While its clinical features were described more than a century ago, the term “cuff tear arthropathy” was first used by Dr. Charles Neer in 1977.^1,2 Cuff tear arthropathy consists of a triad of full thickness rotator cuff tearing with muscle atrophy, degenerative damage to the glenohumeral joint, and superior migration of the humeral head.^2-4 Additional features that may be seen include the concave erosion of the undersurface of the acromion, also known as acromion acetabularization.¹

In terms of demographics, females are disproportionately affected by cuff tear arthropathy, especially those in their seventh decade of life.⁵ In addition, cuff tear arthropathy more commonly affects the patient’s dominant shoulder. The development of a massive rotator cuff tear that goes untreated leads to a progression toward cuff tear arthropathy,⁶ via altered joint kinematics and abnormal joint reactive forces. Additionally, although rotator cuff disease is generally multifactorial in origin, multiple studies have pointed to a genetic component in the disease process.^7-9

Pathophysiology

Mechanical and nutritional factors lead to the development of cuff tear arthropathy.^1,2 The mechanical factors include decentering of the humeral head, loss of concavity compression, and altered joint kinematics due to massive cuff tearing, which leads to superior migration of the humeral head up to the acromion. Instability from the loss of the dynamic shoulder stabilizers due to the torn rotator cuff musculature leads to accelerated cartilage wear and thus joint space narrowing. Additionally, massive tears of the rotator cuff allow joint fluid to escape the glenohumeral articulation. This disruption of the normal balance of the synovial joint fluid also contributes to cartilage degeneration as well as a decline in bone health.^1,2

History

A thorough evaluation of cuff tear arthropathy begins with a history of the present illness. Patients with this condition will most often present with pain, which often occurs at night, as their predominant symptom. They will also report weakness as well as limited motion of the affected shoulder. Overhead movements and range of motion of the shoulder will be particularly difficult. The provider should also inquire about the onset of pain, prior procedures, and functional deficits of the affected shoulder. Notably, the course of the disease is typically progressive, with symptoms worsening over a span of several years.² Neer et al. noted that patients presenting with cuff tear arthropathy had pain for an average of 9.8 years.² Although there is frequently no inciting event, it is still important to inquire about one, as this may result in a rapid deterioration of symptoms.⁶ Lastly, a patient may note the presence of a joint effusion in the shoulder.¹⁰

Physical Examination

With regard to the physical exam, the examiner should begin with inspection of the shoulder joint. There are several classic signs present in this condition, including atrophy and pseudoparalysis. There may be anterosuperior escape of the humeral head from the glenoid, which becomes especially prominent during arm elevation (video 7.1).⁶

Another observation made on physical examination is the presence of shoulder swelling and a benign-appearing effusion, which is a sign of joint fluid in the subacromial bursa. A painless effusion can often be palpated on physical exam, and aspiration of this effusion typically yields light straw-colored fluid.⁶ Lastly, atrophy may be present in the supraspinatus and infraspinatus fossa.

Next, the examiner can investigate active and passive range of motion of the shoulder. Specifically, the examiner should observe range of motion with respect to forward elevation, abduction, external rotation, and internal rotation. Notably, both active and passive range of motion demonstrate significant deficits in the presence of cuff tear arthropathy, and there may be crepitus, or crackling, on range of motion of the shoulder.¹⁰ In some cases, patients may display pseudoparalysis of the affected shoulder, which is most commonly defined as active forward elevation of less than 90 degrees due to a massive cuff tear.¹¹

In addition to inspection, palpation, and range of motion, strength testing for the rotator cuff muscles, including the supraspinatus, infraspinatus, subscapularis, and teres minor, should be performed, as previously discussed. It is also important to assess the integrity of the axillary nerve and the deltoid muscle, as reverse total shoulder arthroplasty, a common surgical treatment option for cuff tear arthropathy, requires both to be functioning. Notably, the axillary nerve supplies sensation to the inferior two thirds of the skin over the deltoid musculature, so deficits would manifest as sensory deficits in this region.¹² In addition, it controls motor function to both the deltoid muscle and the teres minor muscle. Deficits of the deltoid would manifest as inability to abduct the shoulder from 15 to 90 degrees, and deficits of the teres minor would manifest with a positive Hornblower’s sign.

Special Tests

Further, there are also special tests that can be performed to investigate shoulder function in patients with cuff tear arthropathy. These include the drop arm test, external rotation lag sign, internal rotation lag sign, bear-hug test, and Hornblower’s sign. The drop arm test evaluates the integrity of the supraspinatus tendon.^13,14 The examiner passively abducts the patient’s shoulder to 90 degrees and asks the patient to maintain the position. An inability to hold this position, resulting in the sudden dropping of the arm, indicates a positive test and suggests tearing of the supraspinatus. This is demonstrated in video 7.3.

