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Table 2 Clinical practice guideline for the diagnosis and treatment of rotator cuff pathology

From: Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology

Clinical domain Consensus statement Level of evidencea
Screening The following thirteen questions should be included during history taking to determine a patient’s relative priority of need and the proper place of treatment:  
  • How old are you [73]? 2
  • Do you smoke [74]? 3
  • Did your problem occur at work or because of a work-related incident (i. e., Is this Workers’ Compensation Board related) [75]? 2
  • Is your shoulder problem part of an active medicolegal or third party claim [76]? 2
  • Do you have neck pain? If yes, is this separate from your shoulder pain [77]? 2
  • Do you have unexplained sensory deficits in your arm, wrist, or hand (i.e., numbness, tingling, burning) [77]? 2
  • Do you have other upper limb pain? If yes, are you experiencing pain in the forearm, elbow, wrist, or hand [7880]? 2-3
  • Is your shoulder problem associated with fevers, chills, and/or weight loss [77]? 2
  • Are you currently receiving treatment at a chronic pain clinic? If yes, is your shoulder problem part of a generalized pain condition [81]? 2
  • Are you currently receiving active treatment for a generalized joint condition (e.g., arthritis involving multiple joints in your body)? If yes, is this affecting your current shoulder problem [82]? 3
  • Are you currently receiving active treatment for a neurological/neuromuscular condition (e.g., stroke, multiple sclerosis)? If yes, is this affecting your current shoulder problem [77]? 2
  • Are you currently receiving active treatment for a diagnosis of cancer? If yes, is this affecting your current shoulder problem [77]? 2
  • Are you currently receiving active treatment for a medical condition such as diabetes, renal disease, respiratory disease, or ischemic heart disease? If yes, is this affecting your current shoulder problem [77]? 2
Diagnosis The following seventeen questions should be included during history-taking to confirm rotator cuff pathology and/or rule out other conditions:  
  • What is your sex [83]? 2
  • What is your dominant hand [77]? 2
  • What is your occupation [77]? 2
  • When did you first notice you had shoulder pain or a problem with your shoulder [77]? 2
  • Do you have pain in your shoulder [77]? 2
  • Is your shoulder pain a result of a specific injury? If yes, describe how you injured your shoulder in as much detail as possible [84]? 2
  • Can you characterize your pain including: date; severity; onset during activity, onset during overhead activity; presence of night pain; presence of pain at rest [77, 79]? 2-3
  • Does anything help to relieve the pain? If yes, please specify [79]? 2
  • Where do you feel the most pain (i.e., top, side, front, back of shoulder) [85]? 3
  • Does your shoulder feel stiff [79]?  
  • Does your shoulder feel loose or unstable [77]? 2
  • Does your shoulder come out of place [77]? 2
  • Does your shoulder dislocate [77]? 2
  • Has your shoulder dislocated in the past [77]? 2
  • Do you hear or feel unusual sensations such as catching, locking, or grinding in your shoulder joint [86]? 2
  • Do you have painful clicking, grinding, or clunking in your shoulder [86]? 2
  • Does your shoulder feel weak [86]? 2
Physical Examination The following eighteen items should be included during a physical examination to confirm rotator cuff pathology and/or rule out other conditions:  
  • In observing the patient, the shoulder should be exposed and observed from the front and back [85]. 3
  • Active range of motion for the cervical spine should be performed for all planes (i.e., flexion, extension, side flexion, rotation) [87] 2
  • Active range of motion for the shoulder should be performed bilaterally including: shoulder elevation in the scapular plane; shoulder elevation in the sagittal plane; external rotation at 0 degrees abduction; and internal rotation at the spinal level (i.e., the highest vertebral level reached with the thumb extended) [85, 87, 88]. 2
  • Range of motion should be assessed for a painful arc [89]. 2
  • Scapulohumeral rhythm should be assessed for scapular dyskinesis [90]. 2
  • Passive range of motion should only be assessed if active range of motion is limited [85]. 3
