Clinical tests for the diagnosis of rotator

cuff disease
Umile Giuseppe Longo * MD, MSc, Alessandra Berton * MD, Philip Michael Ahrens
FRCS(Tr & Orth) +, Nicola Maffulli MD, MS, PhD, FRCS(Orth) ++, Vincenzo Denaro * MD

* Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del
Portillo, 200, 00128 Trigoria Rome, Italy
+

Department of Orthopaedics, Royal Free Hampstead NHS Trust, Pond Street, London, NW3 2QG, UK

++

Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London

School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England

Corresponding author:
Nicola Maffulli MD, MS, PhD, FRCS(Orth)
Centre Lead and Professor of Sports and Exercise Medicine
Consultant Trauma and Orthopaedic Surgeon
Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry
Mile End Hospital, 275 Bancroft Road, London E1 4DG England
Tel: + 44 20 8223 8839 Fax: + 44 20 8223 8930 n.maffulli@qmul.ac.uk

Abstract
Several tests have been described to examine the shoulder. However, there is a lack of consensus on
clinical assessment of patients with shoulder pain and suspected rotator cuff pathology. This review
reports the diagnostic accuracy of clinical tests for rotator cuff pathology. Sensitivity, specificity,
positive predictive value (PPV), negative predictive value (NPV), and accuracy of 21 clinical tests
for rotator cuff pathology are reported from the available literature. 20 studies investigated
supraspinatus pathology, 12 infraspinatus pathology,and 9 subscapularis pathology. Most tests for
rotator cuff pathology are inaccurate, and the recent literature shows that there is insufficient
evidence to recommend one clinical test over another for diagnosis of rotator cuf
pathology. Poor diagnostic accuracy of clinical tests for rotator cuff pathology may be related to
the close relationships of structures in the shoulder, to a lack of understanding of anatomical basis
of the tests, or their lack of reproducibility.
Key words: Shoulder; Tests; Examination; Diagnosis; Rotator cuff; Sports.

Introduction
Rotator cuff tears are a common cause of shoulder pain and occupational disability

1-4

. More than

50% of individuals older than 60 years have at least a partial-thickness rotator cuff tear

5-7

, with

significant impact on patients quality of life, and marked functional impairment 8. As a large
percentage of older individuals maintain a very active lifestyle, it is important for orthopaedic
surgeons to be able to accurately identify and appropriately manage patients with rotator cuff tears

9-

11

. The history and physical examination of patients with shoulder pain has traditionally been a

cornerstone of the diagnostic process

12-17

. A large number of special tests have been described to

examine the shoulder, and it is not feasible to use all of them at every examination. They should be
used selectively, and tailored to the clinical condition suspected 18-24.
Classically, the supraspinatus, infraspinatus and teres minor tendons have been considered as
contiguous but distinct structures. Later, it has been shown that all the tendons of the rotator cuff
fuse to insert on both tuberosities of the proximal humerus. The subscapularis muscle is an internal
rotator of the humerus. It arises from the subscapularis fossa, in the ventral aspect of the scapula,
and insert on the lesser tuberosity of the humerus. The supraspinatus muscle arises from the dorsal
surface of the scapula in the supraspinatus fossa and from the fascia covering the muscle, passing
over the top of the shoulder joint to insert on the upper aspect of the greater tuberosity. It is a long,
thin muscle. The infraspinatus muscle arises from its covering fascia and from the infraspinatus
fossa and inserts on the greater tubercle immediately below the insertion of the supraspinatus
muscle. It is a thick triangular nuscle, with three pennate origins. The teres minor arises from the
upper two thirds of the dorsal surface of the lateral border of the scapula and from septa between it
and the infraspinatus. It inserts on the greater tuberosity below the insertion of the infraspinatus.
The major points to address during physical examination of patients with suspected rotator cuff
pathology include the loss of active or passive range of motion, painful range of motion, presence of
muscle atrophy, weakness, swelling, or tenderness. Specific tests that can be conducted during the
physical examination to evaluate the functional status and strength of the rotator cuff. Many of these
tests are eponymous, and several authors have described more than one test, leading to confusion
regarding not only the correct way to perform the tests but the correct interpretation of the findings.
Misquoting or misinterpretation of the tests by subsequent authors has compounded this problem 18.
Several studies

25-28

have described the accuracy and reliability of clinical examination, especially

in relation to a pathoanatomical model, with discordant results 29-35.

There is a lack of consensus from the available literature on the diagnostic criteria and concordance
in clinical assessment of patients with shoulder pain and suspected rotator cuff pathology.
This study describes the currently available clinical tests for the diagnosis of rotator cuff pathology.
3

Clinical tests for diagnosis of rotator cuff

Table 1 summarises the clinical tests available for evaluation of a patient with suspected rotator cuff
pathology, including sensitivity, specificity, positive predictive value (PPV), negative predictive
value (NPV), and accuracy. 20 studies investigated supraspinatus testing, 12 infraspinatus testing,
and 9 subscapularis testing.
The reference standard was magnetic resonance imaging in 2 studies, ultrasound in 4 studies,
double-contrast arthrography in 1 study, operation in 10 studies, arthroscopy in 8 studies and a
combined approach in 4 studies.
The number of participants in the studies ranged from 552 to 12, with a mean sample size of 158.
The age of the participants ranged from 16 to 86 years. 17 studies evaluated participants with
subacromial impingement syndrome (SIS), subacromial/subdeltoid bursitis (SDB), partial thickness
rotator cuff tear (PTT), full thickness rotator cuff tear (FTT). 10 studied did not state the degree of
tendon tear. 21 clinical tests were evaluated in 27 studies. The majority of the studies included in
this review were level IV studies
Diagnostic accuracy of the clinical tests

SUPRASPINATUS TENDON

Empty Can test

The Empty Can test

36

, also known as the supraspinatus test or Jobe test, is performed placing

patient arms in 90 abduction and 30 horizontal abduction (in the plane of the scapula) with
thumbs pointing downward so as to produce medial rotation of the shoulder. The examiner then
pushes the patients arms downward while asking the patient to resist the pressure. Pain or weakness
is indicative of a positive test (Figure 1).
In the assessment of supraspinatus tendon tears, the Empty Can test had a sensitivity > 80% in 2
evaluations across 2 studies

37, 38

when assessed by muscle weakness, in 2 evaluations across 2

studies 39, 40 when assessing the provocation of pain as positive, and in 7 evaluations across 6 studies
40-45
40

using weakness or pain or both. Specificity of the empty can test was >80% only in 1 evaluation

when assessed by muscle weakness, and in 2 evaluations, both in Park et al

46

study, when

weakness or pain or both arise. Diagnostic accuracy has not been demonstrated in a large proportion
of the studies.
Full Can test

