Sonography of the Rotator Cuff:Analysis of Interobserver Variability

Rotator Cuff Tears Are Related to the Side Sleeping Position

Purpose

To determine whether there was a relationship between sleep position and symptomatic partial- and full-thickness rotator cuff tears.

Methods

A consecutive series of patients that met the inclusion/exclusion criteria (n = 58) were in seen in clinic between July 2019 and December 2019. All of these individuals had a significant partial-thickness (> 50%) or full-thickness rotator cuff tear determined by either ultrasound, magnetic resonance imaging, or both. All patients in this series either had an insidious onset of shoulder pain or their symptoms were related to the basic wear and tear of daily activities. Traumatic rotator cuff tears (those associated with a significant traumatic event such as shoulder instability, motor vehicle accidents, sports related injuries, etc.) were excluded. Previous shoulder surgery, recurrent rotator cuff tears, and worker's compensation cases also were excluded from this series. As part of the history-taking process, the patients were asked what was their preferred sleeping position-side sleeper, back sleeper, or stomach sleeper. A χ2 test was conducted to determine the relationship between rotator cuff pathology and sleep position.

Results

Of the 58 subjects, 52 of the patients were side sleepers, 4 were stomach sleepers, 1 was a back sleeper, and 1 preferred all 3 positions. Statistical analysis, using the χ2 test (P < .0001), demonstrated that rotator cuff tears were most often seen in side sleepers.

Conclusions

In our study, there appeared to be a relationship between the preference of being a side sleeper and the presence of a rotator cuff tear.

Level of Evidence

Level IV, prognostic case series.

Interobserver reliability of classifying shoulder calcific tendinopathy on plain radiography and ultrasound

INTRODUCTION

Shoulder calcific tendinopathy is a frequent cause of shoulder pain. Diagnosis is usually based on ultrasound (US) and/or X-ray. US is considered an inherently operator-dependent imaging modality and, interobserver variability has previously been described by experts in the musculoskeletal US. The main objective of this study is to assess the interobserver agreement for shoulder calcific tendinopathy attending to the size, type, and location of calcium analyzed in plain film and ultrasound among trained musculoskeletal radiologists.

MATERIAL AND METHODS

From June 2018 to May 2019, we conducted a prospective study. Patients diagnosed with shoulder pain related to calcific tendinopathy were included. Two different experienced musculoskeletal radiologists evaluated independently the plain film and the US.

RESULTS

Forty patients, with a mean age of 54.6 years, were included. Cohen's kappa coefficient of 0.721 and 0.761 was obtained for the type of calcium encountered in plain film and the US, respectively. The location of calcification obtained a coefficient of 0.927 and 0.760 in plain film and US, respectively. The size of the calcification presented an intraclass correlation coefficient (ICC) of 0.891 and 0.86 in plain film and US respectively. No statistically significant differences were found in either measurement.

CONCLUSION

This study shows very good interobserver reliability of type and size measurement (plain film and US) of shoulder calcifying tendinopathy in experienced musculoskeletal radiologists.

Intraobserver Reliability on Classifying Bursitis on Shoulder Ultrasound

Purpose: Bursitis is a common musculoskeletal cause of shoulder pain and treatment varies, thus correctly diagnosing and grading bursitis is paramount in deciding management. Our aim was to assess reliability in grading shoulder bursitis on ultrasonography among fellowship trained musculoskeletal radiologists at our institution. Methods: Retrospective study of patients diagnosed with bursitis on ultrasonography. Single-sonographic images of the subacromial-subdeltoid bursa were collected for each patient and randomized to form a test-bank of varying degrees of bursitis. Three months after the test was administered, the cases were randomized and readministered. The radiologists graded each case as: within normal limits, mild, moderate or severe. Intraobserver variability was measured using Cohen's kappa coefficient. Linear regression model was performed to assess correlation between years of experience and kappa. Results: 10 radiologists reviewed 70 cases of bursitis. Kappa values ranged from .53 to .91, indicating 'moderate' to 'almost perfect' variability amongst radiologists. A moderate positive correlation of improving variability (r = .69) with increasing years of experience exists. Conclusion: Fellowship trained musculoskeletal radiologists were able to grade shoulder bursitis with moderate to almost perfect variability, with a positive correlation of improved variability with increasing experience. This may help clinicians choose the correct treatment more confidently in their patients with shoulder pain.

