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Evaluation of the Weak Shoulder.

Last updated Thursday, February 10, 2005

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Figure 5 - Cuff tear arthropathy

Other diagnostic techniques

Radiographs

Standard radiographs are of limited assistance in evaluating shoulder weakness. Small avulsed fragments of the tuberosity may be seen in younger patients with cuff lesions. Chronic cuff disease may be accompanied by sclerosis of the undersurface of the acromion or traction spurs in the coracoacromial ligament from forced contact with the cuff and the humeral head. In large cuff tears, the head of the humerus may be subluxated upwards toward or against the undersurface of the acromion. In cuff tear arthropathy, the humeral head may have lost the prominence of the tuberosities (become "femoralized") and the coracoid, acromion, and glenoid may have formed a deep socket (become "acetabularized").

Cuff imaging

A number of different studies are available for imaging the rotator cuff. The single contrast arthrogram can reveal full thickness cuff defects by revealing leakage of injected contrast material from the joint into the subacromial subdeltoid bursa. Magnetic resonance imaging can reveal some information about the tendon and muscle. Ultrasonography can reveal the thickness of the various components of the cuff and the extent of cuff defects. Each of these tests adds expense to the evaluation of the patient. Resources can be conserved by not ordering imaging tests unless it will change the management of the patient. Patients under the age of 40 without a major injury are unlikely to have significant cuff defects; thus cuff imaging will not be helpful in their evaluation. At the other extreme, patients with weak external rotation and atrophy of the spinatus muscles whose plain radiographs show the head of the humerus in contact with the acromion do not need cuff imaging to establish the obvious diagnosis of a rotator cuff defect. Finally, the management of patients with nonspecific shoulder symptoms and an unremarkable physical examination is unlikely to be changed by the results of a cuff imaging test. In summary, cuff imaging is usually not needed where a cuff tear is very unlikely (a 35-year-old with the minimally traumatic onset of shoulder pain) or where it is very likely (a 70-year-old with gradual onset of shoulder weakness, spinatus atrophy, and radiographic evidence of contact between the head of the humerus and the acromion). The primary indication for cuff imaging is to establish the diagnosis in situations where it would affect treatment, such as a 47-year-old with weakness of flexion and external rotation after a major fall on the outstretched arm.

Electromyography

Electromyography can be an important diagnostic test for the patient with shoulder weakness in the absence of cuff lesions. It is particularly helpful in younger patients with a history suggestive of cervical radiculopathy or suprascapular nerve lesions and a physical examination showing neurological signs.

Disclaimer

This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.

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