**3. Clinical signs and symptoms**

As the incidence of rotator cuff tears increases with age, especially after age 60, elderly patients are the most likely group to seek help due to massive rotator cuff tears [10, 18]. Some of them might report a traumatic event and an acute loss of function, with or without previous symptoms; however, most will deny any noticeable trauma and complain of variable levels of pain [10]. It is important to ascertain that the pain reported by the patient is actually caused by the massive cuff tear, and not from another source.

If it is accompanied by stiffness, especially with limitation of passive external rotation and passive glenohumeral abduction, it is very likely that the pain is due to adhesive capsulitis rather than MRCT.

Acromioclavicular joint pain, though different from the usual rotator cuff pain [19] is the second most common cause of pain that is not caused by, but is occasionally [1] attributed to rotator cuff tear.

Loss of function and disability are the next biggest complaint, as MRCT is always accompanied by some degree of shoulder weakness. This weakness is especially marked with the limb away from patient's body. Anterosuperior tears usually result with painful weakness of elevation. Posterosuperior tears and global tears cause weakness of elevation and external rotation [20]. This usually spans from hardly any perceived weakness to so-called pseudoparalysis of elevation and/or external rotation [1]. Pseudoparalysis of anterior elevation describes the inability to elevate the arm to 90 deg. in the presence of unrestricted passive range of glenohumeral motion and in the absence of any neurologic impairment [21]. Pseudoparalysis of external rotation describes complete loss of active external rotation power in the presence of unrestricted passive external rotation and in the absence of neurologic impairment [1]. Collin et al. demonstrated that dysfunction of the entire subscapularis and supraspinatus or three rotator cuff muscles are risk factors for pseudoparalysis [13]. There are studies suggesting that primary arthroscopic repair can lead to reversal of preoperative pseudoparalysis in 90% of patients, but this number drops to 43% in revision surgeries [22].

Examination of the patient with suspected massive or irreparable rotator cuff tear should be performed with patient's torso exposed allowing proper comparison between two shoulders. Any atrophy in the supraspinatus or infraspinatus fossa should be noted, indicating a chronic tear. If the coracoacromial arch is incompetent, the outline of humeral head might be more prominent due to anterosuperior subluxation. Visible deltoid atrophy is especially of concern in patients with previous open surgeries. The long head of the biceps tendon might be affected by massive cuff tears and is often torn resulting in a 'Popeye' deformity (a visible bulge just proximal to the elbow).

Active and passive range of movement should of course be assessed and compared with the contralateral side. Active shoulder motion is usually decreased. Limitations of passive motion may be due to scar tissue formation associated with chronic tears, but these are usually mild and not very painful. It is important to discern this from the often much more painful adhesive capsulitis.

In patients with anterosuperior tears, significant weakness of the subscapularis will be noted. The bear hug test will most likely be positive. The belly-press manoeuvre, which tests the upper portion of the subscapularis muscle, is more likely to be abnormal than the lift-off test, which mainly reflects the lower subscapularis muscle function [10, 23]. Increased passive external rotation of the shoulder may also be present [10].

Two provocative manoeuvres can determine the extent of the posterosuperior cuff involvement. The external rotation lag sign. If the patient cannot actively maintain maximal external rotation of the shoulder with the elbow by his side, the test is considered positive for the infraspinatus tendon tear. The Hornblower's sign tests the integrity of teres minor [10]. With the elbow supported, the patient is asked to maintain maximal shoulder external rotation with the shoulder abducted to 90°. Inability to maintain this position is highly sensitive for teres minor tear [15]. The supraspinatus tendon tear is always involved and so patients from both these groups should show weakness of supraspinatus strength (positive empty can test).
