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PM R. 2013 January ; 5(1): . doi:10.1016/j.pmrj.2012.08.019.

Clinical Examination of the Rotator Cuff

Nitin B. Jain, MD, MSPH1,2,3, Reginald Wilcox, PT4, Jeffrey N. Katz, MD, MS2,5, and
Laurence D. Higgins, MD2,3
1Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and

Harvard Medical School, Boston, MA

2Department of Orthopaedic Surgery, Brigham and Women’s Hospital and Harvard Medical
School, Boston, MA
3Harvard Shoulder Service, Harvard Medical School, Boston, MA
4Department of Rehabilitation, Brigham and Women’s Hospital, Boston, MA
5Division
of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital and
Harvard Medical School, Boston, MA
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Abstract
Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability accounting
for 4.5 million physician visits in the United States annually. A careful history and structured
physical examination are often sufficient for diagnosing rotator cuff disorders. We are not aware
of a clinical review article that presents a structured physical examination protocol of the rotator
cuff for the interested clinician. To fill this void, we present a physical examination protocol
developed on the basis of review of prior literature and our clinical experience from dedicated
shoulder practices.
Our protocol includes range of motion testing using a goniometer, strength testing using a
dynamometer, and select special tests. Among the many tests for rotator cuff disorders that have
been described, we chose ones that have been more thoroughly assessed for sensitivity and
specificity. This protocol can be used to isolate the specific rotator cuff tendon involved. The
protocol can be typically completed in 15 minutes. We also discuss the clinical implications and
limitations of the physical examination maneuvers described in our protocol. This protocol is
thorough yet time-efficient for a busy clinical practice. It is useful in diagnosis of rotator cuff
tears, impingement syndrome, and biceps pathology.
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INTRODUCTION
Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability
accounting for 4.5 million physician visits in the United States annually.1 The annual cost of
treating shoulder pain was $7 billion in the year 2000 in the United States.2

The rotator cuff tendons include supraspinatus, infraspinatus, teres minor, and subscapularis
(Figures 1 and 2). The long head of the biceps tendon is also often included in rotator cuff
pathology. Rotator cuff tears often present with shoulder pain, weakness, and loss of range
of motion. These symptoms are not unique to rotator cuff tears and the differential diagnosis
includes labral tears, glenohumeral ligament tears or sprains, coracoacromial and
acromioclavicular ligament tears and sprains, osteoarthritis, adhesive capsulitis, proximal

Corresponding Author: Nitin B. Jain, MD, MSPH, Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s
Hospital, 75 Francis Street, BC-4-016, Boston, MA 02115, Ph: (617) 525-8349, Fax: (617) 525-7900, njain1@partners.org.
 Jain et al. Page 2

peripheral neuropathies, and cervical radiculopathy. Increasing age and traumatic shoulder
injury also increase clinical suspicion of rotator cuff tear.3 A careful history and structured
physical examination can often establish the diagnosis of rotator cuff tear. Nevertheless,
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clinicians tend to rely heavily on imaging data from MRI4 and ultrasound to diagnose rotator
cuff disorders.

The objective of our clinical review is to provide the practicing clinician with a structured
physical examination protocol that the authors use in their shoulder practices. This protocol
is based on a review of the published literature and our clinical expertise.

LITERATURE REVIEW
A review of the literature using MEDLINE was performed for physical examination tests/
maneuvers related to the rotator cuff using the terms: rotator cuff, physical examination,
sensitiv*, diagnos*, specific*. We also used the article by Hegedus et al.5 on sensitivity and
specificity of shoulder tests for this review. The objective of our study is not to present a
systematic review or meta-analysis of special tests but to present a physical examination
protocol for the clinician. Based on this review of literature and the clinical experience of
two of the authors (NBJ and LDH) who manage over 2,000 patients with shoulder disorders
annually, we describe a protocol for physical examination of the rotator cuff. The Appendix
includes a patient encounter form with tabular summarization of the physical examination
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protocol presented in this review. This form can be a useful tool in clinical practice to record
findings.