The Full Can test

47

is performed with patients arms abducted in 90 in the horizontal plane, and

rotated 45 externally, with the thumb pointing upwards. The sign is positive when there is pain or
weakness at the downward pressure applied by the examiner (Figure 2).
The Full Can test demonstrated a lack of diagnostic accuracy in 19 evaluations, using pain and/or
weakness as criteria, across four studies 38, 40, 42, 48.
Painful Arc test
While standing, with the shoulder in external rotation (palm facing up), the patient is asked to
abduct the arm and report the occurrence of pain

49

. The test is considered positive if pain is

experienced between 60 and 120 50, above or below which movement is pain free (Figure 3).
The Painful Arc test demonstrated a lack of diagnostic accuracy for supraspinatus pathology in ten
evaluations across tree studies 46, 48, 51.
Palpation of the supraspinatus
Codman

52

first described the palpation of full thickness rotator cuff tears. He described the ability

to palpate a sulcus produced by a rent in the supraspinatus tendon. The elbow on the affected side
is flexed to 90 and held in that position. The top of the humeral head is palpated with the arm
rotated into internal and external rotation and then hyperextended. In external rotation, an anterior
supraspinatus tear can be felt.
The two studies investigating palpation of the supraspinatus tendon for a tendon rupture both
reported high sensitivity values 53, 54. Wolf and Agrawal 54 also found high specificity, thus producing
the most accurate result reported in this review.
Drop Arm Test for Supraspinatus
In the drop-arm sign described by Codman 55, patients are asked to elevate the arm fully and then to
slowly reverse the motion in the same arc. If the arm dropped suddenly or the patient experiences
severe pain, the test is considered positive. This test was investigated in 10 evaluations across 5
studies 46, 51, 56-58 reporting good specificity (from 77 to 100%), but poor accuracy.
Supraspinatus Muscular Atrophy
Supraspinatus muscular atrophy

59

is present if reduced muscle mass is observed superior to the

supraspinatus fossa. It is an insensitive marker of rotator cuff tear (sensitivity < 60%) even in expert
hands, as supraspinatus muscular atrophy may frequently be obscured by the close proximity of the
uninvolved musculature (trapezius) and overlying adipose tissue 59.
Passive Elevation of the shoulder
Litaker

59

analyzed passive elevation of the shoulder: with the patient supine, the examiner elevates

the shoulder to the maximal distance. Normal elevation is defined as 170 or higher, and

comparison with the contralateral shoulder should not differ by more than 10. Sensivity was 30%,
while specificity 78%. Accuracy was not reported.
Resistance test
Resistance test, or gum-turn test 60, is performed in the standing position with the involved arm at
90 abduction, 2030 anteposition and in external rotation as for the full-can test. The patient is
then asked to trace the path of a spiral drawn on a drawing sheet 20 times; 1 turn is from the centre
to the end of the spiral and vice versa (spiral width = 20 cm).
This test, introduced by Gumina, has not been evaluated in other studies so far. The original article
concluded that, when the test is negative, there is a high probability that the patient does not have a
large or massive cuff tear, because test has a sensitivity of 55% and a specificity of 98% for
supraspinatus tears, with a diagnostic accuracy of 76%.
Resisted Isometric Abduction
Resisted isometric abduction

61

is performed with the elbow extended and arm in neutral rotation,

the patient abducts the arm to 90. The patient is asked to maintain this position as the examiner
applied a downward force to the lateral aspect of the arm, proximal to the elbow (Figure 4). Pain or
weakness indicated a positive test.
The most recent study on physical tests for shoulder dysfunction

48

examined, among the others,

weakness or pain on resisted isometric abduction, defining pain on resisted abduction as the most
sensitive test for diagnosing full thickness tears (75%).

INFRASPINATUS AND TERES MINOR TENDONS

External Rotation Strength test or Patte test

Pattes maneuver62 compares the strength of lateral rotation in 90 of forward elevation. With the
examiner supporting the patients elbow in 90 of forward elevation in the plane of the scapula, the
patient is asked to rotate the arm laterally against resistance (Figure 5).
In seven studies38, 39, 46, 48, 59, 63, 64 the test showed poor accuracy.
External Rotation Lag Sign-ERLS
External Rotation Lag Sign-ERLS 43 is performed with the patient 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 maximal external rotation (i.e., maximum external rotation minus 5 to
avoid elastic recoil in the shoulder) by the physician (Figure 6). The patient is then asked to actively
maintain the position of external rotation in elevation as the physician releases the wrist while
maintaining support of the limb at the elbow (Figure 7). The sign is positive when a lag, or angular
drop, occurs (Figure 8).
6

This test demonstrated good specificity (form 91 to 98%) and better value of diagnostic accuracy
than other tests for infraspinatus tears. 43, 57, 58, 65, 66.
Drop Sign
The drop sign43 is performed with the patient seated on the examination couch 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 9). The patient is asked to actively
maintain this position as the physician releases the wrist while supporting the elbow. The sign is
positive if a lag or "drop" occurs (Figure 10). This test is equivalent to the Hornblowers sign.
Hertel et al reported a specificity of 100% , but specificity was lower in other studies43, 46, 51, 56-58.
Infraspinatus Atrophy
Infraspinatus atrophy

59

is present if a concavity in the infraspinatus fossa is noted in conjunction

with prominence of the scapular spine.

Litaker et al

59

found that one of the clinical findings most closely associated with rotator cuff tear

was evidence of infraspinatus atrophy (P < .001). However, its sensitivity and specificity are
respectively 55% and 19%.
Weakness with external rotation
Weakness in external rotation

59

is evaluated with the patient sitting or standing with the arms

alongside the body. The elbows are flexed to 90 with the thumbs up, with the shoulders rotated
internally 20. The examiner places his hands outside those of the patient's and directs the patient to
resist attempts at pushing the foream internally (Figure 11).
Dropping Sign
The dropping sign

66

is performed with the patient seated, the shoulder is placed in 0 of abduction

and 45 of external rotation with the elbow flexed to 90. The examiner holds the patients forearm
in this position and instructs the patient to maintain it when he lets go of the forearm. On releasing
the forearm, a positive test is recorded when the patients forearm drops back to 0 of external
rotation, despite efforts to maintain external rotation. Walch et al

66

reported it 100% sensitive and

100% specific for degeneration of the infraspinatus.

