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Review Article

Shoulder Ultrasonography Accuracy Compared with Magnetic

Resonance Imaging in the Detection of Rotator Cuff Injuries
Mohamed Walaaeldin Elfaal
Specialist Radiologist at Thumbay Clinics, Dubai, United Arab Emirates

Abstract
Rotator cuff injuries are common and frequently seen by orthopaedic surgeons. Accurate diagnosis of the injury is crucial for appropriate
management. Imaging studies are the cornerstone of diagnosis and have great value compared with clinical assessment alone.

Keywords: ltrasonography, magnetic resonance, MRI, shoulder, rotator cuff

Aetiology Clinical Presentation

Significant causes of rotator cuff tears include:
• Trauma (acute and chronic repetitive)
• Subacromial impingement
• Tendon degeneration
• Hypovascularity.[1]
Epidemiology
Patient’s 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 microtrauma, 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].[6] This fusion occurs between approximately
half and three‑quarters of an inch from the point of the insertion
of the tendons into the humerus.[7]
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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 the following:
• Age – Studies have shown that the success of cuff repair
decreases with advancing age, especially among patients
aged >65 years, and re‑tear 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
Address for correspondence: Dr. Mohamed Walaaeldin Elfaal,
NMC Healthcare, Dubai, United Arab Emirates.
E‑mail: mohamedwalaa@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Elfaal MW. Shoulder ultrasonography accuracy
10.7707/hmj.737 compared with magnetic resonance imaging in the detection of rotator cuff
injuries. Hamdan Med J 2018;11:13-6.

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Elfaal: Rotator cuff ultrasonography
may reduce the anchor‑holding property and tendon
healing at the tuberosity.[12]
Tear characteristics that directly affect the repair outcome are as
follows:
• 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 re‑tear
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‑ qu alit y tendons  –  T hese a re 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
g rade  ≥2 sig nif icantly reduces tendon‑heali ng
rates.[12] A study published by Cho and Rhee[15] showed
that all of the rotator cuffs with a pre‑operative
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 utilising 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
Figure 1: Rotator cuff anatomy, anterior. Reproduced from Holmgren
et  al. 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
14
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].[17]
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.[18,19]
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.[20]
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].[1]
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]
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 and 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,
NPV and accuracy were 88%, 89%, 94%, 80% and 83%,
respectively. However, for full‑thickness tears, the sensitivity
a b
Figure 2: Long‑ (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, Radiopaedia.org, from the case of 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
Hamdan Medical Journal  ¦  Volume 11  ¦  Issue 1  ¦  January-March 2018
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Elfaal: Rotator cuff ultrasonography

a b
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 Radiopaedia.org, from the case of complete
tear of supraspinatus tendon. This is an open‑access article distributed
in accordance with the terms of the Creative Commons Attribution Figure 4: Arthroscopic view of the rotator cuff. The typical appearance of
(CC BY 3.0) license, which permits others to distribute, remix, adapt and the torn cuff as viewed through the arthroscope. This view is from above
build upon this work, for commercial use, provided the original work is the cuff, looking down the torn edge. Reproduced with permission from
properly cited. See: http://creativecommons.org/licenses/by/3.0 University of Washington

and specificity of ultrasonography were both 100%.[22] origin on the acromion. Using the arthroscope and instruments
Therefore, ultrasonography and MRI yielded comparably specifically designed for the purpose of manipulating and
high sensitivity for detecting full‑thickness rotator cuff tears.
repairing the tissue, the surgeon can work from any angle
Ultrasonography performed better in detecting partial‑thickness
around the tissue [Figure 4].[29]
tears, although the difference was not significant.[23]
Full‑thickness rotator cuff tears can be identified using Conclusion
ultrasonography and MRI with similar accuracy. However, as
Ultrasonography and MRI are comparable in both sensitivity
ultrasonography is less expensive, less time‑consuming, more
dynamic and less demanding for patients, it should be used and specificity for the diagnosis of rotator cuff tears.[22]
as the first line of investigation for rotator cuff tears, when However, ultrasonography shows consistently low reliability
appropriate skills are available.[24] in detecting subtle, but clinically important, degeneration of
the soft‑tissue envelope.[27]
On the other hand, ultrasonography is the most operator‑
dependent imaging method for the shoulder[25] and is often As ultrasonography is less expensive and more widely available
considered inferior to MRI for pre‑operative imaging because than MRI, it may be the best modality for identifying tears and
it provides less detail on morphological changes in the rotator could be considered the most appropriate screening method
cuff musculature.[26] when rotator cuff integrity is the main question, provided that
well‑trained radiologists and high‑resolution equipment are
Study findings[27] have shown little agreement between MRI available. However, MRI is superior in surgical planning for
and ultrasonography in characterising full‑thickness rotator larger tears and provides much more information about the
cuff tears. Ultrasonography has been shown to have lower prognostic factors.[30]
interobserver reliability and decreased measurement of large
rotator cuff tears.[27] Financial support and sponsorship
Nil.
Treatment Conflicts of interest
Rotator cuff treatment ranges from conservative treatments There are no conflicts of interest.
such as rest, ice and physical therapy to intra‑articular
injections or even surgery if the injury is severe and involves References
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Hamdan Medical Journal  ¦  Volume 11  ¦  Issue 1  ¦  January-March 2018