Table of Contents  

Elfaal: Shoulder ultrasonography accuracy compared with magnetic resonance imaging in the detection of rotator cuff injuries

Aetiology

Significant causes of rotator cuff tears include:

  • trauma (acute and chronic repetitive);

  • subacromial impingement;

  • tendon degeneration;

  • hypovascularity.1

Epidemiology

Patient age is important because the prevalence of rotator cuff tears increases with age. Approximately 40% of asymptomatic patients aged > 50 years have full-thickness rotator cuff tears,2 and the incidence of partial- and full-thickness tears in symptomatic patients aged > 60 years is > 60%.3 Chronic causes such as repetitive micro-trauma, subacromial impingement, tendon degeneration and hypovascularity are thought to be responsible for most tears and account for this age-dependent incidence. Acute macrotrauma is less frequently responsible for tears.4,5

Anatomy

The rotator cuff consists of four muscles: the subscapularis, supraspinatus, infraspinatus and teres minor muscles. These muscles end in short, flat, broad tendons that fuse intimately with the fibrous capsule to form the musculotendinous cuff (Figure 1). This fusion occurs between approximately half and three-quarters of an inch from the point of the insertion of the tendons into the humerus.6

FIGURE 1

Rotator cuff anatomy, anterior. Reproduced from Holmgren et al.7 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

HMJ-737-fig1.jpg

Clinical presentation

Pain, weakness and loss of shoulder motion are common symptoms reported in rotator cuff pathology. Pain is often experienced in the anterolateral part of the shoulder and is exacerbated by activities requiring the arm to be raised overhead. Night pain is a frequent symptom, especially when the patient lies on the affected shoulder.8

Factors influencing the outcome after rotator cuff repair

Patient factors include:

  • Age – studies have shown that the success of cuff repair decreases with advancing age, especially among patients aged > 65 years, and retear rates may be higher among patients aged > 65 years.9

  • Other patient-related factors (smoking, osteoporosis, hypercholesterolaemia and diabetes) – several other patient-related factors have been reported to affect rotator cuff tendon healing. Smoking not only increases the risk of rotator cuff tears, but has also been reported to influence rotator cuff tear size.10 In the elderly, the risk of rotator cuff tears is increased by osteoporosis.11 Osteoporosis may reduce the anchor-holding property and tendon healing at the tuberosity.12

Tear characteristics that directly affect the repair outcome:

  • Chronicity – this may play an indirect role in repair outcome as it affects the quality of the muscle and tendon unit, resulting in a higher degree of atrophy, fatty infiltration, lamination and retraction.12

  • Tear size – many studies have shown that small and medium tears carry a greater chance of healing than large and massive tears.12 In large and massive tears, the additional suture bridges decrease the retear rate.13

  • Number of tendons – if two or more tendons are involved in the tear, there is a reduced chance of healing, which can lead to poor outcomes.12 Younger patients with single tendon tears are more likely to undergo spontaneous resolution of a radiographic defect.14

  • Poor-quality tendons – these are more prone to non-healing at the tuberosity than healthy cuff tissue.12

  • Fatty infiltration and rotator cuff atrophy – a high fatty infiltration index (of > 1 point) or Goutallier grade ≥ 2 significantly reduces tendon healing rates.12 A study published by Cho et al.15 showed that all of the rotator cuffs with a preoperative global fatty degeneration index of > 2 points had recurrent tears.

  • Muscle–tendon unit retraction – tendon retraction, the gap between the greater tuberosity and the tendon edge, is due to either tendon shortening or muscle retraction. Muscle retraction can be defined by utilizing the position of the muscle–tendon junction in relation to landmarks on the scapula.16

Radiological features

An ultrasonography evaluation criterion for diagnosis of a rotator cuff tear is a hypoechoic area that persists in two different planes. A full-thickness tear is defined by a continuous hypoechoic area from the bursal space to the articular surface, thus a complete absence of the tendon (Figure 2). A partial-thickness tear is diagnosed by a defect on the bursal side of the cuff or a hypoechoic lesion in a mixed hypoechoic and hyperechoic area on the articular side of the cuff.17,18 Tendovaginitis of the long biceps tendon shows a hypoechoic, fluid-filled area around the tendon. The criterion for a rupture is the absence of the tendon in the intertubercular groove. In the case of dislocation, the tendon is always found medial to the groove.19

FIGURE 2

Long-axis (a) and short-axis (b) examination reveals that there is a fluid-filled defect replacing the entire thickness and width of the right supraspinatus, suggesting a full-thickness tear of the supraspinatus tendon. The defect length or retraction is 30 mm. Reproduced from Patel MS20, Radiopaedia.org. From the case Rotator cuff tear. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 3.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/3.0/.