SUBSCAPULARIS TENDON

The lift-off, lag sign in internal rotation, bear-hug, belly-press, belly off, and Napoleon tests are
variants of subscapularis testing, involving active internal rotation of the shoulder in different
positions of shoulder flexion.
Lift-off test

The lift-off test, described by Gerber and Krushell1 in 199167, is performed by placing the hand of
the affected arm on the back (at the position of the midlumbar spine) and asking the patient to
internally rotate the arm to lift the hand posteriorly off of the back (Figure 12). The test is
considered positive if the patient is unable to lift the arm posteriorly off of the back or if he or she
performs the lifting maneuver by extending the elbow or the shoulder.
The evaluation of diagnostic accuracy for the lift-off test produced mixed results. Barth et al

68

indicated a sensitivity of 17.6% and a specificity of 100% for the lift-off test using weakness as a
criterion. Therefore, if the lift-off test is positive, one can be sure that a torn subscapularis tendon is
present. These results were not found by Itoi et al
Rigsby et al

69

38

or Leroux et al 39, while Hertel et al

43

and

confirmed not only good specificity (100%, 99%), but also good sensitivity (62%,

94%) for the lift-off test using weakness and/or pain as criteria.
Internal Rotation Lag Sign
The internal rotation lag sign

43

is performed with patient seated with his or her back to the

physician. The affected arm is held by the physician at almost maximal internal rotation. The elbow
is flexed to 90, and the shoulder is held at 20 elevation and 20 extension. The dorsum of the hand
is passively lifted away from the lumbar region until almost full internal rotation is reached (Figure
13). The patient is then asked to actively maintain this position as the physician releases the wrist
while maintaining support at the elbow. The sign is positive when a lag occurs (Figure 14).
Hertel et al

43

and Rigsby et al

69

analyzed the lag sign in internal rotation- IRLS with similar good

results (sensitivity 97%-98% and specificity 96%-94%), as in Miller et al

specificity 84%). However, Bak et al

57

58

(sensitivity 100%,

found lower sensitivity (31%) and diagnostic accuracy

(56%).
Belly press
Belly press, described by Gerber et al in 1996

70

, is performed with the arm at the side and the

elbow flexed to 90, by having the patient press the palm into his or her abdomen by internally
rotating the shoulder. The test is considered positive (1) if the patient shows a weakness in
comparison to the opposite shoulder, or (2) if the patient pushes the hand against the abdomen by
means of elbow extension or shoulder extension, indicating inability to exerting a force against the
abdomen by active internal rotation produced by the subscapularis (Figure 15).
This test appears to be specific test for demonstrating a subscapularis muscle tendon tear when
positive 68, 69, even if its specificity is lower than lift-off test.
Bear-Hug Test

The bear-hug test, described in 2006 by Barth et al 68, uses resisted internal rotation with the palm
held on the opposite shoulder with the fingers extended while the elbow is held in maximal anterior
translation anterior to the body.
As for the belly press, the bear hug appears to be valuable as a specific test to demonstrate a
subscapularis muscle tendon tear when positive 68, 69 even if its specificity is lower than lift-off test.
Napoleon test
The Napoleon test, first described by Schwamborn and Imhoff

48

and further refined by Burkhart

and Tehrany 4, is variation of the belly-press test. It is performed by placing the hand on the belly
and pushing the hand against the stomach with the wrist straight. It is positive if the wrist is flexed
to 90 to push against the stomach.
Its specificity is >80% in 2 evaluations across two studies

68, 69

, but its sensitivity is >80% only in

one of these evaluations 69.

Discussion
The clinical evaluation of rotator-cuff tears is not straightforward, and even for an intact rotator cuff
there is disagreement on the optimal position for testing individual muscles

47, 71

. A variety of tests

can be used during the examination of shoulder disorders, but the individual contribution of each of
these tests to the differential diagnosis of shoulder pain and the most accurate combination or
32-34

sequence of tests is unclear. The conclusions of previous reviews

were included and integrated

with data from more recent studies 48, 57, 58, 60, 64, 65, 69.
Previous reviews examined respectively 6 34, 12 32, and 15 33 of the 27 papers included in the current
review. Their conclusions are in agreement with this review that most tests for rotator cuff
pathology are inaccurate. Insufficient evidence was found in the more recent literature to
recommend any one clinical examination test for diagnosis of rotator cuf pathology.
Most authors agree that the structure of the rotator cuff does not allow for individual tendon
examination, and the close relationship of other structures in the shoulder may make it difficult to
identify specific pathologies with clinical tests. One of the reasons could be the structural overlap
between the tendon fibres and glenohumeral joint capsule 72. The four tendons of the rotator cuff
join form a common insertion onto the humeral tuberosities

72

. This suggests that no test can

selectively detect a lesion of any one of the rotator cuff tendons, and any result from muscle testing
may implicate a number of structures.
Poor diagnostic accuracy may be also related to a lack of understanding of the anatomical basis of
the test. A recent systematic review

73

yielded 11 papers that had reported on the anatomical basis

for a total of six of 34 clinical tests. Four of these tests had evidence from more than one study of a

valid anatomical basis, but only two tests provided consensus evidence that supported the
anatomical basis provided by the test developer.
Another explanation of the low accuracy of the clinical tests is the lack of reproducibility

74, 75

. This

may results from subtle though critical differences in test position, evaluation of positivity, and
experience in performing each clinical test.
Clinical tests for the rotator cuff tended to be either highly sensitive or highly specific, and very few
demonstrated both high sensitivity and specificity. As a result, few tests provided convincing
evidence of the presence or absence of disease in the settings in which they were applied 34.
Dinnes

34

included Job test and arc of pain among tests with sensitivities >80%, and drop arm test

and passive external rotation among tests with specificity >80%, but concluded that the small
sample sizes did not give conclusive evidence for any single test that can accurately diagnose
rotator cuff disorders. Hegedus

33

considered the external rotation lag sign (ERLS) as a specific

confirmatory test for any rotator cuff tear and diagnostic for an infraspinatus tear, while the bearhug and belly press tests proved valuable in demonstrating a subscapularis tear.
Hughes

32

concluded that the suspicion of a rotator cuff tear may be heightened by positive

palpation, combined painful arc/infraspinatus test, Napoleon test, lift-off test, belly-press test or
drop-arm test, and it may be reduced by a negative palpation and an empty can test.
Recent articles included in this review provided information about external rotation lag sign, drop
sign, and internal rotation lag sign, painful arc of abduction, empty and full can tests, resisted
isometric shoulder abduction and resisted isometric shoulder external rotation, Patte test, lift off
test, Napoleon sign, bear hug, lift off, and belly press sign. Their conclusions do not differ from
previous reports. Most authors agree that clinical tests have limited use in confirming diagnosis 48.
Only Castoldi et al