Ultrasonic Evaluation of the Heel Fat Pad Under Loading Conditions Using a Polymethylpentene Resin Plate: Part 2. Reliability and Agreement Study

Previously, we developed an instrument to evaluate the heel fat pad (HFP) two-layer structure, under varying loading conditions, with ultrasonography from the plantar surface through a polymethylpentene resin plate; the measured values were equivalent to those obtained without this plate. The study described here aimed to determine the intra- and inter-examiner reliabilities of the HFP thickness measurements and the agreement between long- and short-axis measured values using this instrument. Two examiners successively recorded the HFPs of 40 healthy adults twice under the no loading and loading conditions on the long- and short-axis scans. The HFPs were classified into two layers, and their thicknesses were measured. Short-term intra- and inter-examiner reliabilities were determined using the intraclass correlation coefficients. Measurements were repeated 1 mo later to determine the long-term intra-examiner reliability. The agreement between the measured long- and short-axis values was investigated by calculating the minimal detectable changes. The determined short- and long-term intra-examiner reliabilities ranged from 0.750 to 0.999 and from 0.765 to 0.952, respectively. Inter-examiner reliability ranged from 0.765 to 0.997. Differences may occur between the values measured at different axes. The measurements using this evaluation instrument were reliable, and it is best to unify the measurement axis for quantitative research.

Can We Apply Snyder's Arthroscopic Classification to Ultrasound for Evaluating Rotator Cuff Tears? A Comparative Study with MR Arthrography

We aimed to demonstrate the applicability of Snyder's arthroscopic classification of rotator cuff tears (RCT) in shoulder ultrasound (US) and to compare it with MR arthrography (MRA). Forty-six patients (34 males; mean age:34 ± 14 years) underwent shoulder US and MRA. Two radiologists (R1 = 25 years of experience; R2 = 2 years of experience) assigned A1-4, B1-4, or C1-4 values depending on the extent of RCT in both US and MRA. Inter-reader intra-modality and intra-reader inter-modality agreement were calculated using Cohen's kappa coefficient. US sensitivity and specificity of both readers were calculated using MRA as the gold standard. Patients were divided into intact cuff vs. tears, mild (A1/B1) vs. moderate (A2-3/B2-3) tears, mild-moderate (A2/B2) vs. high-moderate (A3/B3) cuff tears, moderate (A2-3/B2-3) vs. advanced (A4/B4) and full-thickness (C) tears. The highest agreement values in inter-reader US evaluation were observed for mild-moderate vs. high-moderate RCT (K = 0.745), in inter-reader MRA evaluation for mild vs. moderate RCT (K = 0.821), in R1 inter-modality (US-MRA) for mild-moderate vs. high-moderate and moderate vs. advanced/full-thickness RCT (K = 1.000), in R2 inter-modality (US-MRA) for moderate vs. advanced/full-thickness RCT (K = 1.000). US sensitivity ranged from 88.89%(R1)-84.62%(R2) to 100% (both readers), while specificity from 77.78%(R1)-90.00%(R2) to 100% (both readers). Snyder's classification can be used in US to ensure the correct detection and characterization of RCT.

Diagnostic Accuracy of Ultrasonography for Rotator Cuff Tears: A Systematic Review and Meta-analysis

Background

With recent improvements in transducer strength, image resolution, and operator training, ultrasound (US) provides an excellent alternative imaging modality for the diagnosis of rotator cuff tears.

Purpose

To evaluate the diagnostic accuracy of US for partial- and full-thickness rotator cuff tears and biceps tendon tears, compare diagnostic values with those of magnetic resonance imaging (MRI) using arthroscopy as the reference standard, assess longitudinal improvements in accuracy, and compare diagnostic values from operators with different training backgrounds.

