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Symptomatic Progression of Asymptomatic Rotator Cuff TearsA Prospective Study of Clinical and Sonographic Variables
Nathan A. Mall, MD1; H. Mike Kim, MD1; Jay D. Keener, MD1; Karen Steger-May, MA2; Sharlene A. Teefey, MD3; William D. Middleton, MD3; Georgia Stobbs, RN1; Ken Yamaguchi, MD1
1 Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes-Jewish Hospital Plaza, 11300 West Pavilion, Campus Box 8233, St. Louis, MO 63110
2 Division of Biostatistics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8067, St. Louis, MO 63110-1093
3 Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, St. Louis, MO 63110
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health (R01 AR051026-01A1). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (Zimmer and Tornier).

A commentary by Peter J. Millett, MD, MSc, is available at www.jbjs.org/commentary and is linked to the online version of this article.
Investigation performed at the Department of Orthopaedic Surgery and the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Nov 17;92(16):2623-2633. doi: 10.2106/JBJS.I.00506
A commentary by Peter J. Millett, MD, MSc, is available here
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The purposes of this study were to identify changes in tear dimensions, shoulder function, and glenohumeral kinematics when an asymptomatic rotator cuff tear becomes painful and to identify characteristics of individuals who develop pain compared with those who remain asymptomatic.


A cohort of 195 subjects with an asymptomatic rotator cuff tear was prospectively monitored for pain development and examined annually for changes in various parameters such as tear size, fatty degeneration of the rotator cuff muscle, glenohumeral kinematics, and shoulder function. Forty-four subjects were found to have developed new pain, and the parameters before and after pain development were compared. The forty-four subjects were then compared with a group of fifty-five subjects who remained asymptomatic over a two-year period.


With pain development, the size of a full-thickness rotator cuff tear increased significantly, with 18% of the full-thickness tears showing an increase of >5 mm, and 40% of the partial-thickness tears had progressed to a full-thickness tear. In comparison with the assessments made before the onset of pain, the American Shoulder and Elbow Surgeons scores for shoulder function were significantly decreased and all measures of shoulder range of motion were decreased except for external rotation at 90° of abduction. There was an increase in compensatory scapulothoracic motion in relation to the glenohumeral motion during early shoulder abduction with pain development. No significant changes were found in external rotation strength or muscular fatty degeneration. Compared with the subjects who remained asymptomatic, the subjects who developed pain were found to have significantly larger tears at the time of initial enrollment.


Pain development in shoulders with an asymptomatic rotator cuff tear is associated with an increase in tear size. Larger tears are more likely to develop pain in the short term than are smaller tears. Further research is warranted to investigate the role of prophylactic treatment of asymptomatic shoulders to avoid the development of pain and loss of shoulder function.

Level of Evidence: 

Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    Jerrold M. Gorski
    Posted on February 10, 2011
    The Natural History of Asymptomatic Rotator Cuff Pathology
    Orthopedic Surgeon, Winthrop University Hospital, Mineola, New York

    To the Editor:

    Dr. Yamaguchi's lead article entitled, "Symptomatic Progression of Asymptomatic Rotator Cuff Tears: A Prospective Study of Clinical and Sonographic Variables" (2010;92:2623-33) in the November JBJS is quite remarkable because it increases our awareness of and provides further scientific confirmation of asymptomatic rotator cuff pathology. How does one obtain objective information about an asymptomatic condition? Dr. Yamaguchi uses the symptomatic progression of the tear as a clinical marker. He promises a longitudinal study to assess the natural history. I suspect he may be starting at the end of the natural history and have to work backwards.

    The natural history of symptomatic rotator cuff tears begins with chronic impingement and, over time, plastic deformation, attenuation and finally tearing occurs. It is reasonable to assume the same continuum for the natural history of asymptomatic cuff pathology.

    Chronic asymptomatic shoulder impingement has already been described in "Shoulder Impingement Presenting as Neck Pain" (1,2). This asymptomatic condition, called the "Referred Shoulder Impingement Syndrome", is asymptomatic for the shoulder, but not the neck. My patients with neck pain due to RSIS, frequently say, "I never suspected my shoulder"; they also say, "no one ever examined my shoulder".

    Why should we care about or examine the shoulder if it is asymptomatic? The real value in studying the asymptomatic shoulder is the likelihood that this may underlie the many enigmatic conditions in the neck and the shoulder. Dr. Ian MacNab (3), who famously described the circulation of the rotator cuff, also informally described the absence of sensory nerve fibers in chronic impingement and speculated that this might be important in the etiology of asymptomatic rotator cuff disease.

    How does one obtain objective information to prove the existence of asymptomatic shoulder impingement? The Neer sign and injection test. I inject the asymptomatic shoulder and measure the subjective benefit three weeks later. The only difference between symptomatic and asymptomatic disease is the presence of pain over the supraspinatus muscle, AKA "my neck". Even with a routine of three cortisone injections, I have yet to diagnose asymptomatic rotator cuff tears, probably because this is earlier in the natural history. Further study and understanding of the natural history of the asymptomatic shoulder will undoubtedly lead to measures that prevent late rotator cuff tears. The immediate benefit to identifying asymptomatic shoulder impingement is to cure chronic neck pain. The authors should be congratulated for their excellent work.


    1. Gorski JM, Schwartz LH. Shoulder impingement presenting as neck pain. J Bone Joint Surg Am. 2003;85:635-8.

    2. Gorski JM. A new "pain in the neck". AAOS Now. 2007 2007 Aug.

    3. MacNab I, McCulloch J. Neck ache and shoulder pain. Baltimore: Williams and Wilkins; 1994. p 318-9.

    Ken Yamaguchi, MD
    Posted on February 10, 2011
    Dr. Yamaguchi and colleagues respond to Dr. Gorski
    Sam and Marilyn Fox Distinguished Professor of Orthopaedic Surgery, Chief, Shoulder and Elbow Service, Washington University School of Medicine, St. Louis, MO

    Dr. Gorski’s letter regarding our article entitled, “Symptomatic Progression of Asymptomatic Rotator Cuff Tears: A Prospective Study of Clinical and Sonographic Variables,” raises an interesting concept that we ill be sure to pay more attention to in the future. That is, a patient with a seemingly asymptomatic rotator cuff tear may actually be manifesting their symptoms in the neck rather than in the shoulder. We did not specifically ask patients whether or not their necks were painful at the time of enrollment into our study. We thus cannot make a specific comment regarding the prevalence of coexistent neck symptoms which may actually be the manifestation of a seemingly asymptomatic rotator cuff condition. We will certainly consider this as a variable to look at with future follow-up of our patient study and thank Dr. Gorski for bringing this to our attention.

    It should be noted with respect to this specific study, that our patient population included those who previously did not have a painful shoulder and then developed a painful shoulder. The results specific to the shoulder should thus still be applicable regardless of whether or not they had had neck pain in addition to newly developed shoulder pain. We again thank Dr. Gorski for his comments and suggestions for future areas of study.

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