The Effect of Rotator Cuff Tear Size on
Shoulder Strength and Range of Motion
Robert A. McCabe, PT, MS, OCS1
Stephen J. Nicholas, MD2
Kenneth D. Montgomery, MD3
John J. Finneran, PT4
Malachy P. McHugh, PhD5
Study Design: Prospective cohort study.
Objectives: To determine the effect of rotator cuff tear size on shoulder strength and range of
Background: Patients with rotator cuff pathology typically present with weakness and motion loss
in various motions. The extent to which the presence of a rotator cuff tear and the size of the tear
affect strength and range of motion is not well understood.
Methods and Measures: Sixty-one patients scheduled for surgery, with a diagnosis of a rotator cuff
tear and/or subacromial impingement, underwent examination for shoulder pain, function, range
of motion, and strength. The extent of rotator cuff pathology was documented during subsequent
surgery (presence of tear, tear size, tear thickness).
Results: There were 10 massive tears, 15 large tears, 13 medium tears, 12 small tears, and 11
rotator cuffs without a tear. Patients had marked weakness in abduction strength at 90° and 10° of
abduction, in external rotation strength at 90°, and in the ‘‘full can’’ test (all, P?.0001). Marked
range of motion losses in shoulder flexion and external rotation at 0° and 90° abduction (all,
P?.001) were also observed. Abduction strength deficit at 10° was affected by rotator cuff tear
size (P?.0001). Twenty of 25 patients with large or massive tears had deficits greater than 50%,
compared with only 1 of 11 patients with no tear, 2 of 12 patients with a small tear, and 5 of 13
patients with a medium tear (P?.0001). Other strength and range of motion deficits or indices of
pain and function were unaffected by tear size.
Conclusions: Weakness of greater than 50% relative to the contralateral side in shoulder abduction
at 10( of abduction was indicative of a large or massive rotator cuff tear. J Orthop Sports Phys Ther
Key Words: handheld dynamometer, shoulder muscle strength
he clinical presentation of patients with rotator cuff tears
displays wide variability. While some patients with acute
injury may have profound functional limitations secondary
to pain, motion loss, and weakness, others may present with
minimal impairments.3,4,8,9,25-28The extent to which weak-
ness and motion loss are affected by rotator cuff tear size is not well
1Senior Physical Therapist, Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill
Hospital, New York, NY.
2Director, Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, NY.
3Attending Orthopaedic Surgeon, Department of Orthopedics, Lenox Hill Hospital, New York, NY.
4Senior Physical Therapist, Sports Physical Therapy of New York, Lake Success, New York, NY.
5Director of Research, Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital,
New York, NY.
This study was approved by the Lenox Hill Hospital Institutional Review Board.
Address correspondence to Malachy McHugh, Nicholas Institute of Sports Medicine & Athletic Trauma,
Lenox Hill Hospital, 130 East 77th Street, New York, NY 10021. E-mail: email@example.com
understood. Previous studies exam-
ining the relationship between
strength, range of motion (ROM),
and pain and rotator cuff pathol-
ogy have reported somewhat con-
and abduction strength tested at
90° of abduction (assessed manu-
ally)9was found to be associated
with larger tears.
Kirschenbaum et al16found no
significant difference in isokinetic
shoulder flexion, abduction, and
external rotation strength between
patients with large or massive tears
as compared with patients with
small or medium tears. Of note,
the strength tests were made fol-
lowing a lidocaine injection. Bry-
ant et al2found that a clinical
examination including manual as-
sessment of weakness in internal
and external rotation had poor
predictive value for tear size.
Cofield et al4
shoulder strength and ROM loss
were associated with larger cuff
tears; however, this relationship
was not specifically quantified.
Weakness in both the ‘‘full can’’
and ‘‘empty can’’ test was shown
to discriminate between full and
partial thickness tears, but was not
examined in regard to tear size.15
Rokito et al30assessed isokinetic
shoulder strength in patients with
full thickness tears prior to under-
130 Journal of Orthopaedic & Sports Physical Therapy
going rotator cuff repair and found that the greatest
deficits were in abduction, followed by flexion and
external rotation. However, the effect of tear size was
not examined. With respect to ROM, Hawkins et al9
reported no correlation between tear size and active
or passive shoulder ROM. Conversely, Post et al28
reported that decreased active elevation was associ-
ated with larger tears.