The external rotation lag sign is another physical examination maneuver performed to assess rotator cuff pathology, specifically to test the infraspinatus (video 7.4; figure 7.1).^15,16 Initially, the patient’s shoulder is fully adducted, and the elbow is placed at 90 degrees of flexion. The examiner places the shoulder in maximal external rotation, and the patient is asked to hold this position. An inability to hold this position indicates weakness of the infraspinatus (video 7.5).

To assess the integrity of the subscapularis muscle, the internal rotation lag sign can be performed. In this maneuver the examiner has the patient maintain internal rotation of the affected shoulder behind the patient’s back, with the dorsum of the hand facing the patient’s back and the shoulder in approximately 20 degrees of extension (video 7.6; figure 7.2). The patient’s shoulder is passively placed in maximal internal rotation by the examiner with the patient’s hand several centimeters posterior to the lumbar spine, and the patient is asked to maintain this position away from the body. A positive test result is indicated by failure to actively maintain this position and indicates a deficit of the subscapularis (video 7.7).

Another test to investigate the integrity of the subscapularis is the belly press test, which can be performed by instructing the patient to maintain their elbows in 90 degrees of flexion with the palms pressed against the abdomen (video 7.7). The examiner applies a posteriorly directed force against the patient’s elbows while the patient is asked to resist the posteriorly directed force by internally rotating the affected shoulder to effectively press the palm into their abdomen. The test is considered positive if the patient cannot fully bring the elbows forward by internally rotating at the shoulders and if the wrist remains in flexion while pressing the palms against the belly. A positive test indicates a subscapularis tear.

The lift off test can also assess for subscapularis deficits, by having the patient place the dorsum of the hand along their back with the elbow held in about 90 degrees of flexion (video 7.8). The test is considered positive if the patient is unable to lift the hand off the back. This test may be challenging to perform in cases of advanced arthropathy, where the patient will have limited motion of the shoulder.

The last provocative maneuver for subscapularis function discussed is the bear hug test. The hand of the affected shoulder is placed on the contralateral shoulder with the fingers extended and the elbow at 90 degrees. The patient is instructed to hold this position while the examiner applies an external rotation force to the patient’s forearm. A test is positive when the patient cannot maintain this position, or if they display weakness compared to the opposite, unaffected, shoulder. Barth et al. determined that a positive test result indicates a tear of at least 30 percent of the subscapularis.¹⁷

To assess the function of the teres minor muscle, the Hornblower’s sign can be assessed. For this maneuver, the patient’s shoulder is positioned in 90 degrees of abduction with the elbow in 90 degrees of flexion (video 7.10). The examiner externally rotates the shoulder 90 degrees and then subsequently releases the arm with the patient attempting to hold the original position. The test is considered positive if the patient is unable to maintain the position and the patient’s shoulder falls into internal rotation.

Sensitivities and specificities for all examinations described in chapter 7 are outlined in table 7.1.^13,18-20

Key Terminology

Bear Hug Test

Physical examination technique used to assess the integrity of the subscapularis tendon. The hand of the patient’s affected shoulder is placed on the contralateral shoulder with the fingers extended and the elbow at 90 degrees. The patient is instructed to hold this position while the examiner applies an external rotation force to the patient’s arm. A test is positive when the patient cannot maintain this position. ↵

Belly Press Test

Physical examination technique used to assess the integrity of the subscapularis tendon. The patient is asked to press the hand into the belly and internally rotate the shoulder against resistance. A test is positive if the patient’s wrist flexes or they demonstrate weakness to resistance. ↵

Cuff Tear Arthropathy

Disorder of the shoulder consisting of a triad of full thickness rotator cuff tearing with muscle atrophy, degenerative damage to the glenohumeral joint, and superior migration of the humeral head. ↵

Drop Arm Test

Physical examination maneuver performed to assess the integrity of the supraspinatus tendon. The examiner passively abducts the patient’s shoulder to 90 degrees and asks the patient to maintain the position. An inability to hold this position, resulting in the sudden dropping of the arm, suggests tearing of the supraspinatus. ↵

External Rotation Lag Sign

Physical examination maneuver performed to test the infraspinatus. Initially, the patient’s shoulder is fully adducted, and the elbow is placed at 90 degrees of flexion. The examiner places the shoulder in maximal external rotation, and the patient is asked to hold this position. An inability to hold this position indicates a positive test result. ↵