65

stated that the ERLS is highly specific and acceptably sensitive for diagnosis

of full-thickness tears, even in the case of an isolated lesion of the supraspinatus tendon. Bak et al

57

stated that a positive lag sign (ERLS or DAT) is indicative of a full-thickness supraspinatus tear, but
a negative lag sign does not exclude a tear.
Overall, in patients with suspected acute rotator cuff tear, clinical tests are not accurate in
differentiating rotator cuff disorders from other causes of shoulder pain. Other information, such as
mechanism of injury, pain behaviour, and location of pain when combined with clinical tests might
provide a more accurate indication of clinical patterns. A combination of criteria, not just clinical
tests, may prove to be of greater use in the clinic 32. Other authors 46, 65 proposed that a combination
of several signs, including history as well as the conventional radiographic signs, will dramatically
improve our diagnostic accuracy, probably to a level where additional imaging is only necessary to
determine the degree of degeneration of the tendon and muscular cuff 76.
10

Pathology of the tendon of the long head of the biceps and impingement are commonly associated
with rotator cuff tears. There is significant crossover between rotator cuff tears and long head of the
biceps tendon testing

77-79

. However, for the purposes of this review we did not include articles

describing tests for the tendon of the long head of the biceps and impingement.
Authors preferred physical exam manoeuvres
In clinical practice, it is not always possible to perform all the tests for shoulder examination, and
often the shoulder is so painful that it is not possible to perform any test.
Our preferred physical exam manoeuvres are the Jobe test for the supraspinatus tendon, the Patte
and the Hornblower tests for the infraspinatus tendon, and the liftoff / bellypress depending on
range of motion for the subscapularis tendon.
Conclusions
In conclusion, poor diagnostic accuracy of clinical tests for rotator cuff pathology may be related to
the close relationships of structures in the shoulder, to a lack of understanding of the anatomical
basis of the tests and to the lack of their reproducibility. Other information, such as mechanism of
injury, pain behaviour, and location of pain, when combined with conventional radiographic signs,
might provide a more accurate evaluation of clinical conditions.

11

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Maffulli N, Longo UG, Gougoulias N, et al. Long-term health outcomes of youth sports injuries. Br J Sports Med. 2010;44:21-25.
Maffulli N, Longo UG, Loppini M, et al. Current treatment options for tendinopathy. Expert Opin Pharmacother. 2010;11:2177-2186.
Maffulli N, Longo UG, Spiezia F, et al. Sports injuries in young athletes: long-term outcome and prevention strategies. Phys Sportsmed.
2010;38:29-34.
Maffulli N, Longo UG, Gougoulias N, et al. Sport injuries: a review of outcomes. Br Med Bull. 2010.
Maffulli N, Longo UG, Denaro V. Novel approaches for the management of tendinopathy. J Bone Joint Surg Am. 2010;92:2604-2613.
Maffulli N, Longo UG, Franceschi F, et al. Movin and Bonar scores assess the same characteristics of tendon histology. Clin Orthop Relat
Res. 2008;466:1605-1611.
Kibler W, Warme B, Sciascia A, et al. Nonacute shoulder injuries. Orthopedic knowledge update: Sports medicine. W. Kibler (Ed.)
Rosemont, IL: American Academy of Orthopedic Surgeons. 2009:19-39.
Mighell M. Massive irreparable rotator cuff tears. In M. Frankle (Ed.), Rotator cuff deficiency of the shoulder. New York: Thieme Medical.
2008:8-11.
Denaro V, Ruzzini L, Longo UG, et al. Effect of dihydrotestosterone on cultured human tenocytes from intact supraspinatus tendon. Knee
Surg Sports Traumatol Arthrosc. 2010;18:971-976.
Smith MA, Smith WT. Rotator cuff tears: an overview. Orthop Nurs.29:319-322; quiz 323-314.
Denaro V, Ruzzini L, Barnaba SA, et al. Effect of Pulsed Electromagnetic Fields on Human Tenocyte Cultures From Supraspinatus and
Quadriceps Tendons. Am J Phys Med Rehabil. 2010.
Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000;61:3079-3088.
Longo UG, Franceschi F, Ruzzini L, et al. Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med. 2008;36:533538.
Longo UG, Franceschi F, Ruzzini L, et al. Characteristics at haematoxylin and eosin staining of ruptures of the long head of the biceps
tendon. Br J Sports Med. 2009;43:603-607.
Longo UG, Franceschi F, Ruzzini L, et al. Light microscopic histology of supraspinatus tendon ruptures. Knee Surg Sports Traumatol
Arthrosc. 2007;15:1390-1394.
Longo UG, Franceschi F, Ruzzini L, et al. Higher fasting plasma glucose levels within the normoglycaemic range and rotator cuff tears. Br J
Sports Med. 2009;43:284-287.
Longo UG, Franceschi F, Spiezia F, et al. Triglycerides and total serum cholesterol in rotator cuff tears: do they matter? Br J Sports Med.
2010;44:948-951.
Tennent TD, Beach WR, Meyers JF. A review of the special tests associated with shoulder examination. Part I: the rotator cuff tests. Am J
Sports Med. 2003;31:154-160.
12

19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.