Inspection and Palpation

Inspection of the rotator cuff assesses supraspinatus and infraspinatus atrophy in the
suprascapular and infrascapular fossae, respectively (Figures 1a and b). Muscle atrophy is
examined with tactile assessment feeling for loss of muscle bulk and comparison with the
contralateral side. In cases of massive rotator cuff tears the humeral head can be appreciated
to be superiorly displaced abutting the acromion.

The long head of the biceps tendon in the bicipital groove is palpated for tenderness between
the greater and lesser tuberosities of the humeral head. The acromioclavicular joint is also
palpated for tenderness by following the distal end of the clavicle to the acromioclavicular
junction.

Range of Motion
The supraspinatus assists in elevation (abduction) of the arm; infraspinatus and teres minor
in external rotation, and; subscapularis in internal rotation. Active and passive range of
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motion is assessed. If time is a constraint, the authors recommend limiting the assessment to
active range of motion only since rotator cuff tears lead to loss of active range of motion and
passive range of motion is often preserved. Passive motion is typically limited in
glenohumeral articular disorders.

Range of motion is measured in degrees and best assessed with a goniometer. Goniometers
are commercially available via numerous vendors. If range of motion cannot be assessed
with a goniometer due to time constraints, subjective assessment of range of motion and
comparison with the contralateral shoulder is recommended.

The protocol outlined below for range of motion measurement is modified from prior
studies6,7 and performed in the standing position. To effectively explain the protocol to the
patient, it is helpful for the clinician to demonstrate the range of motion maneuver to the
patient before asking the patient to perform the maneuver.

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Forward Flexion—Flexion is performed by asking the patient to raise the arm straight up
in front of them as high as the patient can with the thumb pointing upwards. The flexion
angle is formed by aligning the goniometer with the lateral epicondyle of the humerus, the
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middle of the glenoid fossa, and a vertical line in the coronal plane (Figure 3a).

Isolated Abduction—Abduction is performed by asking the patient to raise the arm at the
side as high as they can with the examiner stabilizing the scapula by holding it down. The
abduction angle is formed by aligning the goniometer with the lateral epicondyle of the
humerus, the middle of the posterior glenohumeral joint line, and a vertical line in the
sagittal plane (Figure 3b).

External Rotation at 0 Degrees (in neutral)—This is performed with the patient in 0

degrees of glenohumeral joint abduction, 90 degrees of elbow flexion, and neutral
supination/pronation forearm position. The patient is then asked to keep his elbow to his/ her
waist and rotate the arm outwards. The external rotation angle is formed by aligning the
goniometer with the ulna styloid process, the olecranon process of the ulna, and a horizontal
line in the transverse plane (Figure 3c).

External/ Internal Rotation at 90 Degrees (in abduction)—The patient is in 90

degrees of glenohumeral abduction, 90 degrees of elbow flexion, and neutral supination/
pronation of forearm. The patient is then asked to keep the elbow at 90 degrees and move
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the forearm upwards as high as they can and then downwards as low as they can. The
external rotation and internal rotation angles in 90 degrees of abduction are formed by
aligning the goniometer with the ulnar styloid process, the olecranon process of the ulna,
and a horizontal line in the horizontal plane (Figure 3d).

Highest Posterior Anatomy Reached with Thumb—The patient is asked to reach his
back with the dorsum (back) of his/ her thumb. The patient is then asked to reach as high as
they can along the spine. The highest level that the patient can reach is marked. The bony
landmarks adapted from Malanga et al.8 are the inferior border of the scapula that
corresponds to the T7 level and the top of the iliac crests that corresponds to the L4 level.
Follow up the spinous processes from L4 to mark the L1 level. The highest point is noted as
follows: above T7; between T7 and above L1; between L1 and above L4; L4 and below; and
to the body (if the patient cannot reach their back).