HMJ-737-fig2a.jpgHMJ-737-fig2b.jpg

In magnetic resonance imaging (MRI), the criteria for a rotator cuff tear are increased signal intensity in association with a discontinuity or irregularity of the tendon on T2- and proton density (PD)-weighted images (Figure 3). A full-thickness tear is diagnosed by a continuous tendon gap that connects the bursal space with the articular surface. A partial-thickness tear shows a high signal intensity in T2-weighted and fat-suppressed PD-weighted images within the tendon substance without retraction of the tendon.21 Tendovaginitis of the long biceps tendon is diagnosed when an increased signal is present within the tendon sheath on T2-weighted sequences. The biceps tendon is primarily evaluated on the transverse planes.11

FIGURE 3

Coronal STIR image (a) and sagittal T2 image (b) showing a complete tear of the supraspinatus tendon, which is retracted medially, uncovering the humeral head, with subacromial bursal fluid collection. Reproduced from Rabou AA1 Radiopaedia.org. From the case Complete tear of supraspinatus tendon. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 3.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/3.0/.

HMJ-737-fig3a.jpgHMJ-737-fig3b.jpg

Many studies have compared the accuracy of ultrasonography with that of MRI in the diagnosis of rotator cuff muscle injuries.

Ultrasonography has been found to be able to detect different tendon pathologies (tendinitis, partial- and full-thickness tears), in addition to the causal factors. Compared with MRI, the sensitivity of ultrasonography for tendinitis detection has been reported to be 85%, with 86% negative predictive value (NPV) and 90% accuracy, while for partial-thickness tears its sensitivity, specificity, positive predictive value (PPV), NPV and accuracy were 88%, 89%, 94%, 80% and 83%, respectively. However, for full-thickness tears, the sensitivity and specificity of ultrasonography were both 100%.22 Therefore, ultrasonography and MRI yielded comparably high sensitivity for detecting full-thickness rotator cuff tears. Ultrasonography performed better in detecting partial-thickness tears, although the difference was not significant.23

Full-thickness rotator cuff tears can be identified using ultrasonography and MRI with similar accuracy. However, as ultrasonography is less expensive, less time-consuming, more dynamic and less demanding for patients, it should be used as the first line of investigation for rotator cuff tears, when appropriate skills are available.24

On the other hand, ultrasonography is the most operator-dependent imaging method for the shoulder25 and is often considered inferior to MRI for preoperative imaging because it provides less detail on morphological changes in the rotator cuff musculature.26

Study findings27 have shown little agreement between MRI and ultrasonography in characterizing full-thickness rotator cuff tears. Ultrasonography has been shown to have lower interobserver reliability and decreased measurement of large rotator cuff tears.27

Treatment

Rotator cuff treatment ranges from conservative treatments such as rest, ice and physical therapy to intra-articular injections or even surgery if the injury is severe and involves a complete tear of the muscle or tendon.28

Arthroscopic features

With the advent of arthroscopy, innovative shoulder surgeons found that a few very small incisions in the skin and deltoid muscles surrounding the shoulder joint could enable access to every part of the rotator cuff. These incisions are small enough to not affect the function of the deltoid muscle or injure its origin on the acromion. Using the arthroscope and instruments specifically designed for the purpose of manipulating and repairing the tissue, the surgeon can work from any angle around the tissue (Figure 4).29

FIGURE 4

Arthroscopic view of the rotator cuff. The typical appearance of the torn cuff as viewed through the arthroscope. This view is from above the cuff, looking down the torn edge. Reproduced with permission from University of Washington.29

HMJ-737-fig4.jpg

Conclusion

Ultrasonography and MRI are comparable in both sensitivity and specificity for the diagnosis of rotator cuff tears.22 However, ultrasonography shows consistently low reliability in detecting subtle, but clinically important, degeneration of the soft tissue envelope.27

As ultrasonography is less expensive and more widely available than MRI, it may be the best modality for identifying tears and could be considered the most appropriate screening method when rotator cuff integrity is the main question, provided well-trained radiologists and high-resolution equipment are available. However, MRI is superior in surgical planning for larger tears and provides much more information about the prognostic factors.30

Conflict of interest

The author reports no conflict of interest.

References

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