Previous studies have utilized isokinetic16,30
manual9,28,15strength tests to examine shoulder weak-
ness in patients with rotator cuff pathology. Isokinetic
strength testing is time consuming, requires the use
of expensive equipment, and may not be feasible in
the typical clinical setting. Conversely, manual
strength testing is inherently subjective and has ques-
tionable reliability.10Strength testing with the use of
a handheld dynamometer provides an objective test
that is easy to administer in a clinical setting.
Handheld dynamometry has been shown to be sensi-
tive in detecting small but significant side-to-side
differences in shoulder strength in professional base-
ball pitchers7,18and is a viable option for testing
patients with rotator cuff pathology. Handheld
dynamometry has been shown to have similar repro-
ducibility to isokinetic testing for shoulder abduction
The purpose of this study was to determine to what
extent rotator cuff tear size affects shoulder strength
(assessed using a handheld dynamometer) and shoul-
Sixty-one patients (46 males [mean age ± SD, 51 ±
16 years] and 15 females [mean age ± SD, 57 ± 15
years]) with a rotator cuff tear and/or subacromial
impingement, as diagnosed by an orthopedic sur-
geon, participated in this study. The average (±SD)
duration of symptoms was 22 ± 42 months. Twenty-
two patients had a gradual onset of symptoms and 39
patients had a sudden onset associated with a specific
injury. The dominant arm was involved in 42 patients
while the nondominant arm was involved in 19
patients. The exclusion criteria were the following:
prior surgery to either shoulder, a history of a
neuromuscular, neurovascular, or musculoskeletal
condition involving either upper extremity or cervical
pathology within the past year. All subjects were
nonsymptomatic and had no history of rotator cuff
pathology on the contralateral side. The rights were
protected and informed consent was received from
all patients. The protocol for the study was approved
by the Lenox Hill Hospital Institutional Review
All patients were evaluated by 1 of 2 physical
therapists prior to undergoing arthroscopic evalua-
tion. Both therapists had more than 8 years of
experience in an orthopedic setting at the initiation
of this study. Subject assessment of shoulder function
was performed using the patient self-evaluation sec-
tion of the American Shoulder and Elbow Surgery
rating scale.29This provided a measurement for pain,
function with activities of daily living (ADL), and
overall shoulder function (0%-100%). Active shoulder
ROM was measured with a plastic goniometer for
abduction, flexion, and external rotation with the
patient in a standing position. External rotation was
tested with the shoulder positioned at both 0° and
90° of shoulder abduction. Shoulder strength was
then measured for each patient with a handheld
dynamometer (Lafayette Instruments, Lafayette, IN).
Strength tests included resisted elevation in the
scapular plane at 90° of abduction with the humerus
externally rotated (full can test), resisted external
rotation with the shoulder at 90° of abduction, and
resisted abduction with the shoulder positioned at
both 90° and 10° of abduction (palm facing down).
All measurements were taken while subjects were in
the standing position. The average of 2 trials for each
strength test was recorded. ROM measurements were
made prior to strength measurements. For strength
testing, abduction strength was tested first, followed
by the full can test and external rotation. The order
of testing shoulder abduction strength at 90° and 10°
of abduction was alternated for each patient to
minimize any potential systematic abduction fatigue
effects. Considering that there were only 2 trials per
test, fatigue effects should have been minimal. All
strength and ROM tests were repeated on the
contralateral shoulder. For ROM, side-to-side differ-
ences were reported in degrees. For strength mea-
([noninvolved – involved/noninvolved] × 100).
Goniometric range of motion20
dynamometry strength tests19have been shown to
have good reliability in the upper extremity.
Arthroscopic evaluation was subsequently carried
out by 1 of 2 orthopedic surgeons. The surgeons
were blinded to the results of the strength and ROM
testing. Tear size was quantified using the classifica-
tion introduced by DeOrio and Cofield,5which cat-
egorizes tear size according to greatest diameter:
small, less than 1 cm; medium, 1 to 3 cm; large, 3 to
5 cm; and massive, greater than 5 cm. Any coexisting
pathologies, including the presence of calcium depos-
its, acromioclavicular arthritis, a type II or III
acromion (hooked acromion), or a tear of the biceps
and/or labrum were recorded. Details regarding the
thickness of the tear and extent of retraction were
documented as well.
One-way analysis of variance was used to examine
the effect of rotator cuff tear size on strength deficits,
loss of ROM, pain, function, and self-assessment. Post
hoc pairwise comparisons were made with Tukey’s
test. Chi-square analysis was used to compare strength
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005 131
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deficits (dichotomizing patients into 2 groups) be-
tween patients with larger and massive rotator cuff
tears and the rest of the patients.