Strength Testing
Strength testing is performed using a portable hand-held dynamometer. Numerous devices
are commercially available for this purpose and measure strength in kilograms or pounds.
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After positioning the shoulder for each of the maneuvers (described below), the patient is
told, “This part of the test requires me to match your resistance. Now, please to push into the
dynamometer as hard as you can.” Once the examiner feels that they have matched the
subject’s resistance so that the muscle contraction is truly isometric the patient is asked to
continue pushing into the dynamometer, while the tester resists the force exerted by the
subject, maintaining positional equilibrium throughout the 5 second period of exertion. The
examiner lets them know when the 5 seconds time is up. The examiner disregards the
muscle performance measurement if it is determined that the patient in appropriately used
other musculature to complete the desired task. All maneuvers are performed twice on each
arm with a 10 second rest between repetitions. The scores are then averaged for each arm
and evaluated for symmetry. The protocol below is modified from prior studies9 and our
experience.

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External Rotation (measures force predominately exerted by infraspinatus

muscle)—The patient is instructed to sit with their arm in neutral rotation while holding
their elbow and forearm at 90 degrees of flexion. The forearm is in midrange of motion
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between supinatation and pronation with the thumb directed upward. The tester places the
dynamometer on the lateral surface of the distal forearm just proximal to the ulnar styloid
process (Figure 4a).

Abduction (measures force predominately exerted by supraspinatus muscles)

—The patient sits with both shoulders in approximately 90 degrees abduction and
approximately 45 degrees of horizontal abduction (elbows are fully extended with palms
facing down). The tester places dynamometers on each distal arm at the lateral humeral
epicondyle (Figure 4b).

Internal Rotation (measures force predominately exerted by subscapularis

muscle)—The subject sits with their arm at approximately 90 degrees of forward flexion
and their elbow at 90 degrees of flexion. The tester places the dynamometer under the
subject’s hand. The tester places one finger tip of the hand not holding the dynamometer on
the subject’s olecranon process to ensure the patient is producing an internal rotation
moment and not an adduction moment (Figure 4c).

Special Tests
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Over twenty-five special tests are described for examination of the rotator cuff10–25. It is not
feasible to perform all of these tests in clinical practice. Therefore, we present selected
special tests for each of the rotator cuff tendons that have been more rigorously assessed for
sensitivity and specificity10,12,14,19,22,23,26–32 and are useful in clinical practice to diagnose
rotator cuff tears. In table 1, we present data on sensitivity and specificity of select special
tests. The purpose of this table is not to present a comprehensive review of sensitivity and
specificity of special tests but to familiarize the reader with some of the data on these tests
and our rationale for their selection. We also present selected tests for impingement
syndrome. This syndrome was described by Neer21,33 as impingement of the supraspinatus
and possibly of the long head of the biceps tendon against the anterior edge and
undersurface of the anterior third of the acromion, the coracoacromial ligament, and the
acromioclavicular joint. Several authors34–36 have also described this phenomenon as
“supraspinatus syndrome” prior to Neer’s description. A positive test of the rotator cuff
below implies that the respective tendon is torn. A positive test for the biceps tendon implies
biceps tendonitis/tenosynovitis.

Tests for Subscapularis

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Lift-off Test12—The examiner assists the patient to get in a position where he/ she touches
their lower back with the arm fully extended and internally rotated (Figure 5a). A test is
judged positive if the patient is unable to lift the dorsum of his hand off his/her back
reflecting weakness of the subscapularis.

Passive Lift Off (Lag Sign)11—The examiner passively brings the patient’s arm behind
the body into maximal internal rotation (around the lower back region and pull it backwards
away from the back). The result of this test is considered normal if the patient maintains
maximum internal rotation after the examiner releases the patient’s hand. The test is positive
if the patient cannot maintain this position due to weakness of the subscapularis.

Belly Press Test11—The examiner instructs the patient to press the abdomen with the
hand flat and attempts to keep the arm in maximum internal rotation. The test result is
normal when the elbow does not drop backward, meaning that it remains in front of the

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trunk (Figure 5b). A positive test, sign of subscapularis weakness, is when the elbow drops
back behind the trunk.
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Belly-Off Sign23—The examiner assesses the subscapularis in this test by passively

bringing the shoulder of the patient into flexion and maximum internal rotation with the
elbow 90° flexed. The elbow of the patient is supported by one hand of the examiner while
the other hand brings the arm into maximum internal rotation placing the palm of the hand
on the abdomen. The patient is then asked to keep the wrist straight and actively maintain
the position of internal rotation as the examiner releases the wrist (Figure 5c). If the patient
cannot maintain the above position, lag occurs and the hand lifts off the abdomen resulting
in a positive belly-off sign. Otherwise, the test is negative.

