Rotator Cuff Injuries: Symptoms

Shoulder pain is the first and most common symptom of a rotator cuff injury. Pain is typically accompanied by stiffness, weakness, and reduced range of motion.

Common Symptoms and Signs of Rotator Cuff Injuries

The symptoms appear suddenly after a traumatic injury or gradually occur over time and may affect one or both shoulders.

Typical symptoms are described below:

• Areas of pain include the rounded edge of the shoulder, the top of the shoulder, and/or deep inside the shoulder joint. It may also spread beyond the shoulder into the top part of the upper arm. Less commonly, pain occurs at the back of the shoulder.
• Acute or sharp pain typically follows a traumatic event.
• Gradual and mild pain occurs over time, but the intensity steadily increases.
• Pain increases with movement, such as raising the arm above the level of the head or reaching behind the back.
• Night-time pain occurs when lying on the affected side and the painful joint becomes pressed.
• Shoulder stiffness increases with physical activity or prolonged rest, such as after waking in the morning.
• Reduced range of motion is often accompanied by shoulder pain and stiffness. However, sometimes the arm can still be passively moved, meaning that someone else can lift the affected arm and rotate it through a complete range of motion.
• Muscle weakness is experienced when lifting the arm overhead, reaching the back, or holding the arm away from the body.
• Reduced muscle mass makes the muscles at the back of the shoulder appear smaller on the injured side than on the unaffected side.
• Swelling and tenderness may occur in the front of the shoulder.
• Cracking and popping sensations (shoulder crepitus) are also common and may indicate the shoulder’s ball and socket joint is not gliding smoothly.

These symptoms tend to interfere with everyday activities that involve lifting the arms, as well as recreational activities or sports such as baseball, basketball, tennis, golf, and swimming.

Some people with rotator cuff injuries don't experience any pain or stiffness. Instead, they might only notice weakness in their shoulder.

Ignoring Symptoms Worsens Rotator Cuff Injury

People with mild symptoms often tend to modify their shoulder movements and continue to remain active.

These modified movements (such as using a bad form during heavy lifting) lead to a cascade of events in the shoulder, as follows:

• Mal-tracking occurs between the shoulder joint’s humerus head (ball) and the glenoid cavity (socket). Mal-tracking refers to the abnormal rubbing or incorrect gliding between 3 bones in the shoulder: the humerus, glenoid, and acromion. Over time the humerus can migrate up and make a “pseudo-joint” (false joint) with the acromion.
• Mal-tracking increases strain and pressure on the rotator cuff muscles.
• Increased strain and pressure on the muscles cause pain as well as additional weakness and instability in the rotator cuff.

With time, the symptoms progressively worsen, and the injured muscle or tendon becomes chronically inflamed, partially torn, or completely torn.

Rotator Cuff Injuries: Diagnosis

The diagnostic process involves:

• Collecting a detailed medical history
• Checking the shoulder’s range of motion and specific movements that exacerbate pain
• Performing a focused musculoskeletal examination of the shoulder and a thorough nerve and blood vessel (neurovascular) examination to check sensation, strength, reflexes, and pulse

The doctor also identifies or rules out other conditions that may be causing or contributing to the symptoms.

Medical History and Physical Evaluation

The initial evaluation includes two areas of focus:

• Patient history: Specific questions are asked about:
  • Type of the symptoms, including when they started and what movements or activities make them flare up
  • Location and severity of the pain
  • Severity of the stiffness
  • Daily activities that are easy and difficult to perform
  • Information on past injuries and surgeries
  • Information on other medical problems, such as shoulder impingement, or arthritis
  • Family history of rotator cuff injury
• Physical examination: The doctor evaluates:
  • The shoulder’s range of motion and strength of the rotator cuff muscles and tendons
  • Swelling and/or redness near the shoulder
  • Loss of muscle mass near the shoulder or shoulder blade
  • The surrounding joints, such as the neck (cervical spine) and upper back (thoracic spine)

Further evaluation involves performing one or more diagnostic tests.

Rotator Cuff Pain Tests

The following tests aim to check for rotator cuff injury or shoulder impingement that may be contributing to rotator cuff pain. All tests performed by a healthcare professional:

• Painful arc test checks for rotator cuff pain while moving the shoulder through its range of motion.
  • The patient is asked to straighten and raise their arm out to the side, then up towards the ceiling. The clinician helps support the arm while it’s being raised, if needed.
  • Pain in the shoulder when the arm aligns with the level of the ear or head suggests a rotator cuff problem.
• Drop arm test checks for the strength of the rotator cuff.
  • The clinician raises the patient’s arm straight out to the side, and the patient is asked to slowly lower it down.
  • A sudden dropping of the arm or a loss of strength while lowering the arm suggests rotator cuff weakness.
• Hawkins-Kennedy test checks for shoulder impingement contributing to rotator cuff pain.
  • The patient sits with their arm bent at 90° at the shoulder and elbow.
  • The examiner supports the patient's arm from below to ensure maximum relaxation and gently rotates the arm internally (toward the patient’s body).
  • Any feeling of pain or resistance at the joint indicates shoulder impingement.

Imaging Tests

Depending on the patient’s symptoms and the results of the pain tests, a doctor may order medical imaging right away or prescribe non-surgical treatment and take a wait-and-watch approach.

Common imaging tests are listed below.

MRI

Magnetic resonance imaging (MRI) is the gold standard for evaluating rotator cuff injuries because it provides a detailed, cross-sectional view of the shoulder. MRIs help visualize:

• The location and size of the tear
• Thinning of muscle tissue
• Degenerative changes in the tendon and muscle

These attributes make MRI a useful tool in diagnosing rotator cuff injuries as well as planning for rotator cuff surgery.

X-rays

Plain x-rays, also called radiographs, help the doctor assess for arthritis of the shoulder, bone impingement, and calcific tendonitis (formation of calcium deposits in the tendons). With the exception of the latter, radiographs do not confirm an injury to the rotator cuff itself, but they reveal risk factors for degenerative tears or evidence of prior shoulder injury.

Ultrasound

Ultrasonography or ultrasound is an increasingly utilized method for diagnosing rotator cuff injuries and other soft tissue injuries of the shoulders. Unlike X-rays, ultrasound allows the doctor to identify different soft tissues (eg, muscles); it can be performed in the doctor’s office; and no radiation is delivered to the patient.

Moreover, because ultrasound offers real-time imaging, the clinician can ask the patient to move his or her shoulder and observe the soft-tissue movements on the screen, helping them verify or rule out shoulder impingement issues.

These imaging tests are also utilized to monitor the progress of treatment and to investigate potential causes of persistent symptoms.