Franceschi F, Longo UG, Ruzzini L, et al. To detach the long head of the biceps tendon after tenodesis or not: Outcome analysis at the 4-year
follow-up of two different techniques. Int Orthop. 2007;31:537-545.
Franceschi F, Longo UG, Ruzzini L, et al. Arthroscopic management of calcific tendinitis of the subscapularis tendon. Knee Surg Sports
Traumatol Arthrosc. 2007;15:1482-1485.
Franceschi F, Longo UG, Ruzzini L, et al. The Roman Bridge: a "double pulley - suture bridges" technique for rotator cuff repair. BMC
Musculoskelet Disord. 2007;8:123.
Franceschi F, Longo UG, Ruzzini L, et al. Soft tissue tenodesis of the long head of the biceps tendon associated to the Roman Bridge repair.
BMC Musculoskelet Disord. 2008;9:78.
Franceschi F, Longo UG, Ruzzini L, et al. No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when
associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med. 2008;36:247-253.
Franceschi F, Ruzzini L, Longo UG, et al. Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for
rotator cuff tears: a randomized controlled trial. Am J Sports Med. 2007;35:1254-1260.
Ostor AJ, Richards CA, Prevost AT, et al. Interrater reproducibility of clinical tests for rotator cuff lesions. Ann Rheum Dis. 2004;63:12881292.
de Winter AF, Jans MP, Scholten RJ, et al. Diagnostic classification of shoulder disorders: interobserver agreement and determinants of
disagreement. Ann Rheum Dis. 1999;58:272-277.
Winters JC, Groenier KH, Sobel JS, et al. Classification of shoulder complaints in general practice by means of cluster analysis. Arch Phys
Med Rehabil. 1997;78:1369-1374.
Norregaard J, Krogsgaard MR, Lorenzen T, et al. Diagnosing patients with longstanding shoulder joint pain. Ann Rheum Dis. 2002;61:646649.
Deeks JJ. Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests. Bmj. 2001;323:157-162.
Knottnerus JA, van Weel C, Muris JW. Evaluation of diagnostic procedures. Bmj. 2002;324:477-480.
Reid MC, Lachs MS, Feinstein AR. Use of methodological standards in diagnostic test research. Getting better but still not good. Jama.
1995;274:645-651.
Hughes PC, Taylor NF, Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Aust J
Physiother. 2008;54:159-170.
Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual
tests. Br J Sports Med. 2008;42:80-92; discussion 92.
Dinnes J, Loveman E, McIntyre L, et al. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders:
a systematic review. Health Technol Assess. 2003;7:iii, 1-166.
Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? Br J Sports Med.
2009;43:259-264.
Jobe FW, Jobe CM. Painful athletic injuries of the shoulder. Clin Orthop Relat Res. 1983:117-124.
Noel E, Walch G, Bochu M. [Jobe's maneuver. Apropos of 227 cases]. Rev Rhum Mal Osteoartic. 1989;56:803-804.
13

38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.

Itoi E, Minagawa H, Yamamoto N, et al. Are pain location and physical examinations useful in locating a tear site of the rotator cuff? Am J
Sports Med. 2006;34:256-264.
Leroux JL, Thomas E, Bonnel F, et al. Diagnostic value of clinical tests for shoulder impingement syndrome. Rev Rhum Engl Ed.
1995;62:423-428.
Kim E, Jeong HJ, Lee KW, et al. Interpreting positive signs of the supraspinatus test in screening for torn rotator cuff. Acta Med Okayama.
2006;60:223-228.
Morgan CD, Burkhart SS, Palmeri M, et al. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator
cuff tears. Arthroscopy. 1998;14:553-565.
Itoi E, Kido T, Sano A, et al. Which is more useful, the "full can test" or the "empty can test," in detecting the torn supraspinatus tendon? Am
J Sports Med. 1999;27:65-68.
Hertel R, Ballmer FT, Lombert SM, et al. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5:307-313.
Boileau P, Ahrens PM, Hatzidakis AM. Entrapment of the long head of the biceps tendon: the hourglass biceps--a cause of pain and locking
of the shoulder. J Shoulder Elbow Surg. 2004;13:249-257.
Holtby R, Razmjou H. Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. J Orthop
Sports Phys Ther. 2004;34:194-200.
Park HB, Yokota A, Gill HS, et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J
Bone Joint Surg Am. 2005;87:1446-1455.
Kelly BT, Kadrmas WR, Speer KP. The manual muscle examination for rotator cuff strength. An electromyographic investigation. Am J
Sports Med. 1996;24:581-588.
Kelly SM, Brittle N, Allen GM. The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy. Clin
Rehabil.24:149-158.
Hanchard N, Cummins J, C. J. Evidencebased clinical guidelines for the diagnosis, assessment and physiotherapy management of shoulder
impingement syndrome. London, Chartered Society of Physiotherapy. 2004.
Hermann B, DW R. Value of anamnesis and clinical examination in degenerative impingement syndrome in comparison with surgical
findings a prospective study. In Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis 2000.
Calis M, Akgun K, Birtane M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis.
2000;59:44-47.
Codman EA. Rupture of the supraspinatus tendon. 1911. Clin Orthop Relat Res. 1990:3-26.
Lyons AR, Tomlinson JE. Clinical Diagnosis of tears of the rotator cuff. THE JOURNAL OF BONE AND JOINT SURGERY. 1992;74-B:414415.
Wolf EM, Agrawal V. Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears. J Shoulder Elbow Surg. 2001;10:470-473.
Codman EA. The shoulder. Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston: Thomas Todd;
1934. Rupture of the supraspinatus tendon. 1934:123-177.
Murrell GA, Walton JR. Diagnosis of rotator cuff tears. Lancet. 2001;357:769-770.
14

57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.

Bak Klaus MD. The Value of Clinical Tests in Acute Full-Thickness Tears of the Supraspinatus Tendon: Does a Subacromial Lidocaine
Injection Help in the Clinical Diagnosis? A Prospective Study. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2010;26:734742.
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;89:1162-1168.
Litaker D, Pioro M, El Bilbeisi H, et al. Returning to the bedside: using the history and physical examination to identify rotator cuff tears. J
Am Geriatr Soc. 2000;48:1633-1637.
Gumina S, Bertino A, Di Giorgio G, et al. A new test of resistance in the diagnosis of postero-superior rotator cuff tears. Chir Organi Mov.
2008;91:85-86.
Clarkson H. Musculoskeletal assessment: joint range of motion and manual muscle strength. Baltimore, Lippincott Williams & Wilkins.
2000:146155.
Patte D, Gerber C. Pathologie du dfil sous-acromial et coraco-humral du jeune. Pathologie de l'appareil locomoteur lie au sport. Paris.
Pfizer. 1987.
Walch G, Liotard JP, Boileau P, et al. [Postero-superior glenoid impingement. Another impingement of the shoulder]. J Radiol. 1993;74:4750.
Salaffi F, Ciapetti A, Carotti M, et al. Clinical value of single versus composite provocative clinical tests in the assessment of painful
shoulder. J Clin Rheumatol.16:105-108.
Castoldi F, Blonna D, Hertel R. External rotation lag sign revisited: accuracy for diagnosis of full thickness supraspinatus tear. J Shoulder
Elbow Surg. 2009;18:529-534.
Walch G, Boulahia A, Calderone S, et al. The 'dropping' and 'hornblower's' signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br.
1998;80:624-628.
Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br.
1991;73:389-394.
Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy.
2006;22:1076-1084.
Rigsby R, Sitler M, Kelly JD. Subscapularis tendon integrity: an examination of shoulder index tests. J Athl Train.45:404-406.
Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am. 1996;78:1015-1023.
Jenp YN, Malanga GA, Growney ES, et al. Activation of the rotator cuff in generating isometric shoulder rotation torque. Am J Sports Med.
1996;24:477-485.
Clark JM, Harryman DT, 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am.
1992;74:713-725.
Green R, Shanley K, Taylor N, et al. The anatomical basis for clinical tests assessing musculoskeletal function of the shoulder. Physical
Therapy Reviews. 2008;13:17-24.
Longo UG, Franceschi F, Loppini M, et al. Rating systems for evaluation of the elbow. Br Med Bull. 2008;87:131-161.
15

75.
76.
77.
78.
79.
80.

