Tomas Balčiūnas1, Ugnė Janonytė1, Kristina Valatkevičienė2
1Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania.
2Department of Radiology, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania.
Abstract
Background. Rotator cuff tears (RCTs) are common injuries, constituting 60% of shoulder problems, often stemming from repetitive use or traumatic incidents, their prevalence increasing with age. The rotator cuff comprises four muscles, along with their tendinous extensions, crucial for shoulder joint stability and movement. RCTs can be diagnosed with ultrasound (US) and magnetic resonance imaging (MRI) and each of the methods presents with its’ benefits and drawbacks.
Aim. This review aims to evaluate the diagnostic capabilities of US and MRI in detecting RCTs.
Methods. The Google Scholar and PubMed databases were used for the narrative literature review, with keywords: “rotator cuff tears”, “magnetic resonance imaging”, “ultrasound”, “diagnostic imaging” in the search fields. 42 articles were selected for further analysis.
Results. Several studies found no significant difference in sensitivity or specificity between MRI and US for diagnosing RCTs. However, US tends to underestimate tear size and retraction, while MRI offers superior reliability for surgical planning, especially in larger tears. Thus, US could be considered the primary diagnostic method for RCTs due to its dynamic nature and cost-effectiveness, with MRI serving to confirm diagnoses in uncertain cases or for detailed anatomical evaluation.
Conclusions. In terms of accuracy, cost, and safety, US emerges as the primary choice, when assessing RCTs. However, it should be noted that US may demand a more specialized expertise. MRI could be used to confirm diagnoses in uncertain cases or for anatomical evaluation prior to surgery.
Keywords: rotator cuff tears, magnetic resonance imaging, ultrasound, diagnostic imaging.
https://doi.org/10.53453/ms.2024.5.16
Diagnostic performance of ultrasound and magnetic resonance
imaging in assessing rotator cuff tears
Tomas Balčiūnas
1
, Ugnė Janonytė
1
, Kristina Valatkevičienė
2
!",
Abstract
Background. Rotator cuff tears (RCTs) are common injuries, constituting 60% of shoulder problems, often
stemming from repetitive use or traumatic incidents, their prevalence increasing with age. The rotator cuff
comprises four muscles, along with their tendinous extensions, crucial for shoulder joint stability and
movement. RCTs can be diagnosed with ultrasound (US) and magnetic resonance imaging (MRI) and each of
the methods presents with its’ benefits and drawbacks.
Aim. This review aims to evaluate the diagnostic capabilities of US and MRI in detecting RCTs.
Methods. The Google Scholar and PubMed databases were used for the narrative literature review, with
keywords: "rotator cuff tears", "magnetic resonance imaging", "ultrasound", "diagnostic imaging" in the search
fields. 42 articles were selected for further analysis.
Results. Several studies found no significant difference in sensitivity or specificity between MRI and US for
diagnosing RCTs. However, US tends to underestimate tear size and retraction, while MRI offers superior
reliability for surgical planning, especially in larger tears. Thus, US could be considered the primary diagnostic
method for RCTs due to its dynamic nature and cost-effectiveness, with MRI serving to confirm diagnoses in
uncertain cases or for detailed anatomical evaluation.
Conclusions. In terms of accuracy, cost, and safety, US emerges as the primary choice, when assessing RCTs.
However, it should be noted that US may demand a more specialized expertise. MRI could be used to confirm
diagnoses in uncertain cases or for anatomical evaluation prior to surgery.
Keywords: rotator cuff tears, magnetic resonance imaging, ultrasound, diagnostic imaging.
Journal of Medical Sciences. 5 May, 2024 - Volume 12 | Issue 3. Electronic - ISSN: 2345-0592
Medical Sciences 2024 Vol. 12 (3), p. 150-157, https://doi.org/10.53453/ms.2024.5.16
150
1. Introduction
Rotator cuff tears (RCTs) are a common type of
shoulder injury seen in doctor's offices and
hospitals, making up 60% of shoulder problems. If
they're not diagnosed and treated right, they can
lead to disability and trouble using the shoulder
properly [1]. RCTs can develop from repetitive use
over time, leading to the development of a RCTs
within these tendons or traumatic injuries. The
likelihood of getting RCTs goes up with age, and
both partial and complete tears become much more
common after the age of 50 [2,3]. Grunsky et al
claims that being older, having the tear in the
dominant shoulder, and having a higher body mass
index are all separate factors that can lead to a
RCTs [4]. RCTs lead to shoulder pain, but the
intensity of the pain doesn't always match how
severe the tear is, especially until the tears are
larger than 2.5 cm [5]. The Rotator Cuff is
composed of four muscles – the subscapularis,
supraspinatus, infraspinatus, and teres minor –
along with their tendinous extensions. These
tendons attach to the head of the humerus, playing
a crucial role in stabilizing the shoulder joint
during movement and enabling rotation of the
shoulder [6]. While any of these tendons can tear,
the tendons of the supraspinatus and infraspinatus
are most commonly affected [7,8]. This type of
injury can be diagnosed with ultrasound (US) and
magnetic resonance imaging (MRI) and each of the
methods presents with its’ benefits and drawbacks.