Ten patients had a massive rotator cuff tear, 15
patients had a large tear, 13 patients had a medium
tear, 12 patients had a small tear, and 11 patients did
not have a tear (requiring only a subacromial decom-
pression). Full-thickness tears were seen in 3 of 12
small tears, 11 of 13 medium tears, and all large and
massive tears. The rotator cuff tear was retracted in 1
of 12 small tears, 7 of 13 medium tears, 13 of 15
large tears, and all 10 massive tears. Twenty-one
supraspinatus (11 had a small tear, 6 had a medium
tear, 3 had a large tear, and 1 had a massive tear). All
other tears involved 2 or more tendons. Twelve
patients had a labral tear (2 had no rotator cuff tear,
5 had a small tear, 4 had a medium tear, and 1 had a
large tear). Eight patients had acromioclavicular joint
arthritis (4 had a small rotator cuff tear, 1 had a
medium tear, and 3 had a large tear). Five patients
had a medial spur (3 had a small rotator cuff tear, 1
had a medium tear, and 1 had a massive tear). Four
patients had a type II or III acromion (2 had no
rotator cuff tear, 1 had a medium tear, and 1 had a
The patient sample as a whole had marked
strength deficits, as compared to the contralateral
side, in all tests (P?.0001): abduction strength at 90°
FIGURE 1. Relationship between rotator cuff tear size and abduc-
tion strength deficit at 10° abduction. Bars are mean ±SD for
percent deficit as compared to the asymptomatic contralateral
shoulder. Main effect of tear size (P?.0001). Strength deficits in
patients with large (*P?.01) and massive (†P?0.05) tears were
greater than the deficits in patients with no tear or small tears.
(mean ± SD, 53% ± 36%), full can test (48% ± 32%),
abduction strength at 10° (40% ± 29%), and external
rotation strength at 90° (31% ± 78%). Only abduc-
tion strength deficit at 10° was affected by rotator
cuff tear size (P?.0001, Figure 1). Tear size did not
affect strength deficits in abduction at 90° (P = .07),
full can test (P = .14), or external rotation at 90° (P =
.17) (Table 1). Abduction strength deficit at 10° was
also affected by tear thickness (P?.05). Patients with
full thickness tears had a mean (±SD) deficit of 47%
± 27% compared to 35% ± 35% in patients with
partial thickness tears and 21% ± 24% in patients
with no tear. Abduction strength deficits at 10°
(P?.01) and 90° (P?.05) were affected by the
retraction of the rotator cuff tear: for abduction at
10°, patients with retracted tears had a mean (± SD)
deficit of 52% ± 23% compared to 32% ± 34% in
patients with nonretracted tears and 21% ± 24% in
patients with no tear (the corresponding mean [±SD]
deficits at 90° were 64% ± 34% for patients with
retracted tears, 41% ± 41% for patients with
nonretracted tears, and 44% ± 20% for patients with
no tear). Abduction deficit at 10° was also affected by
the number of tendons involved in the rotator cuff
tear (P?.001): patients with more than 1 tendon
involved had a mean (±SD) deficit of 54% ± 27%
compared to 31% ± 27% in patients with 1 tendon
involved and 21% ± 24% in patients with no tear. No
other strength deficits were affected by rotator cuff
tear thickness, retraction, or number of tendons
The patient sample as a whole had shoulder ROM
losses (P?.001) in flexion (mean ± SD, 26° ± 33°),
external rotation at 90° (mean ± SD, 21° ± 25°) and
external rotation at 0° (mean ± SD, 16° ± 17°) when
compared to the contralateral side. Loss of external
rotation at 0° of shoulder abduction was affected by
tear size (P?.05, Figure 2), but tear size did not
affect loss of external rotation ROM at 90° of
abduction (P = .39) or loss of flexion ROM (P = .82).
Patients with massive tears had a mean (±SD) loss of
external rotation ROM at 0° of 27° ± 24°, while
patients with a small tear only had a loss of 5° ± 9°
(P?.05). However, the mean (±SD) external rotation
ROM loss was 14° ± 15° in patients with no tear.
ROM losses were unaffected by rotator cuff tear
thickness, retraction, or number of tendons involved.
