Understanding Rotator Cuff Tears: A Must-Know for the APRN Certification Exam

The rotator cuff is a group of four muscles and their tendons—supraspinatus, infraspinatus, teres minor, and subscapularis—that stabilizes the shoulder joint and enables a wide range of movement. A tear can occur from acute trauma or degenerative overuse, most commonly involving the supraspinatus tendon.

These injuries range from partial tears to full-thickness disruptions, and patients may experience significant pain and functional impairment. Prompt recognition and differentiation from non-musculoskeletal causes (such as myocardial infarction) is critical in both exam and clinical encounters.

Rotator cuff tears result from:

✅ Acute trauma (e.g., lifting a heavy object or falling)

✅ Chronic degeneration, especially in a patient over 40, due to tendon tear and age-related weakening

Tendon fibers fray or rupture, leading to inflammation, impaired movement, and muscular weakness. Associated bursitis or impingement may further contribute to pain and dysfunction.

Patients with rotator cuff tears often present with:

✅ Dull, aching shoulder pain, especially with overhead activity; weakness, particularly with abduction and external rotation

✅ Difficulty sleeping on the affected side

✅ Preserved passive range of motion but limited active range of motion

Classic exam findings include:

✅ Positive drop arm test; patients cannot smoothly lower the arm from abduction

✅ Empty can test: pain or weakness with resisted shoulder abduction thumbs-down position

Diagnosis is primarily clinical, supported by:

✅ History: Acute injury or chronic overuse, dominant arm involvement, night pain

✅ Physical examination: Focused on shoulder examination with strength testing and special maneuvers

✅ Plain radiographs to rule out fractures or arthritis

✅ MRI or ultrasound for definitive evaluation, especially if surgical intervention is considered

 ★★★★★ Certification Tip: Recognize the difference between limited active and passive range of motion—this helps differentiate rotator cuff tear from conditions like adhesive capsulitis (frozen shoulder).

Shoulder pain may signal more than a musculoskeletal injury. It's vital to consider:

✅ Myocardial infarction: Left shoulder pain with nausea, diaphoresis, or chest discomfort— especially in women and older adults

✅ Cervical radiculopathy: Pain radiates from the neck, often with numbness or tingling in a dermatomal pattern

✅ Adhesive capsulitis: Gradual stiffness and restricted active and passive range of motion

✅Subacromial bursitis: Overlapping pain but typically without muscle weakness; often improves with NSAIDs alone

 ❗ Red Flag Reminder: Always rule out cardiac causes first when a patient presents with unexplained left shoulder pain and systemic symptoms.

Management will depend on the rotator cuff tear severity and the patient’s functional demands.

Conservative treatment (first line):

✅ Activity modification and avoidance of aggravating movements

✅ NSAIDs for pain and inflammation

✅ Physical therapy to strengthen supporting muscles and restore mobility

✅ Ice, rest and home excercise programs

Rotator cuff tears represent a core concept in primary care orthopedics and often appear on certification exams due to their prevalence and the importance of accurate and early diagnosis.

Key takeaways include: 

✅ Distinguishing rotator cuff tear from other causes of shoulder pain, including cardiac ischemia

✅ Understanding the difference between active and passive motion deficits

✅ Applying evidence-based conservative management before escalating to imaging or surgery

Ready to dive deeper into topics like atopic dermatitis and other high-yield certification exam content? Explore our FNP review products.