  • If active range of motion is limited, assess shoulder using external rotation lag sign and Hornblower’s sign [91, 92]. 2
  • If active and passive ranges of motion are limited, assess isolated glenohumeral joint range of motion [93]. 2
  • If adhesive capsulitis is suspected, bilaterally assess forward elevation and external rotation at 0 degrees abduction at the glenohumeral joint [94]. 3
  • Palpation of the shoulder should occur at the point of maximum tenderness [89]. 2
  • Manual muscle testing should be performed for the supraspinatus muscle in the scapular plane (i.e., thumb pointing down), and having the patient resist against a downward pressure placed on the forearms [95]. 2
  • Manual muscle testing should be performed for the infraspinatus muscle by having the patient externally rotate from 45 degrees of internal rotation against resistance [96]. 2
  • The Belly Press test should be used to assess subscapularis strength [97]. 2
  • The Lift-off test should be used to assess subscapularis strength [98]. 2
  • Neer’s impingement sign should be used to confirm impingement [99]. 2
  • Hawkins-Kennedy sign should be used to confirm impingement [95]. 2
  • Speed’s test should be used to confirm biceps muscle or tendon pathology [100]. 2
  • Cross body adduction test should be used to rule out acromioclavicular joint sprain [87]. 2
Investigations The following four guidelines for investigations are recommended for patients that present with rotator cuff pathology:  
  • From a diagnostic and treatment perspective, a x-ray is a necessary test [49]. 2
  • If rotator cuff disorder is suspected, the following x-ray views should be ordered at the initial visit: true anteroposterior view (Grashey view), axillary, and trans-scapular lateral [49, 101]. 2
  • Ultrasound is the cost-effective investigation for defining a full-thickness rotator cuff tear [50]. 2
  With respect to full-thickness rotator cuff tears, magnetic resonance imaging (MRI) is only required for surgical planning [102]. 2
Treatment The following seven guidelines for investigations are recommended for patients that present with rotator cuff pathology. These guidelines were expanded and merged to create clinical care pathways for three classifications of rotator cuff injuries: acute, chronic, and acute-on-chronic injuries.  
  Acute rotator cuff pathology  
  • Patients without pre-existing history of rotator cuff problems, presenting with an acute, traumatic injury (i.e., definable traumatic event) of the rotator cuff resulting in dramatic loss of shoulder function, should be referred to a surgeon, and seen by the surgeon within 6 weeks after consultation with a primary care practitioner [103]. 2
  Chronic and acute-on-chronic rotator cuff pathology  
  • All patients with chronic rotator cuff disorders should attempt a non-operative rotator cuff home exercise and stretch program [56, 104]. 2
  • Patients presenting to healthcare professionals with chronic rotator cuff disorder should be prescribed a non-operative rotator cuff rehabilitation program at the initial visit, if one has not already been prescribed [56]. 2
  • Stage 1 home programs (Weeks 0–6) should focus on decreasing shoulder pain and increasing shoulder range of motion through exercise, stretching, and high repetition movement patterns, four times every day (i.e., pulley exercises, assisted range of motion for abduction, elevation, external rotation, internal rotation) [56]. 2
  • Stage 2 home programs (Weeks 6–12) should focus on improving strength and muscular control at least once a day (i.e., banding exercises, scapular stabilizing exercises) [56]. 2
  • Patients that are not able to achieve pain-free status with improved range of motion after 6 weeks should attempt additional pain control (i.e., cortisone injection) in adjunct to the non-operative rotator cuff home program [56]. 2
  • Patients that fail a non-operative rotator cuff home program after 12 weeks should receive an ultrasound (i.e., the patient did not improve, remained symptomatic, elected to have surgery, and has not already had ultrasonography) [50, 56]. 2
  1. aConsensus statements were assigned the highest level of evidence available based on the systematic review. Evidence sources are listed in bracketed numbers after each statement. Levels of evidence were adapted from Wright et al. [33].