Rotator cuff tear size did not affect pain (P = .17),
function with ADL (P = .71), overall function (P =
.99), or chronicity of injury (P = .54). Tear size was
affected by patient age (P?.001). Patients who did
not have a rotator cuff tear were significantly younger
than the other patients (P?.05): no tear mean ( ±
SD) age, 36 ± 14 years; small tear mean ( ± SD) age,
56 ± 13 years; medium tear mean ( ± SD) age, 51 ±
16 years; large tear mean ( ± SD) age, 57 ± 15 years;
massive tear mean ( ± SD) age, 62 ± 9 years. The
mechanism of injury (gradual onset versus sudden
132J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
TABLE 1. Effect of rotator cuff tear size on strength deficits (mean ± SD) and range of motion (ROM) deficits (mean ± SD) for the tests
with nonsignificant effects (P?.05). Strength and ROM deficits are expressed compared to the asymptomatic contralateral shoulder.
Strength Deficits (%)ROM Deficits (deg)
Effect of tear size
43.9 ± 20.3
47.7 ± 31.8
37.2 ± 47.1
63.0 ± 36.3
75.0 ± 22.4
P = .07
39.0 ± 34.8
40.9 ± 32
36.9 ± 32.9
56.0 ± 29.4
65.3 ± 23.5
P = .14
37.3 ± 30.9
33.9 ± 27.5
24.7 ± 39.4
39.3 ± 55.0
70.6 ± 27.8
P = .17
21 ± 35
21 ± 25
22 ± 33
30 ± 31
35 ± 45
P = .39
24 ± 22
18 ± 22
11 ± 22
24 ± 25
31 ± 32
P = .82
FIGURE 2. Relationship between rotator cuff tear size and loss of
external rotation range of motion (ROM). Bars are mean ±SD for
ROM loss as compared to the asymptomatic contralateral shoulder.
Main effect of tear size (P?.05). ROM loss in patients with massive
tears was greater (*P?.05) than the ROM loss in patients with small
onset) was unaffected by tear size (P = .51). Pain,
function with ADL, and overall function were also
unaffected by rotator cuff tear thickness, retraction,
or number of tendons involved.
There were no differences in strength or ROM
deficits between men and women (P = .52-.90) and
rotator cuff tear sizes were not different between men
and women (P = .79).
A receiver-operating characteristic curve (Figure 3)
was created to determine whether the abduction
strength deficit at 10° was a useful test for identifying
patients with large or massive rotator cuff tears. The
true positive and false positive rates were computed
for deficits from 10% to 90% in 10% increments. The
strength deficit that yielded the smallest error ([100 –
true positive rate] ± false positive rate) was 50%. Six
of 10 patients with massive tears and 14 of 15 patients
with large tears had deficits in abduction strength at
10° that were greater than 50%. By comparison, only
1 of 11 patients with no tear, 2 of 12 patients with a
small tear, and 5 of 13 patients with a medium tear
had deficits that were greater than 50% (Mantel-
Haenszel chi-square test [P?.0001]). Using a deficit
of 50% to categorize patients, the abduction strength
test at 10° of abduction had a sensitivity of 80%, a
specificity of 78%, a positive predictive accuracy of
71%, and a negative predictive accuracy of 85%.
In the present study, the only strength measure-
ment affected by rotator cuff tear size was shoulder
abduction tested at 10° of abduction. Twenty of 28
patients with a deficit greater than 50% (compared to
the asymptomatic contralateral side) had a large or
massive tear compared with 5 of 33 patients with a
FIGURE 3. The receiver-operating characteristic (ROC) curve for the
shoulder abduction strength test at 10° of abduction. True and false
positive rates are calculated for identifying large and massive rotator
cuff tears based on the percent strength deficit. True and false
positive rates are plotted for strength deficits from 10% to 90% in
0 10 20 30 40 50 60 70 80 90 100
False Positive Rate (%)
True Positive Rate (%)
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005133
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deficit that was 50% or less. The lack of effect of tear
size on the other tests may be attributable to the test
positions. The other 3 strength tests involved posi-
tioning the arm in 90° of shoulder elevation (full can
test) or 90° of shoulder abduction (external rotation
and abduction tests). Impingement symptoms during
testing in these positions may have contributed to the
measured weakness and obscured differences due to
rotator cuff tear size. Ben-Yishay et al1effectively
demonstrated improved shoulder abduction strength
following subacromial lidocaine and bupivacaine in-
jection in patients with impingement.
The only other factors that were affected by tear
size were age and loss of shoulder external rotation
motion compared to the contralateral side. Age has
long been recognized as a diagnostic indicator in this
patient population. McLaughlin et al21in 1951 re-
ported an average age of 57 years for patients with
massive tears and 41 years for patients with incom-
plete tears. The decrease in active external rotation
motion in patients with massive tears may reflect an
external rotation lag sign.11However, the range of
motion loss was not progressively worse with increas-
ing tear size. Patients with no tear actually had
greater (nonsignificant) loss of motion than patients
with a small tear.
