Drop Arm Test and Lift-Off Test: Full-Thickness Rotator Cuff Tear Guide
In short
Detecting complete tendon detachment is critical for timely orthopaedic referral. Learn how the Drop Arm test detects supraspinatus tears and the Gerber Lift-Off test assesses subscapularis integrity.
In this guide (8 sections)
The Importance of Detecting Full-Thickness Rotator Cuff Tears
While partial rotator cuff tears present with painful but preserved movement, full-thickness massive tears cause severe mechanical failure. The humeral head loses its dynamic downward concavity compression, migrating upward against the acromion.
Early clinical differentiation determines whether a patient requires prompt surgical repair within the biological window or conservative rotator cuff rehabilitation.
The Drop Arm Test for Supraspinatus Rupture
The Drop Arm test (Codman sign) evaluates the eccentric control of the supraspinatus tendon as the arm lowers against gravity:
- Procedure: The clinician passively abducts the patient affected arm to 90 degrees with the forearm pronated. The patient is instructed to slowly and smoothly lower the arm down to their side.
- Positive Finding: The patient cannot lower the arm smoothly; around 90 to 60 degrees, the arm suddenly drops uncontrollably to their side, or the patient reports severe pain and uses trunk lateral flexion to substitute.
- Clinical Implication: A positive test carries a specificity of over 95 percent for a massive full-thickness supraspinatus tear.
The Gerber Lift-Off Test for Subscapularis Integrity
The subscapularis is the largest rotator cuff muscle, providing anterior stability and internal rotation:
The patient places the dorsum of their hand behind their lower back at mid-lumbar level. They are asked to actively lift the hand backward away from their spine. An inability to lift the hand off the back, or immediate collapse under gentle resistance, confirms subscapularis tendon tear or severe denervation.
Rotator Cuff Diagnostic Cluster
| Clinical Sign | Isolated Specificity | Combined Cluster Value | |
|---|---|---|---|
| Drop Arm Sign | 95 percent | When all 3 signs are positive, probability of a full-thickness tear reaches 98% | |
| Painful Arc Sign (60° to 120°) | 67 percent | Screens for subacromial mechanical impingement | |
| Infraspinatus Muscle Weakness Test | 90 percent | Identifies posterior cuff extension |
Frequently Asked Questions
What if a patient cannot reach behind their back for the Lift-Off test?
If severe internal rotation stiffness prevents reaching behind the back, use the Belly-Press test (Napoleon test). The patient presses the palm against the abdomen with elbow forward. If the wrist flexes or the elbow drops backward, it indicates subscapularis weakness.
Can older patients with a positive drop arm sign avoid surgery?
In elderly, sedentary individuals with chronic atraumatic tears, physiotherapy focused on anterior deltoid retraining and intact subscapularis/infraspinatus compensation can restore functional overhead reach without surgical repair.
Pathomechanics of Massive Rotator Cuff Tears
The supraspinatus tendon inserts into the superior facet of the greater tuberosity. Its hypovascular watershed zone, located approximately 1 centimetre proximal to the insertion footprint, is prone to age-related degenerative tendon tears. In full-thickness tears, the deltoid muscle pulls the humeral head upward unchecked by the rotator cuff force couple, causing subacromial space narrowing below 6 millimetres on plain radiographs.
Conservative Scapular and Rotator Cuff Rehabilitation
When surgical repair is contraindicated or during early conservative care, physiotherapy targets the intact force couples. Scapular stabilizers (serratus anterior and lower trapezius) are conditioned alongside the anterior subscapularis and posterior infraspinatus/teres minor to restore dynamic humeral head depression.
Indian Domestic and Functional Adaptations
Rotator cuff tears severely impair reaching for items on overhead kitchen lofts, hanging laundry on clotheslines, and washing the back during bucket baths. Modifying storage heights and using long-handled bathing sponges prevents painful compensatory shoulder hitching.
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