Bear Hug Test10—The examiner instructs the patient to place the palm of the involved
side on the opposite shoulder, extend the fingers (so that the patient could not resist by
grabbing the shoulder), and position the elbow anterior to the body. The examiner then asks
the patient to hold that position (resisted internal rotation) as the examiner tries to pull the
patient’s hand from the shoulder with an external rotation force applied perpendicular to the
forearm (Figure 5d). The test is considered positive indicating subscapularis weakness if the
patient cannot hold the hand against the shoulder or if he or she shows weakness of resisted
internal rotation of greater than 20% compared with the opposite side. If the strength is
comparable to that of the opposite side, without any pain, the test is negative.
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Tests for Supraspinatus and Infraspinatus

External Rotation Lag Sign at 0 Degrees14—The patient is seated with his or her
back to the physician. The elbow is passively flexed to 90°, and the shoulder is held at 20°
elevation (in the scapular plane) and near maximum external rotation (i.e., maximum
external rotation minus 5° to avoid elastic recoil in the shoulder) by the physician. The
patient is then asked to actively maintain the position of external rotation as the physician
releases the wrist while maintaining support of the limb at the elbow (Figure 6a). The sign is
positive when a lag, or angular drop, occurs. The magnitude of the lag is recorded to the
nearest 5°. A positive test indicates postero-superior cuff (supraspinatus and infraspinatus)
deficiency37.

External Rotation Lag Sign at 90 Degrees (Drop Sign)14—The patient is seated

with his or her back to the physician, who holds the affected arm at 90° of elevation (in the
scapular plane) and at almost full external rotation, with the elbow flexed at 90° (Figure 6b).
In this position the maintenance of the position of external rotation of the shoulder is a
function mainly of the infraspinatus. The patient is asked to actively maintain this position
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as the physician releases the wrist while supporting the elbow. The sign is positive if a lag or
‘drop’ occurs. The magnitude of the lag is recorded to the nearest 5°. A positive test
indicates postero-inferior cuff deficiency37.

Jobe’s Test (Empty Can Test)15—This test is performed by first assessing the deltoid
with the arm at 90° of abduction and neutral rotation. The shoulder is then internally rotated
and angled forward 30°; the thumbs should be pointing toward the floor (Figure 6c). Manual
muscle testing against resistance is performed with the examiner pushing down at the distal
forearm. This test is regarded as positive when there is weakness to resistance with arm in
90° of abduction as compared with when it is angled forward 30°, and is indicative of
supraspinatus pathology.

Drop Arm Test25—This test assesses the supraspinatus and is performed by passively
abducting the patient’s shoulder to 180 degrees and then observing as the patient slowly

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lowers the arm to the waist. This test is positive when the arm drops to the side. The patient
may be able to lower the arm slowly to 90 degrees (because this is a function mostly of the
deltoid muscle as opposed to the supraspinatus) but will be unable to continue the maneuver
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as far as the waist. In this case, too, the test is positive.

Test for Teres Minor

Hornblower’s Sign38—The examiner supports the patient’s arm at 90 degrees of
abduction in the scapular plane with elbow flexed at 90 degrees. The patient then attempts
external rotation of the forearm against resistance of the examiner’s hand. If the patient
cannot externally rotate, they assume a position characteristic of a positive hornblower’s
sign (Figure 7).

Test for Biceps Tendon

Speed’s Test39—The patient is asked to flex his shoulder (elevate it anteriorly) against
resistance (from the examiner) while the elbow is extended and the forearm supinated
(Figure 8). The test is positive when pain is localized to the bicipital groove for biceps
tendon pathology.

Impingement Signs
Neer’s Sign21—The impingement sign is elicited with the patient seated and the examiner
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standing. Scapular rotation is prevented with one hand while the other hand raises the arm in
forced forward elevation, causing the greater tuberosity to impinge against the acromion
(Figure 9). A positive test is if the maneuver produces pain.