Hornblower’s Sign

Physical examination maneuver used to assess pathology of the teres minor. The patient’s shoulder is placed in 90 degrees of abduction and 90 degrees of external rotation with the elbow also bent to 90 degrees, and the patient is asked to hold this position. The test is positive if the arm falls into internal rotation, assuming a position as if blowing a horn. ↵

Internal Rotation Lag Sign

Physical examination maneuver used to assess the subscapularis. The test is performed by placing the patient’s hand behind their back with the shoulder in maximal internal rotation and their hand elevated several centimeters off of the lumbar spine. The patient is instructed to maintain this position. A positive test is indicated by failure to actively maintain this position (with the hand falling toward the patient’s body). ↵

Lift Off Test

Physical examination maneuver used to assess the subscapularis. The test is performed with the patient positioning their hand behind the back at the level of the lumbar spine with the palm facing outward. The patient is asked to lift their hand off their back. A test is positive if there is weakness to resistance or inability to perform the motion. ↵

Pseudoparalysis

Active forward elevation of less than 90 degrees due to a massive rotator cuff tear. The arm appears to be paralyzed but is, in fact, neurologically intact. ↵

References

1. Macaulay AA, Greiwe RM, Bigliani LU. Rotator cuff deficient arthritis of the glenohumeral joint. Clin Orthop Surg. 2010;2(4):196-202. ↵

2. Neer CS, 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65(9):1232-1244. ↵

3. Jensen KL, Williams GR, Jr., Russell IJ, Rockwood CA, Jr. Rotator cuff tear arthropathy. J Bone Joint Surg Am. 1999;81(9):1312-1324. ↵

4. Nam D, Maak TG, Raphael BS, Kepler CK, Cross MB, Warren RF. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS exhibit selection. J Bone Joint Surg Am. 2012;94(6):e34. ↵

5. Abate M, Di Carlo L, Salini V, Schiavone C. Risk factors associated to bilateral rotator cuff tears. Orthop Traumatol Surg Res. 2017;103(6):841-845. ↵

6. Feeley BT, Gallo RA, Craig EV. Cuff tear arthropathy: current trends in diagnosis and surgical management. J Shoulder Elbow Surg. 2009;18(3):484-494. ↵

7. Longo UG, Berton A, Papapietro N, Maffulli N, Denaro V. Epidemiology, genetics and biological factors of rotator cuff tears. Med Sport Sci. 2012;57:1-9. ↵

8. Motta Gda R, Amaral MV, Rezende E, et al. Evidence of genetic variations associated with rotator cuff disease. J Shoulder Elbow Surg. 2014;23(2):227-235. ↵

9. Petrillo S, Longo UG, Margiotti K, et al. Genetic factors in rotator cuff pathology: potential influence of col 5A1 polymorphism in outcomes of rotator cuff repair. BMC Med Genet. 2020;21(1):82. ↵

10. Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. 2007;15(6):340-349. ↵

11. Tokish JM, Alexander TC, Kissenberth MJ, Hawkins RJ. Pseudoparalysis: a systematic review of term definitions, treatment approaches, and outcomes of management techniques. J Shoulder Elbow Surg. 2017;26(6):e177-e187. ↵

12. Elzanie A, Varacallo M. Anatomy, Shoulder and Upper Limb, Deltoid Muscle. Treasure Island, FL: StatPearls; 2022. ↵

13. Jain NB, Luz J, Higgins LD, et al. The diagnostic accuracy of special tests for rotator cuff tear: the ROW cohort study. Am J Phys Med Rehabil. 2017;96(3):176-183. ↵

14. Sgroi M, Loitsch T, Reichel H, Kappe T. Diagnostic value of clinical tests for supraspinatus tendon tears. Arthroscopy. 2018;34(8):2326-2333. ↵

15. May T, Garmel GM. Rotator Cuff Injury. Treasure Island, FL: StatPearls; 2021. ↵

16. Varacallo M, El Bitar Y, Mair SD. Rotator Cuff Syndrome. Treasure Island, FL: StatPearls; 2021. ↵

17. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22(10):1076-1084. ↵

18. Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. Arch Phys Med Rehabil. 2008;89(6):1162-1168. ↵

19. Rabin A, Chechik O, Goldstein Y, Dolkart O, Maman E. The infraspinatus test may not be used to screen for shoulder external rotator strength deficits among patients with shoulder pathology. J Orthop Sci. 2019;24(6):1037-1041. ↵

20. Ladermann A, Collin P, Zbinden O, Meynard T, Saffarini M, Chiu JC. Diagnostic accuracy of clinical tests for subscapularis tears: a systematic review and meta-analysis. Orthop J Sports Med. 2021;9(9):23259671211042011. ↵