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Acute traumatic rotator cuff tear — MSRA MCQ

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ModerateSoft Tissue InjuryAcute traumatic rotator cuff tearMSRA

A 56-year-old right-hand-dominant painter attends a GP-led urgent treatment centre 2 days after falling from a step ladder onto his outstretched right arm. He had immediate shoulder pain and was unable to continue working. Anteroposterior and axial shoulder radiographs show no fracture or dislocation. He has bruising over the lateral upper arm. Passive glenohumeral movement is near full, although painful at the end range. He can actively abduct only to 25 degrees and cannot maintain abduction when the arm is passively positioned at 90 degrees. Resisted external rotation is markedly weak compared with the left. Deltoid contraction and sensation over the lateral shoulder are normal. Distal neurovascular examination is normal. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Make an urgent orthopaedic referral for a suspected acute traumatic rotator cuff tear

Explanation lettering: D = shown as A · A = shown as D

This presentation is highly suggestive of an acute traumatic rotator cuff tear: there is a clear traumatic mechanism, normal radiographs excluding fracture and dislocation, marked loss of active abduction, inability to maintain passive abduction, and substantial external-rotation weakness. Near-preserved passive movement makes adhesive capsulitis unlikely. Normal deltoid contraction and preserved lateral-shoulder sensation make an axillary nerve palsy less likely. An acute rotator cuff tear after trauma requires urgent secondary-care referral in UK pathways; management should not be delayed by a trial of routine conservative treatment or by waiting for primary-care MRI confirmation. Imaging may subsequently be arranged through the urgent specialist pathway. A is appropriate for uncomplicated soft-tissue shoulder injuries or degenerative cuff-related pain without acute power loss, but not here. B may have a role in selected non-traumatic subacromial pain after assessment, but does not address a potentially repairable acute tendon rupture. C is plausible because ultrasound can demonstrate cuff disruption, but routine imaging before referral risks delay. E similarly delays urgent assessment and uses MRI as a gatekeeper when the clinical presentation already meets the referral threshold.

Reference: NHS England: Clinical commissioning policy – orthopaedic procedures (2026) — https://www.england.nhs.uk/long-read/clinical-commissioning-policy-orthopaedic-procedures/ NHS Tayside RefGuide: Rotator Cuff Tear (2026) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/rotator-cuff-tear/?UNLID=22638775202621594927