Longo UG, Loppini M, Denaro L, et al. Rating scales for low back pain. Br Med Bull. 2010;94:81-144.
Lippi G, Longo UG, Maffulli N. Genetics and sports. Br Med Bull. 2010;93:27-47.
Longo UG, Lamberti A, Maffulli N, et al. Tissue engineered biological augmentation for tendon healing: a systematic review. Br Med Bull.
2010.
Longo UG, Lamberti A, Maffulli N, et al. Tendon augmentation grafts: a systematic review. Br Med Bull. 2010;94:165-188.
Longo UG, Oliva F, Denaro V, et al. Oxygen species and overuse tendinopathy in athletes. Disabil Rehabil. 2008;30:1563-1571.
Scheibel M, Magosch P, Pritsch M, et al. The belly-off sign: a new clinical diagnostic sign for subscapularis lesions. Arthroscopy.
2005;21:1229-1235.

16

Figure legends:
Figure 1: The Empty Can test (or Jobe test) is performed placing patient arms in 90 abduction and 30 horizontal abduction (in the plane of the
scapula) with thumbs pointing downward so as to produce medial rotation of the shoulder. The examiner then pushes the patients arms downward
while asking the patient to resist the pressure. Pain or weakness is indicative of a positive test.
Figure 2: The Full Can test is performed with patients arms abducted in 90 in the horizontal plane, and rotated 45 externally, with the thumb
pointing upwards. The sign is positive when there is pain or weakness at the downward pressure applied by the examiner.
Figure 3: The painful arc test. While standing, with the shoulder in external rotation (palm facing up), the patient is asked to abduct the arm and
report the occurrence of pain. It is considered positive if pain is experienced between 60 and 120, above or below which movement is pain free.
Figure 4: Resisted isometric abduction is performed with the elbow extended and arm in neutral rotation, the patient abducts the arm to 90. The
patient is asked to maintain this position as the examiner applied a downward force to the lateral aspect of the arm, proximal to the elbow. Pain or
weakness indicated a positive test.
Figure 5: Pattes maneuver compares the strength of lateral rotation in 90 of forward elevation. With the examiner supporting the patients elbow
in 90 of forward elevation in the plane of the scapula, the patient is asked to rotate the arm laterally against resistance.
Figure 6: External Rotation Lag Sign-ERLS is performed with the patient 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 maximal external rotation (i.e., maximum external rotation
minus 5 to avoid elastic recoil in the shoulder) by the physician.
Figure 7: External Rotation Lag Sign-ERLS. The patient is then asked to actively maintain the position of external rotation in elevation as the
physician releases the wrist while maintaining support of the limb at the elbow
Figure 8: External Rotation Lag Sign-ERLS: The sign is positive when a lag, or angular drop, occurs
Figure 9: The drop sign is performed with the patient seated on the examination couch 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. The patient is asked to actively
maintain this position as the physician releases the wrist while supporting the elbow.
Figure 10: The drop sign is positive if a lag or "drop" occurs.
17

Figure 11: Weakness with external rotation is evaluated with the patient sitting or standing with the arms alongside the body. The elbows are flexed
to 90 with the thumbs up, with the shoulders rotated internally 20. The examiner places his hands outside those of the patient's and directs the
patient to resist attempts at pushing the foream internally.
Figure 12: The lift-off test is performed by placing the hand of the affected arm on the back (at the position of the midlumbar spine) and asking the
patient to internally rotate the arm to lift the hand posteriorly off of the back. The test is considered positive if the patient is unable to lift the arm
posteriorly off of the back or if he or she performs the lifting maneuver by extending the elbow or the shoulder.
Figure 13: The internal rotation lag sign is performed with patient seated with his or her back to the physician. The affected arm is held by the
physician at almost maximal internal rotation. The elbow is flexed to 90, and the shoulder is held at 20 elevation and 20 extension. The dorsum
of the hand is passively lifted away from the lumbar region until almost full internal rotation is reached. The patient is then asked to actively
maintain this position as the physician releases the wrist while maintaining support at the elbow.
Figure 14: The internal rotation lag sign is positive when a lag occurs.
Figure 15: Belly press is performed with the arm at the side and the elbow flexed to 90, by having the patient press the palm into his or her
abdomen by internally rotating the shoulder. The test is considered positive (1) if the patient shows a weakness in comparison to the opposite
shoulder, or (2) if the patient pushes the hand against the abdomen by means of elbow extension or shoulder extension, indicating inability to
exerting a force against the abdomen by active internal rotation produced by the subscapularis

18

Table 1: Performance characteristics of tests for rotator cuff disease.

Tests for
rotator cuff disease:
SUPRASPINATUS TESTS:
Empty Can or Jobe testWeakness

Empty Can or Jobe testPain

Empty Can or Job testWeakness or Pain or Both

Author

No.
Pz.

Age

Noel et al, 198937

227

52

Ito et al, 199942

Itoi et al, 200638
Leroux et al, 199539
Kim et al, 200640

136
149
55
200

43
53
51
59.5

Operation &
Arthroscopy
Operation & MRI
Arthroscopy
Operation
MRI

Kelly et al, 201048

34

57 (44-63)

Ultrasound

Ito et al, 199942

136

43

38

Itoi et al, 2006

Leroux et al, 199539
Kim et al, 200640

149
55
200

Kelly et al, 201048

Salaffi et al, 201064

Morgan et al, 1998

41

Reference
standard

Degree of
tear

Sensivity
(%)

Specificity
(%)

PPV

NPV

Accuracy

Not stated

95

65

86

85

85

FTT
Not stated
Not stated
PTT or FTT
FTT
Any degree of SIS
FTT
PTT
SDB

77
87
79
75.8
59.9
51.9
60
75
73.3

68
43
67
70.9
88.9
66.7
33.3
13.3
46.7

44

90

70
79

79
56.1
92.1

67
85.5
50.5

Operation & MRI

FTT

63

55

31

82

53
51
59.5

Arthroscopy
Operation
MRI
Ultrasound

203

58 (23-81)

