Anterior fullness or squared-off shoulder suggesting dislocation
Ecchymosis and swelling pattern
Anterior arm bruising suggesting biceps injury
Active versus passive range of motion
Preserved passive range with markedly reduced active elevation
Strength and provocative maneuvers
Rotator cuff focused maneuvers
Supraspinatus assessment
Empty can or Jobe test weakness
Drop arm sign
Infraspinatus and teres minor assessment
External rotation weakness
External rotation lag sign
Subscapularis assessment
Lift-off weakness
Belly-press weakness
Pain-limited testing caveat
If pain prohibits exam, reassess after analgesia
Neurovascular and associated exam
Neurovascular and regional exam
Axillary nerve function
Lateral deltoid sensation
Deltoid strength
Distal perfusion
Radial pulse symmetry
Capillary refill
Cervical spine screening
Spurling provocation if radicular symptoms
Scapular dyskinesis and AC joint tenderness
AC joint injury mimic
Differential Diagnosis
Life-threatening or limb-threatening considerations
High-risk alternatives
Glenohumeral dislocation with neurovascular injury
Axillary artery injury
Axillary nerve neuropraxia
Proximal humerus fracture
Surgical neck fracture
Greater tuberosity fracture
Septic arthritis
Fever and atraumatic severe pain
Common mimics and related pathology
Musculoskeletal mimics
Long head biceps tendon rupture
Popeye deformity
Supination pain
AC joint sprain or separation
Superior shoulder pain
Rotator cuff contusion or strain
Rapid improvement over days
Labral tear
Mechanical catching
Cervical radiculopathy
Neck pain with dermatomal symptoms
Adhesive capsulitis
Reduced passive range of motion
Coding alignment
Coding and terminology mapping
ICD-10 acute rotator cuff tear
M75.1 rotator cuff tear or rupture, not specified as traumatic
S46.0X rotator cuff muscle and tendon injury at shoulder and upper arm level, traumatic category
SNOMED CT concepts
Rotator cuff tear
Traumatic rupture of rotator cuff tendon
Laboratory Tests
When labs are useful
Selective lab strategy
No routine labs for isolated suspected cuff tear
Imaging-driven diagnosis predominates
If operative planning or significant comorbidity
Hemoglobin for significant ecchymosis or anticoagulation
INR if warfarin use and bleeding concern
Infection or systemic concern
Infection evaluation set
If fever, erythema, atraumatic severe pain, or immunosuppression
White blood cell count for systemic inflammation support
C-reactive protein for inflammatory signal
Blood cultures if septic physiology
Co-injury evaluation
Trauma-related labs
If polytrauma or high-energy mechanism
Type and screen if hemorrhage concern
Basic metabolic panel for analgesic planning and renal risk
Diagnostic Tests
Scoring Systems
Symptom and function scales
QuickDASH
Baseline disability tracking for follow-up
ASES score
Specialist clinic outcome tracking
Constant-Murley score
Post-treatment recovery tracking
MRI
MRI shoulder utility
Best modality for tear characterization
Full-thickness versus partial-thickness
Tendon retraction and muscle atrophy
Timing considerations in acute trauma
Early MRI if high suspicion and surgical candidacy
Pitfalls
Pain-related guarding can mimic weakness, MRI clarifies anatomy
CT
CT indications in acute traumatic shoulder pain
Occult fracture concern with negative radiographs
Greater tuberosity fracture
Glenoid rim fracture
Preoperative bony detail needs
Complex proximal humerus fracture patterns
Not primary for cuff tendon visualization
Tendon assessment limited compared with MRI and ultrasound
Ultrasound (or US)
Ultrasound applications
Point-of-care ultrasound for rotator cuff
Full-thickness tear signs
Dynamic assessment during abduction
Effusion and bursitis assessment
Subacromial-subdeltoid bursa fluid
Advantages and limitations
Rapid and bedside capable
Operator dependence and limited retraction assessment
Disposition
Admission, urgent referral, discharge
Disposition pathways
Emergent orthopedic or surgical consultation
Shoulder dislocation with neurovascular compromise
Open fracture or skin tenting
Urgent orthopedic referral within 3 to 7 days
Suspected acute full-thickness tear with major weakness
Pseudoparalysis with preserved passive range of motion
Routine outpatient follow-up
Suspected strain or partial tear with improving function
Normal radiographs and stable neurovascular exam
Safe discharge criteria
Discharge readiness criteria
Pain controlled with oral regimen
Functional plan for sleep and basic activities
No fracture or dislocation on initial imaging when obtained
Clear return plan if symptoms worsen
Intact neurovascular exam documented
Repeat after analgesia and any manipulation
Follow-up planning
Follow-up essentials
Imaging plan
MRI or ultrasound arranged if high suspicion and persistent weakness
Therapy plan
Early gentle range of motion if stable and per ortho guidance
Work and sport restrictions
Avoid overhead lifting and heavy load on affected arm
Treatment
Analgesia and symptom control
Pain control strategy
First-line non-opioid regimen
Acetaminophen PO
1000 mg every 6 to 8 hours
Maximum 3000 mg per day if chronic use or older age
Ibuprofen PO
400 mg every 6 to 8 hours