The fact that reliability was not documented for the
strength and ROM tests is a limitation in this study.
The lack of an effect of some of the strength and
ROM tests on rotator cuff tear size may in part be
attributable to measurement error. However, previous
studies have shown good reliability in the upper
extremity for goniometric range of motion20and
handheld dynamometry strength tests.19Additional
limitations were that the study sample was limited to
those patients who were scheduled for surgery and
had unilateral symptoms. While the abduction
strength deficit at 10° of abduction may be useful in
identifying large and massive tears, this finding is
based on a patient population of those patients who
had either failed nonsurgical treatment or for whom
nonsurgical treatment was not considered. Therefore,
the usefulness of this test in patients having nonsurgi-
cal treatment for a rotator cuff injury remains to be
determined. The exclusion of patients with bilateral
symptoms was necessary to assess the effect of tear
size on strength and ROM deficits. However, it is
common for patients with rotator cuff pathology to
have bilateral symptoms and the current results
would not be applicable to such patients.
Severe weakness in the initiation of shoulder ab-
duction in patients with large and massive rotator
cuff tearsis consistent
McLaughlin,22who stated, ‘‘No patient who had
complete or massive avulsion of the cuff from the
humerus was able to initiate abduction of the arm
against gravity in any position.’’ While all patients in
the present study were able to generate some force
with the findingsof
against the dynamometer at 10° of abduction (range,
1 to 25 N for patients with a massive tear), 8 patients
were unable to abduct their arm to 90° for testing in
that position. A deficit of 100% was recorded for
those tests. With a handheld dynamometer it is
possible to objectively quantify weakness at the initia-
tion of abduction first noted by McLaughlin.22
The biomechanical reason for the effect of rotator
cuff tear size on abduction strength at 10° is unclear.
Some authors have suggested that the supraspinatus
tion.6,12,17,25,30Conversely, McLaughlin22had previ-
ously claimed that supraspinatus function was not
necessary for the initiation and maintenance of
abduction. Because abduction weakness at 10° in-
creased with both the size of the tear and the
number of tendons involved, this weakness could not
be solely attributed to supraspinatus disruption. In
this regard, the current findings support the conten-
tion of McLaughlin.22
The gold standard for noninvasive diagnosis of
rotator cuff tears is magnetic resonance imaging
(MRI). Ianotti et al14reported that MRI had excel-
lent sensitivity, specificity, and positive and negative
predictive accuracy in differentiating full-thickness
tears, partial thickness tears, and intact tendons.
However, the accuracy of MRI in detecting tear size
was not reported. Motamedi et al24reported the
accuracy of MRI in quantifying tear size in patients
with recurrent tears. Based on their sample of 33
shoulders, MRI had a sensitivity of 79%, a specificity
of 85%, a positive predictive accuracy of 90%, and a
negative predictive accuracy of 69% for the detection
of large and massive rotator cuff tears. The abduction
strength test at 10° of shoulder abduction used in the
present study had similar sensitivity (80% versus
79%), lower specificity (78% versus 85%), lower
positive predictive accuracy (71% versus 90%), and
higher negative predictive accuracy (85% versus
69%). A negative predictive accuracy of 85% indicates
that, if a patient has a strength deficit of less than
50% in shoulder abduction at 10° of abduction, it is
likely that the patient does not have a large or
massive rotator cuff tear. However, it is important to
note that this test does not rule tears of a smaller
The receiver-operating characteristic curve for ab-
duction strength deficit at 10° of shoulder abduction
captures 84% of the area under its curve. Generally,
tests capturing 90% to 100% of the area under the
curve are considered excellent, and those capturing
80% to 90% are considered good.23The combination
of shoulder abduction deficit at 10° of abduction and
patient age decreased the area under the receiver-
operating characteristic curve to 70%, indicating that
the combination of variables did not improve the
detection of large or massive rotator cuff tears.
134J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
CONCLUSION Download full-text
Weakness of greater than 50% relative to the
contralateral side in shoulder abduction at 10° of
abduction was indicative of a large or massive rotator
cuff tear. Other shoulder strength tests were not
affected by tear size. Because patients with large and
massive rotator cuff tears are thought to have a poor
prognosis for nonoperative treatment,31any clinical
test that can identify large and massive tears would be
valuable to physical therapists. The abduction
strength test at 10° of abduction may be a useful
adjunct to the clinical exam in patients with sus-
pected rotator cuff pathology.
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