Ultrasound

40
50
46.3
60.3
33.3
37.5
12.5
37.5
50.89

22
93.9
57.6

57 (44-63)

78
86
93.9
79.6
51.9
64.3
73.3
64.3
56.12

96
46.2
81.3

34

Not stated
Tendinitis
PTT or FTT
FTT
Any degree of SIS
FTT
PTT
SDB
Not stated

85.23

17.22

62
73.5
50
50
41.9
50
53.43

81

2381 years)

Arthroscopy

Ant

27

Post
Comb
Any severity
PTT
FTT
FTT
Not stated

85
59
44.1
32.1
52.6
89
84

68
54
89.5
67.8
82.4
50
58

88.4
11.6
68

46.8
88.4
71

60.2
63.7
70

84

58

Park et al, 200546

552

nr

Arthroscopy

Ito et al, 199942

Hertel et al, 199643

136
100

43
51 (16-79)

Operation & MRI

Operation

72.5
69
53.3
46.7
45.2
60
57
71

19

Boileau et al, 200444

21

62 (47-69
years).

Operation

Holtby & Razmjou

200445

50

50 (24-79)

Operation or
Arthroscopy

Litaker et al, 200059

Full Can testPain

Full Can testPain or weakness or both

Muscle Atrophy
(observed)
Palpation

nr

PTT

62

54

FTT
Massive FTT

41
88

70
70

Not stated

64

65

78,3

47,9

PTT or FTT
FTT

98.5/71.2
83.9/55.5

43,3/73,9
58.7/90.5

46/57,3
81.5/92.7

98,3/83,9
62.7/48.3

61,5/73
76/66.5

N/A

448

57

40

200

59.5

Bak et al, 201057

104

18-75

Ultrasound and
arthroscopy in 29 pz;
ultrasound in 75 pz

FTT

76

39

61

56

60

Ito et al, 199942

136

43

Operation & MRI

FTT

77

74

49

91

75

Itoi et al, 200638

Kim et al, 200640

149
200

53
59.5

Arthroscopy
MRI

57 (44-63)

Ultrasound

53
67.9
81
75
35.7
7.1
50

85.8
48.1

34

83
77.3
59.9
44.8
68.4
70
73.7

54.2
87.2

Kelly et al, 201048

Not stated
PTT or FTT
FTT
Any degree of SIS
FTT
PTT
SDB

Ito et al, 199942

136

43

Operation & MRI

FTT

66

64

37

85

Itoi et al, 200638

Kim et al, 200640

149
200

53
59.5

Arthroscopy
MRI

57 (44-63)

Ultrasound

50
67.9
77.8
25
30.8
7.1
38.5

91.1
44.5

34

80
71.2
55.5
34.5
65
70
65

52.2
84.4

Kelly et al, 201048

Not stated
PTT or FTT
FTT
Any degree of SIS
FTT
PTT
SDB

Ito et al, 199942

136

43

Operation & MRI

FTT

86

57

Kim et al, 200640

200

59.5

MRI

PTT or FTT
FTT

89.4/59.1
73.7/41.6

53.7/82.1
68.3/90.5

48.7/61.9
83.4/90.4

92.2/80.3
54.4/41.6

Litaker et al, 200059

448

57

Double-contrast
arthrography

Not stated

55

73

81.3

43.7

Lyons & Tomlinson,

199253

42

nr

Operation

Any degree of SIS

91

75

94

66

Kim et al, 2006

Full Can testWeakness

Double-contrast
arthrography
MRI

81

78
71
66.5
48.5
54.5
44.1
63.6
64
74
69
62.5
33.3
51.5
44.1
54.5

65.5/74.5
72/57

20

Passive Elevation
AbductionWeakness

AbductionPain

Resistance test
or Gum-Turn test)
Drop Arm Test for
Supraspinatus

Painful arc sign

Wolf & Agrawal,

200154

109

51.2 (26-86)

Arthroscopy

FTT

95.7

96.8

95.7

96.8

Litaker et al, 200059

448

57

Double-contrast
arthrography

Not stated

30

78

73.6

35.6

Kelly et al, 201048

34

57 (44-63)

Ultrasound

Any degree of SIS

37.9

50

39.4

FTT
PTT
SDB

65
75
65

30.8
14.3
38.5

51.5
50
54.5

Any degree of SIS

55.2

75

57.6

FTT
PTT
SDB

75
68.8
68.8

41.2
11.1
41.2

57.6
38.2
54.5

Kelly et al, 201048

34

57 (44-63)

Ultrasound

96.3

Gumina et al,200860

53

64.2 (46-79)

Arthroscopy

Not stated

55

98

97

68

76

Calis et al, 200051

120

51.6 (18-70)

MRI

Regardless

7.8

97.2

87.5

29.9

33.6

Zlatkin Stage 1
Zlatkin Stage 2
Zlatkin Stage 3
Any severity
PTT
FTT

4.4
6.2
15
26
14.3
34.9

100
96.1
100
88
77.5
87.5

81
8
65

39.7
86.8
66.8

48.6
69.9
66.5

60

Park et al, 200546

552

nr

Arthroscopy

Murrell & Walton,

200156

400

nr

Operation

Not stated

10

98

Bak et al, 201057

104

18-75

Ultrasound and
arthroscopy in 29 pz;
ultrasound in 75 pz.

FTT

41

83

75

53

Miller et al, 200858

Park et al, 200546

37
552

55.5 (20-86)
nr

Not stated
Any severity
PTT
FTT
Zlatkin Stage 1
Zlatkin Stage 2
Zlatkin Stage 3
Any degree of SIS
FTT
PTT

73
73.5
67.4
75.8
9.5
37.5
45
29.6
70
75

77
81.10
47
61.8
88.4
73
78.5
50
44
20

61
88.2
14.9
61
40
72
75

85
61.5
91.3
76.4
54.7
38.7
50

Calis et al, 200051

120

51.6 (18-70)

Kelly et al, 201048

34

57 (44-63)

Ultrasound
Arthroscopy

MRI

Ultrasound

49.4
68
53.1
50
58.8
31
62.1
56.7

21

Tests for
rotator cuff disease:
INFRASPINATUS TESTS:
External Rotation Strength
test or Patte test -Weakness

External Rotation Strength

test or Patte test -Pain

External Rotation Lag SignERLS (Weakness in active

external rotation arm in 20 of
abduction)

55

22.2

Not stated

97.5

9.9

44.8

Litaker et al, 200059

448

57

Author

No.
Pz.