Hawkin’s Sign13—The examiner forward flexes the humerus to 90° and forcibly
internally rotates the shoulder. This maneuver drives the greater tuberosity farther under the
coracoacromial ligament. Pain with this maneuver is considered positive for impingement.

DISCUSSION
We present a structured physical examination protocol for evaluation of the rotator cuff. The
protocol is based on prior literature and the clinical experience of the authors. The
examination will assist in diagnosis of impingement syndrome, rotator cuff tears, and biceps
tenosynovitis. Structural diagnosis of rotator cuff tear requires imaging.

Shoulder pain is a common presenting symptom in musculoskeletal clinics. Rotator cuff

disorders are often the cause of shoulder pain. The available literature on special tests and
other physical examination maneuvers is extensive and focuses on specific tests. Often, tests
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described in the literature have limited data to support their use. As a result, it is difficult for
a practicing clinician to discern what tests are most useful. Clinicians heavily rely on MRI
for diagnosis of rotator cuff disorders. MRI is not only expensive but also difficult to put
into clinical context since more than 40 percent of asymptomatic individuals who are 50
years and older have abnormalities on shoulder MRI40,41. Diagnostic shoulder ultrasound is
a less expensive alternative to MRI in the diagnosis of rotator cuff disorders42. Tennent et al.
presented a review of the special tests associated with rotator cuff tears24. Our study focuses
on providing the clinician with a tool to diagnose rotator cuff tears and includes several
examination maneuvers in addition to special tests. Our study synthesizes data from prior
literature and presents a physical examination protocol including select tests. In our
practices, this protocol takes 10–15 minutes to complete. In some cases if the clinician
cannot dedicate 10–15 minutes for physical examination, we suggest that they select from
the presented tests based on their clinical judgment and suspicion.

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The protocol presented in this review has important clinical implications and limitations.
Rotator cuff disorders can be localized to the specific tendon that is involved from the plane
of range of motion or muscle group strength that is limited. Supraspinatus assists in
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elevation (abduction) of the arm; infraspinatus and teres minor in external rotation, and;
subscapularis in internal rotation. Range of motion and strength testing can also be used to
follow patients longitudinally and assess for improvement after non-operative or operative
intervention. Usually the active range of motion is limited in rotator cuff tears whereas both
active and passive ranges of motions are restricted in glenohumeral osteoarthritis and
adhesive capsulitis. Age standardized values for dynamometry testing are available.43
However, this data has not been validated in subsequent studies and is not specific for
rotator cuff disorders. Kim et al. have presented data on shoulder strength using
dynamometry for abduction and external rotation in subjects with and without rotator cuff
tears44. However, this data has also not been reproduced in other studies. We recommend
comparison to the contralateral side for strength measurements and range of motion testing.

The special tests described in this review evaluate specific tendons of the rotator cuff. The
Jobe’s test and drop arm test evaluate the supraspintus whereas the lift-off test, passive lift-
off, and external rotation lag signs assess the infraspinatus and teres minor. The belly press
test, belly-off sign, and bear hug test are specific to the subscapularis. Neer’s sign and
Hawkin’s sign test for impingement that may result from outlet obstruction or non-outlet
impingement syndrome21. Internal impingement of the shoulder has also been described as a
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distinct entity due to excessive or repetitive contact of the greater tuberosity of the humeral
head with the postero-superior aspect of the glenoid45. The causes of internal impingement
include articular-sided rotator cuff tears and labral tears/fraying. There is little to no data on
differentiating partial-thickness tears from full-thickness tears for these tests.

The biceps tendon is often affected in rotator cuff disorders and there are surgical and
interventional implications for associated biceps pathology46–48. Speed’s test and tenderness
in the bicipital groove assess biceps tenosynovitis/biceps tendonitis. If the biceps tendon/
tendon sheath is invloved, a biceps tenodesis/tenotomy is often indicated during surgical
intervention47,49. If non-surgical intervention is pursued, physical therapy or an ultrasound
guided injection of steroid in the biceps tendon sheath is an option50,51. Similarly if the
acromioclavicular joint is tender, a distal clavicle excision or acromioclavicular joint
injection may be indicated52,53.