2. Methods
The Google Scholar and PubMed databases were
used for the literature review, with keywords and
their combinations: "rotator cuff tears", "magnetic
resonance imaging", "ultrasound", "diagnostic
imaging" in the regular and advanced search fields.
For this narrative review 42 articles were selected
for further analysis based on their credibility and
relevancy on the topic. The ensuing narrative
review is structured to unveil prevailing trends and
identify existing knowledge gaps.
3. Results
3.1. Ultrasonography for detecting rotator cuff
tears
In recent times, ultrasonography has become
increasingly favored for identifying (RCTs), as it
offers efficient, cost-effective, time-saving
shoulder imaging capabilities. The key ultrasound
sign of RCTs is tendon discontinuity, often
accompanied by tendon retraction. This
discontinuity typically appears as fluid-filled gaps,
usually anechoic but occasionally echogenic with
comet tail artifacts. Additionally, the bursal surface
may show focal flattening or concavity at the tear
site, with unexplained fluid in the bursa [9,10].
High accuracy rates have been documented in the
literature for US detecting RCTs. For example,
Liang et al. conducted meta-analysis that included
seven prospective studies covering 554 partial and
full thickness RCTs in 868 patients. The pooled
sensitivity and specificity were respectively 95@%
and 72@%, indicating high efficiency of US in
diagnosing RCTs [11]. Consistent results have been
documented in prior studies when comparing US
findings with those obtained from surgical
examinations [12,13]. However, it's crucial to
recognize that while US excels in detecting full-
thickness RCTs, its accuracy diminishes when
identifying partial-thickness tears. [14-17]. In the
study by Singisetti et al., US revealed 89@%
sensitivity and 43@% specificity for supra-spinatus
RCTs, and 30@% sensitivity with 100@% specificity
for subscapularis RCTs. Among 19 false negatives,
one was a full-thickness tear, and 18 were partial-
thickness tears, all involving the sub-scapularis
tendon. This highlights US's reduced accuracy for
smaller and partial tears, especially in the
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subscapularis tendon [18]. Thus, surgeons need to
be prepared to adapt surgical strategies during
arthroscopy to accommodate the differing US
accuracy in identifying full-thickness versus
partial-thickness RCTs. It is important to note, that
US also demonstrates high reliability in identifying
recurrent RCTs, as reported by Gilat et al., US
showed 80.8@% sensitivity and 100@% specificity
for retear diagnosis, rising to 94.7@% sensitivity
when partial retears were excluded, with
maintained 100@% specificity [19]. Moreover,
preoperative shoulder US is also valuable for
evaluating RCTs and predicting tendon reparability
during surgery. In a prospective study Cox et al.
concludes, that visualizing the tear edge suggests a
high likelihood of successful arthroscopic repair,
while non-visualization indicates moderate chances
of irreparability [20]. Nonetheless, there are
arguments suggesting that the complex anatomy of
the shoulder requires a substantial period to master
effective US evaluation. False-positive and false-
negative sonographic findings of RCTs can result
from various factors such as technique-related
issues and anatomical complexities, e.g. anisotropy,
transducer positioning and frequency or patient-
related factors like obesity [21]. For example, Kim
et al. suggests, that novices require approximately
30 scans to achieve competence in detecting RCTs,
as third-year residents demonstrate significantly
higher diag-nostic accuracy compared to second-
year residents [22]. In a study by Rutten et al., only
a marginal enhancement was observed as the
general radiologist's experience increased, thus the
hypothesis that US of the shoulder is highly related
to experience could be refuted [23].
3.2. Magnetic resonance imaging for detecting
rotator cuff tears.
According to the appropriateness criteria set by the
American College of Radiology (ACR), MRI is
considered the benchmark for evaluating shoulder
pain, whether it results from trauma or not, in cases
where rotator cuff disease is suspected. MRI offers
detailed and thorough imaging of soft tissue
components, particularly the rotator cuff and
labrum, making it the preferred diagnostic test [24].
Also, it can assess the dimensions and
configuration of the tear, the extent of tendon
withdrawal, the visibility of muscle wasting, and
the condition of the remaining rotator cuff tendon
[25]. Diagnostic accuracy of MRI to accurately
identify full-thickness RCTs was substantial, with
both sensitivity and specificity ratings exceeding
0.90. In cases of partial RCTs, the specificity
remained high (above 0.90), though the sensitivity
was reduced, ranging from 0.67 to 0.83 [26].
Various classification systems for RCTs have been
suggested. Unfortunately, there is no
comprehensive classification system that
encompasses all the considerations necessary for
managing rotator cuff injuries [27]. When assessing
full-thickness tears, MRI stands out as the optimal
diagnostic tool, as it provides a comprehensive
three-dimensional assessment of all the tendons in
the rotator cuff, extending from the point where
muscle and tendon join (myotendinous junction) to
their attachment points on the greater and lesser
tuberosities [28]. Studies on cadaver samples have
shown that full-thickness RCTs occur in 5 to 25@%
of cases. Meanwhile, a recent investigation
involving older individuals with symptoms who
had not sought medical attention revealed that
imaging tests detected full-thickness tears in 30@%
of these individuals [29]. The most definitive
indication of such a tear is the observation of a total
disruption in the tendon, spanning from the
articular side all the way to the bursal side.
