow Flags

  • •Workers' compensation or litigation involvement affecting rehabilitation motivation
  • •Fear-avoidance beliefs limiting active participation in therapy
  • •Catastrophizing about shoulder function and prognosis
  • •High anxiety or depression affecting pain perception and recovery
  • •Inconsistent symptom presentation or non-mechanical pain pattern
  • •Poor sleep quality secondary to pain affecting tissue healing
  • •Unrealistic expectations about timeline for return to overhead activities

Osteopathic Techniques

Exercise is the main treatment: surgery may give little or no extra benefit over exercise for pain and function, with low-certainty evidence. No trials of manual therapy for tears specifically were found.

Region

Glenohumeral joint (Spencer sequence)

Technique

Articulation, shoulder (Spencer technique)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials in rotator cuff tears. In rotator cuff disease overall, the best placebo-controlled trial of manual therapy plus exercise found no clinically important difference.

Rationale

Gentle mobilisation alongside a cuff exercise program. Untested in tears.

How it's done, cautions & evidence

How it's done

Patient side-lying, affected shoulder up. Stabilise the shoulder girdle with one hand and support the arm at the forearm and wrist with the other. Work through seven stages: extension, flexion, circumduction with compression, circumduction with traction, abduction (then adduction with external rotation), internal rotation, and traction in abduction. At each barrier use slow rhythmic oscillations, then a gentle isometric contraction to reach the new barrier.

Cautions

Its isometric step is a muscle energy technique, so do not use it with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in Rotator Cuff Tear

Searched 24 Oct 2026: no trials of shoulder articulation in rotator cuff tears. A 2016 Cochrane review of rotator cuff disease found the one high-quality trial of manual therapy plus exercise versus placebo showed no clinically important difference.

Region

Rotator cuff, deltoid and periscapular muscles

Technique

Soft tissue, shoulder and periscapular muscles
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials in rotator cuff tears. In non-specific shoulder pain, massage helped short-term but added nothing to exercise.

Rationale

Eases tension around the shoulder; short-term help at best. Untested in tears.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the muscles around the shoulder: the rotator cuff, deltoid and the muscles around the shoulder blade. In trials it was given alongside shoulder exercise.

Evidence in Rotator Cuff Tear

Searched 24 Oct 2026: no trials of soft tissue technique in rotator cuff tears. In non-specific shoulder pain, a 2014 meta-analysis found low-quality evidence of short-term benefit versus no treatment, and a 2015 trial found adding massage to exercise gave no extra benefit.

Region

Upper and mid thoracic spine

Technique

Muscle energy, thoracic
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials in rotator cuff tears. Thoracic MET beat placebo in shoulder impingement in one trial.

Rationale

Low-force, patient-powered upper-back technique. Helped in impingement; untested in tears.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Rotator Cuff Tear

Searched 24 Oct 2026: no trials of thoracic MET in rotator cuff tears. A 2022 placebo-controlled trial of 75 patients with shoulder impingement found thoracic MET improved pain and disability up to 12 months.

Region

Periscapular and upper thoracic muscles

Technique

Soft tissue, thoracic and rib cageNo trials found

Rationale

Eases tension in the shoulder blade muscles. No trials in rotator cuff tears.

How it's done & evidence

How it's done

Hands-on soft-tissue work (kneading, stretching and sustained pressure) to the thoracic paraspinals, rhomboids, middle trapezius and the muscles along the rib angles, usually prone or side-lying.

Evidence in Rotator Cuff Tear

Searched 24 Oct 2026: no trials of periscapular soft tissue technique in rotator cuff tears.

Sources

Region

Pectoralis minor and anterior shoulder

Technique

Soft tissue, pectoralis minorNo trials found

Rationale

Eases tightness at the front of the shoulder. No trials in rotator cuff tears.

How it's done, cautions & evidence

How it's done

Stretch and sustained pressure to pectoralis minor (ribs 3–5 to the coracoid). A manual stretch can be given supine or sitting; in one study the supine stretch lengthened the muscle more than the sitting one, and a self-stretch most of all. Ischaemic compression of tender trigger points can come first, and a doorway self-stretch (15–20 second holds) suits home care.

Cautions

Conservative care is for pectoralis minor syndrome without arterial or venous thrombosis: rule those out first.

Evidence in Rotator Cuff Tear

Searched 27 Oct 2026: no trials of pectoralis minor soft tissue technique in rotator cuff tears.

Rehabilitation Exercises

Pendulum Circles (Codman's Exercise)

Range of MotionBeginner

Passive Range of Motion with Pulley System

Range of MotionBeginner

Sleeper Stretch (Internal Rotation)

StretchingBeginner

Posterior Shoulder Stretch (Cross-Body Adduction)

StretchingBeginner

External Rotation with Resistance Band (Neutral Position)

StrengtheningIntermediate

Internal Rotation with Resistance Band

StrengtheningIntermediate

Prone Horizontal Abduction (T-Y-I Series)

StrengtheningIntermediate

Quadruped Rhythmic Stabilization

StrengtheningIntermediate

Scapular Retraction and Depression (Prone or Standing)

PosturalBeginner

Proprioceptive Training on Unstable Surface (Push-up Position)

BalanceAdvanced

Side-Lying External Rotation

StrengtheningIntermediate

Prone External Rotation (90/90 Position - Thrower's Position)

StrengtheningAdvanced

Referral Criteria

  • •Acute complete rotator cuff tear with inability to achieve active range of motion despite 4-6 weeks of conservative treatment
  • •Persistent functional limitation affecting work or activities of daily living unresponsive to 8-12 weeks of conservative management
  • •Positive imaging findings (ultrasound or MRI) confirming rotator cuff tear with progressive symptoms or functional decline
  • •Suspicion of superior labral pathology (SLAP lesion) or associated labral tear
  • •Failure to progress despite appropriate osteopathic and physiotherapy intervention; consider orthopedic surgical consultation
  • •Development of secondary impingement syndrome or frozen shoulder despite appropriate management
  • •Neurological deficits suggesting nerve involvement beyond mechanical shoulder dysfunction
  • •Patient desire for surgical intervention for definitive repair, particularly in high-demand or younger patients