Age

Reference
standard

Degree of
tear

Sensivity
(%)

Specificity
(%)

Itoi et al, 200638

149

53

Arthroscopy

Not stated

84

53

Kelly et al, 201048

34

57 (44-63)

Ultrasound

Leroux et al., 199539

55

51

Operation

Any degree of SIS

FTT
PTT
SDB
Not stated

51.9
64.3
71.4
64.3
83

66.7
31.6
15
36.8
61

149

53

Arthroscopy

Not stated

54

54

34

57 (44-63)

Ultrasound

Any degree of SIS

FTT
PTT
SDB
Tendonitis

34.5
65.2
78.3
69.6
92

100
30
18.2
50
30

29

93

Not stated

76

57

78

54

90.1
69.1
84
67
74.2

90.6
10.1
69.1

45.8
87.7
70.5

58.7
64.1
70.1

91.13

31.13

71.12

Itoi et al, 2006

38

Kelly et al, 201048

External rotation Sterngth

test or Patte test- Weaknes
or Pain or both

SDB
Double-contrast
arthrography

66.6
PPV

68.8
NPV

Accuracy

53.3
45.5
38.2
48.5
21

97

42.4
54.6
58.8
63.6

Leroux et al, 199539

55

51

Operation

Litaker et al, 200059

448

57

Double-contrast
arthrography

Park et al, 200546

552

nr

Arthroscopy

Any severity
PTT
FTT

Walch et al, 199363

Salaffi et al, 201064

439
203

58 (23-81)

Ultrasound

Not stated

41.6
19.4
50.5
79
62.21

Hertel et al, 199643

100

51

Operation

Not stated

70

100

100

56

78

Castoldi et al, 200965

401

50

Arthroscopy or
open surgery

Isolated PTT

12

98

73

73

73

PTT/FTT zone 1, 2
Isolated FTT zone 3
FTT zone 3/ 1, 2

14
13
32

96
98
93

63
25
30

72
73
94

71
94
88

22

Drop Sign (Weakness in

active external rotation arm
in 90 of abduction)

Muscle atrophy Infraspinatus

Passive external rotation

98

86

92

91

62

93

64

93

88

65

93

62

94

89

97

93

66

99

93

98

98

54

Bak et al, 201057

104

18-75

Ultrasound and
arthroscopy in 29 pz;
ultrasound in 75 pz

FTT

45

91

87

57

Miller et al, 200858

37

55.5 (20-86)

Ultrasound

Not stated

46

94

77

78

Hertel et al, 199643

100

51

Operation

Not stated

21

100

199

32

43

Bak et al, 201057

104

18-75

Ultrasound and
arthroscopy in 29 pz;
ultrasound in 75 pz

FTT

45

70

65

50

56

Miller et al, 200858

37

55.5 (20-86)

Not stated

73

77

61

85

Litaker et al, 200059

448

57

Not stated

55

73

81.4

43.4

Litaker et al, 200059

448

57

Not stated

19

83

70

33.9

Operation

Supraspinatus and
infraspinatus tendons
tear between 2.5 and 5.0
cm

100

100

Reference
standard

Degree of
tear

Sensivity
(%)

Specificity
(%)

PPV

NPV

Accuracy

Not stated
Not stated

79
0
17.6
46

59
61
100
69

0
100

88
76.7

77.8

59

85

62

100

100

69

79

Walch et al, 1998

Lift off test-Pain

Lift off testWeakness or Pain or both

56

Walch et al, 199866

Operation

Ultrasound
Double-contrast
arthrography
Double-contrast
arthrography

Dropping sign

Tests for
rotator cuff disease:
SUBSCAPULARIS TESTS:
Lift off test-Weakness

Supraspinatus FTT (3, 4)

FTT in zone 3, 4/ tears 1,
2
FTT zone 5/ 3, 4, 1, 2,
PTT
FTT 5, 6/ 3, 4, 1, 2, PTT
Supraspinatus and
infraspinatus tendons
tear between 2.5 and 5.0
cm

66

54

Author

No.
Pz.

Itoi et al, 200638

Leroux et al, 199539
Barth et al, 200668
Itoi et al, 200638

149
55
68
149

Walch et al, 199363

439

Hertel et al, 199643

100

Age
53
51

Operation
Operation

53

51

Operation

Not stated

N/A

65

23

Lag Sign in internal rotationIRLS (Weakness in active

internal rotation)

Bear-hug test

Belly-press test

Scheibel et al, 200580

Gerber & Krushell,
199167
Rigsby et al, 201069

12

55.3(26-83)

Operation & MRI

58

13

51 (35-64)

Operation

92

Hertel et al, 199643

100

51

Operation

Scheibel et al, 200580

Rigsby et al, 201069

12
95

55.3(26-83)

Operation & MRI

18-75

Ultrasound and
arthroscopy in 29 pz;
ultrasound in 75 pz

95

Bak et al, 201057

104

Miller et al, 200858

Barth et al, 200668

37
68

Rigsby et al, 201069

95

Barth et al, 200668

68

80

Scheibel et al, 2005

Rigsby et al, 201069

16
95

Belly off

Rigsby et al, 201069

95

Napoleon test,

Barth et al, 200668

Scheibel et al, 200580
Rigsby et al, 201069

68
16
95

55.5 (20-86)
47 (16-76)

47 (16-76)

55.3(26-83)

47 (16-76)
55.3(26-83)

Arthroscopy

Arthroscopy

N/A

FTT
PTT

94
22

99
99

Not stated

97

96

FTT
Any severity
Tears of Less Than
100% of Subscapularis
Tears of Less Than 75%
of Subscapularis
FTT
PTT
Any severity
Tears of Less Than
100% of Subscapularis
Tears of Less Than 75%
of Subscapularis

Operation & MRI

Arthroscopy
Operation & MRI

N/A

FTT
PTT
FTT
PTT
Not stated
FTT

N/A

97

96

96

75
98

94

31

87

75

50

56

100
60

84
91.7

28
75

100
84.6

82.4

N/A
N/A

52.9

69.2

50

63.6

88
53
40

91
92
97.9

N/A

88.9

29.4

83.3

21.4

75

38
88
29
90
69
25
69
98

81.5

79.7

80.9
80

N/A

97
98
nr
nr
97.9

N/A
N/A

83.3

75.8

76.5

N/A

97

N/A

SIS = subacromial impingement syndrome

SDB = Subacromial/subdeltoid bursitis
24

PTT = partial thickness tear;

FTT = full thickness tear

25