Typically, this disruption exhibits a fluid-like
signal because it contains fluid, along with healing
granulation tissue, growth of myofibroblasts,
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transformation into chondroid tissue, and/or blood
accumulation. In less frequent cases, full thickness
tears may show a medium level of T2 signal
intensity, likely due to chronic scarring or the
blending of signals with nearby histological
alterations like scarring or mucoid deterioration
[25]. Secondary indicators of full-thickness tears
encompass the retraction of the tendon, upward
movement of the humeral head, and muscle
atrophy@[29].
Partial-thickness tears of the rotator cuff affect only
a segment of the tendon and can happen on the
articular or bursal side, or within the tendon itself,
which are known as intrasubstance or interstitial
tears [30]. MRI and magnetic resonance
angiography (MRA) demonstrated comparable
effectiveness in detecting bursal-surface partial-
thickness tears. However, the marginal increase of
about 5@% in sensitivity and specificity for tears
identified through MRA, as opposed to unenhanced
MRI, might not justify the additional costs and
drawbacks associated with MRA in a clinical
setting [31]. Therefore, MRI continues to be among
the top diagnostic tools for identifying partial-
thickness tears in rotator cuff injuries. The
identification of partial-thickness tears in the
rotator cuff using MRI is based on morphological
characteristics like thinning, fraying, and
unevenness, or the presence of fluid signals within
the tendon. A low T1 signal combined with a high
T2 or short tau inversion recovery@(STIR) signal
signifies the presence of water, and such a water
signal within a tendon is indicative of a tendon tear
[32]. MRI plays a crucial role in identifying
intratendinous tears that arthroscopy might not
reveal, as arthroscopy only allows for the
examination of the tendon's external surface.
However, these tears are frequently overlooked due
to the positioning of the patient. When the arm is
placed by the side in an MRI scanner, the rotator
cuff layers are pressed together, making it difficult
to see tears within the tissue [33].
3.3. Discussion
Assessing the diagnostic capabilities between US
and MRI in identifying RCTs is crucial for
applying effective treatment plans and optimizing
patient outcomes. In a meta-analysis by Jesus et al.
no significant difference in either sensitivity or
specificity between MRI and US in diagnosing full-
thickness tear or partial-thickness RCTs was found
[34]. Similar findings were reported in a
retrospective analysis by Elmorsy et al., while
analyzing patients undergoing shoulder
arthroscopy, which had preoperative US or MRI
evaluation. After analyzing sensitivity, specificity,
positive and negative predictive value, no
significant difference was found between US and
MRI in detecting any type of RCTs. However, US
exhibited higher specificity for detecting partial-
thickness tears compared to MRI [35]. Okoroha et
al. compared US and MRI in evaluating full-
thickness RTCs in 114 patients undergoing
arthroscopic repair. It was determined that US
tended to underestimate tear size and retraction
compared to MRI, with increasing discrepancies
between the modalities as the tear size increases.
MRI showed superior interobserver reliability for
tear size, retraction, and atrophy, Thus, suggesting
MRI's superiority for surgical planning for larger
tears, as US is less reliable in detecting subtle soft
tissue degeneration [36]. Thus, given their similar
diagnostic accuracy, US could serve as the primary
diagnostic method for RCTs, while MRI could be
utilized to confirm diagnoses in uncertain cases,
where other shoulder conditions are suspected,
such as articular cartilage injuries or labral tears,
especially when overlapping with rotator cuff
disorders like glenohumeral instability in younger
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patients or osteoarthritis in older patients, or for
thorough anatomical evaluation prior to surgery.
Moreover, US is more dynamic and patient-
friendly, reducing both waiting times and costs,
given skilled operators [37, 38]. It is important to
note, that MRI also has some absolute
contraindications, such as the presence of cardiac
implantable electronic devices or neurostimulation
systems, cochlear implants, cerebral artery
aneurysm clips, etc. [39]. While further
investigation is necessary, the use of contrast-
enhanced ultrasound (CEUS) is emerging as a
promising diagnostic tool for RCTs. In their study,
Tang et al. evaluated CEUS, MRI and US
diagnostic methods, and discovered that CEUS
successfully detected lesions in all 31 patients
involved, while US and MRI misinterpreted 4
small lesions [40]. Artificial intelligence and
machine learning are also gradually being
integrated into diagnostic processes, marking a
significant shift towards more data-driven and
automated medical assessments. This evolution
promises to enhance diagnostic accuracy and
efficiency, especially for complex RCTs where
nuanced interpretation of data is crucial [41,42].
4. Conclusion.
In terms of accuracy, cost, and safety, US emerges
as the optimal primary choice, when assessing
suspected RCTs. However, it should be noted that
US may demand a more specialized radiologist
expertise. MRI could be used to confirm diagnoses
in uncertain cases or for anatomical evaluation
prior to surgery.
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