We present special tests that have better sensitivity and specificity for rotator cuff tears.
However, overall the studies5,8,10–12,17–19,22,23,26–30,54,55 in this area have numerous
drawbacks. These include retrospective study design, recruitment of patients from surgical
clinics, and use of arthroscopic findings as gold standard that leads to biased estimates for
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sensitivity and specificity due to inclusion of only patients undergoing surgery who have a
high probability of rotator cuff tear. The sensitivities and specificities of special tests have
wide ranges from different studies and in some cases are low. This may lead to missed
cases. Therefore, the clinician should also rely on their clinical judgment and not solely on
these tests. Further discussion on sensitivity and specificity of special tests is beyond the
scope of this manuscript.

Conclusion
In this clinical review, we present a thorough evaluation of the rotator cuff for a
musculoskeletal/sports medicine practitioner. This review can also be a useful teaching tool
for practicing clinicians, fellows, and residents. The physical examination should also be put
in clinical context with patient’s presentation and imaging findings. The physical
examination protocol can be used in patients where rotator cuff tears, impingement
syndrome, and biceps tenosynovitis are suspected.

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Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
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Acknowledgments
Funding: Dr. Jain is supported by funding from National Institute of Arthritis and Musculoskeletal and Skin
Diseases (NIAMS) project number 1K23AR059199, Foundation for PMn and Biomedical Research Institute at
Brigham and Women’s Hospital. Dr. Katz is supported by NIH/NIAMS P60 AR 47782

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Figure 1. Anatomy of the anterior rotator cuff (reproduced and modified with permission from
Primal Pictures Limited)
a=Supraspinatus tendon; b=Subscapularis tendon; c=Long head of biceps brachii tendon;
d=Long head of biceps brachii tendon sheath; e=Greater tuberosity of the humerus;
f=Acromion; g=Coracoid; h=Supraspinatus muscle; i=Subscapularis muscle
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Figure 2. Anatomy of the posterior rotator cuff (reproduced and modified with permission from
Primal Pictures Limited)
a=Supraspinatus tendon; b=Infraspinatus tendon; c=Teres Minor tendon; d=Greater
tuberosity; e=Acromion; f=Infraspinatus muscle; g=Teres Minor muscle
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Figure 3. Range of motion testing

a. Forward flexion
b. Isolated abduction
c. External rotation in neutral
d. External rotation in abduction

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Figure 4. Strength testing using a dynamometer

a. External rotation
b. Abduction
c. Internal rotation

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Figure 5. Special tests for subscapularis

a. Lift-off test
b. Belly-press test
c. Belly-off sign
d. Bear hug test

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Figure 6. Special tests for supraspinatus and infraspinatus

a. External rotation lag sign in neutral
b. External rotation lag sign in abduction
c. Jobe’s test
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Figure 7. Hornblower’s Sign

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Figure 8. Speed’s test

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Figure 9. Neer’s sign

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Table 1
Sensitivity and Specificity of Special Tests for Rotator Cuff Tears
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Test Range of Diagnostic Values (%) References

Subscapularis
Life-off test (and lag sign) Sensitivity: 17–100 10,12,14,19,23,56
Specificity: 60–98

Belly press test Sensitivity: 40–43 10,57

Specificity:93–98

Belly-off sign Sensitivity: 14–86 23,57,58

Specificity: 91–95

Bear hug test Sensitivity: 60 10

Specificity: 92

Supraspinatus and Infraspinatus

External rotation lag sign Sensitivity: 46–98 14,19,38
Specificity: 72–98

Jobe’s test Sensitivity: 53–89 22,57,59,60

Specificity: 65–82

Drop arm test Sensitivity: 10–73 19,22,57,61

Specificity: 77–98
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Teres Minor
Hornblower’s sign Sensitivity: 100 38
Specificity: 93

Biceps Tendon
Speed’s test Sensitivity: 53 62
Specificity: 67

Impingement Signs
Neer’s sign Sensitivity: 68–89 17,22,56
Specificity: 49–98

Hawkin’s sign Sensitivity: 72–92 17,22,56

Specificity: 44–78
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