Maximum 2400 mg per day
Naproxen PO
250 to 500 mg every 12 hours
Avoid with significant renal disease or GI bleed risk
Topical option
Diclofenac topical
Apply to shoulder region per product labeling
Avoid on broken skin
Short-course opioid if severe pain limiting function
Hydromorphone PO
1 mg every 6 to 8 hours as needed
Lowest effective quantity and duration
Immobilization and early mobility
Activity and immobilization plan
Sling for comfort
Brief use to reduce pain
Early passive range of motion if fracture excluded
Pendulum exercises as tolerated
Avoid prolonged immobilization
Stiffness and adhesive capsulitis risk
Definitive management pathways
Tear-specific management
Suspected full-thickness acute traumatic tear
Early orthopedic evaluation for surgical candidacy
Earlier repair consideration in younger or high-demand patients
Partial-thickness tear or strain
Nonoperative pathway with analgesia and physiotherapy focus
Reassessment if persistent weakness beyond 2 to 6 weeks
Evidence framing for ED practice
Evidence and guideline framework
Class I concept
Neurovascular exam documentation in traumatic shoulder injury
Exclude fracture and dislocation before attributing weakness to cuff tear
Class IIa concept
Early specialist referral when pseudoparalysis suggests acute full-thickness tear
Ultrasound or MRI to define tear when management hinges on tear type
ACEP Level C style consensus
Analgesia, sling for comfort, and early follow-up for suspected cuff tear
Avoid corticosteroid injection in the acute traumatic setting without specialist plan
Special Populations
Pregnancy
Pregnancy considerations
Imaging selection
Ultrasound preferred when feasible
MRI without gadolinium acceptable when clinically necessary
Medication selection
Acetaminophen preferred first-line
NSAID avoidance in later pregnancy per obstetric guidance
Positioning and comfort
Left lateral tilt in later pregnancy if supine symptoms
Geriatric
Geriatric considerations
Higher likelihood of pre-existing degenerative tearing
Trauma may unmask chronic tear
Higher fracture risk with low-energy falls
Low threshold for radiographs and CT if persistent pain
Medication risk
NSAID renal and GI risk
Opioid delirium and fall risk
Pediatrics
Pediatric considerations
Traumatic cuff tears uncommon
Proximal humerus physeal injury more likely
Imaging focus
Radiographs prioritized to exclude fracture and growth plate injury
Referral triggers
Persistent weakness after pain control and normal radiographs
Background
Epidemiology
Epidemiology overview
Degenerative tears increase with age
Traumatic tears more likely to be full-thickness in older adults after a fall
Mechanisms associated with acute tearing
Fall on outstretched hand
Shoulder dislocation event
Pathophysiology
Pathophysiology essentials
Tendon failure patterns
Supraspinatus most commonly involved
Larger tears can involve infraspinatus and subscapularis
Functional consequence
Loss of force coupling leading to superior humeral head migration
Pseudoparalysis from loss of cuff function rather than true neurologic paralysis
Therapeutic Considerations
Therapeutic rationale
Nonoperative success drivers
Pain control enabling rehab participation
Scapular stabilization and deltoid compensation
Surgical timing concept in acute traumatic tears
Earlier repair can reduce retraction progression and improve tendon quality
Imaging value
Tear size, retraction, and muscle quality guide operative versus nonoperative planning
Patient Discharge Instructions
copy discharge instructions
Discharge instructions for suspected acute traumatic rotator cuff tear
Sling use for comfort
Remove several times daily for gentle pendulum motion if advised and no fracture
Pain control plan
Acetaminophen as directed on label or clinician instructions
NSAID only if safe for you and approved by clinician
Activity restrictions
Avoid lifting, pushing, pulling, or overhead activity with the injured arm
Follow-up plan
Orthopedics or sports medicine appointment within recommended timeframe
Imaging appointment if MRI or ultrasound ordered
Return to ED immediately
New numbness, tingling, or weakness in hand or arm
Hand becomes cold, pale, or very painful
Severe swelling or rapidly expanding bruising
Fever or increasing redness and warmth around shoulder
Worsening pain not controlled with prescribed medications
References
Guidelines and evidence sources
Core reference set
American Academy of Orthopaedic Surgeons guidance on rotator cuff tears
Nonoperative care and indications for surgical referral
American College of Radiology Appropriateness Criteria for acute shoulder pain imaging
Radiographs first-line for trauma
MRI or ultrasound for suspected cuff tear when radiographs non-diagnostic
Emergency medicine practice framework
Neurovascular assessment and fracture exclusion in traumatic shoulder presentations
Coding and terminology sources
Terminology references
ICD-10-CM code set for shoulder tendon injuries
Traumatic tendon injury category S46
SNOMED CT concepts for rotator cuff tear and tendon rupture
Standardized problem list mapping for EHR
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.