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Positive painful arc and positive external rotation resistance test results are the most accurate for diagnosing rotator cuff disease

Hermans J, Luime J, Meuffels D, et al. Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. JAMA. 2013;310:837-47.

Review question

What are the most accurate physical signs for diagnosing rotator cuff disease?


The rotator cuff is the group of 4 ligaments that stabilize the shoulder joint. They connect to the 4 muscles that move the shoulder in various directions.

Rotator cuff disease (RCD) is damage to the rotator cuff from any cause (acute injuries, repetitive strains, degeneration with aging, or inflammation).

RCD is the most common cause of shoulder and arm pain, especially during overhead activities.

However, patients with a chronic full-thickness rotator cuff tear may have painless loss of active motion.

How the review was done

The source of this summary is a meta-analysis of 5 studies (from an initial set of 28) evaluating the examination of referred patients by specialists. Publication period was 2005 to 2010.

The 5 studies covered the examination of 442 shoulders (between 30 and 203 across studies) in 432 patients 20 to 86 years of age (average about 54 years).On average, 64% had RCD.

15 examination tests were included.

What the researchers found

Identifying rotator cuff disease

  • A positive painful arc test result was the only finding showing a small to moderate increase in the likelihood of having rotator cuff disease. This test is done by the examiner raising the person’s straight arm from their side to over their head, noting any pain
  • A normal painful arc test is an arc test in which no pain occurs. This was the only finding showing a small decrease in the likelihood of having RCD.
  • A positive drop arm test result might help to identify patients with rotator cuff disease. In this test, the patient is asked to lower the arm slowly, to their side, from a position starting from extension laterally at shoulder height. The test is positive if the arm drops suddenly accompanied by pain.

Identifying full-thickness tears

  • A positive (painful) external rotation lag test and internal rotation lag test were the most accurate results for identifying full-thickness tears. (The examiner passively rotates the patient’s arm into full external rotation).
  • A normal (painless) internal rotation lag test result was most accurate for identifying patients without a full-thickness tear. (The hand of the affected arm is lifted off of the patient’s back by examiner, and the patient is asked to maintain position.)


A positive painful arc test result and a positive external rotation resistance test result are the most accurate results for detecting rotator cuff disease.

A positive lag test (external or internal rotation) result is the most accurate for diagnosing full-thickness rotator cuff tears.



Advanced statistical methods contrasting and combining results from different studies.

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