Study Design

Systematic review; Level of evidence, 3.

Methods

The PubMed and Cochrane Library databases were systematically searched for full-text journal articles published between January 1, 2010, and April 1, 2020. The inclusion criteria were studies that evaluated the diagnostic accuracy of US for rotator cuff tears or biceps tendon tears utilizing arthroscopy as the reference standard. The exclusion criteria were studies with <10 patients, studies including massive tears without reporting diagnostic data for specific tendons, and studies lacking diagnostic outcome data. Extracted outcomes included diagnostic accuracy, sensitivity, specificity, negative predictive value, and positive predictive value. The mean difference and 95% confidence interval were calculated for both US and MRI diagnostic values, and meta-analysis was conducted using the Mantel-Haenszel random-effects model.

Results

In total, 23 eligible studies involving 2054 shoulders were included. US demonstrated a higher median diagnostic accuracy for supraspinatus tendon tears (0.83) and biceps tendon tears (0.93) as compared with subscapularis tendon tears (0.76). US was found to have a higher median accuracy (0.93) for full-thickness supraspinatus tears than partial-thickness tears (0.81). US had superior median sensitivity for partial-thickness supraspinatus tears when performed by radiologists as opposed to surgeons (0.86 vs 0.57). Meta-analysis of the 5 studies comparing US and MRI demonstrated no statistically significant difference in diagnostic sensitivity, specificity, or accuracy for any thickness supraspinatus tears (P = .31-.55), full-thickness tears (P = .63-.97), or partial-thickness tears (P = .13-.81).

Conclusion

For experienced operators, US is a highly sensitive and specific diagnostic modality for the diagnosis of supraspinatus tears and demonstrates statistically equivalent capability to MRI in the diagnosis of both full- and partial-thickness rotator cuff tears.

Reliability of ultrasound in evaluating the plantar skin and fat pad of the foot in the setting of diabetes

Ultrasound can be used to assess injury and structural changes to the soft-tissue structure of the foot. It may be useful to assess the feet of people with diabetes who are at increased risk of plantar soft-tissue pathological changes. The aim of this study was to determine if ultrasound measurements of plantar soft-tissue thickness and assessments of tissue acoustic characteristics are reliable in people with and without diabetes mellitus. A repeated measures design was used to determine intra-observer reliability for ultrasound measurements of plantar skin and fat pad thickness and intra- and inter-observer reliability of plantar skin and fat pad tissue characterisation assessments made at foot sites which are at risk of tissue injury in people with diabetes. Thickness measurements and tissue characterisation assessments were obtained at the heel and forefoot in both the unloaded and compressed states and included discrete layers of the plantar tissues: skin, microchamber, horizontal fibrous band, macrochamber and total soft-tissue depth. At each site, relative intra-observer reliability was achieved for the measurement of at least one plantar tissue layer. The total soft-tissue thickness measured in the unloaded state (ICC 0.925-0.976) demonstrated intra-observer reliability and is the most sensitive for detecting small change on repeated measures. Intra-observer agreement was demonstrated for tissue characteristic assessments of the skin at the heel (k = 0.70), fat pad at the lateral sesamoid region (k = 0.70) and both skin and fat pad at the second (k = 0.80, k = 0.70 respectively) and third metatarsal heads (k = 0.90, k = 0.79 respectively). However, acceptable inter-observer agreement was not demonstrated for any tissue characteristic assessment, therefore the use of multiple observers should be avoided when making these assessments.

Detecting Rotator Cuff Tears: A Network Meta-analysis of 144 Diagnostic Studies

BACKGROUND

Many imaging techniques have been developed for the detection of rotator cuff tears (RCTs). Despite numerous quantitative diagnostic studies, their relative accuracy remains inconclusive.

PURPOSE

To determine which of 3 commonly used imaging modalities is optimal for the diagnosis of RCTs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Studies evaluating the performance of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and ultrasound (US) used in the detection of RCTs were retrieved from the PubMed/MEDLINE and Embase databases. Diagnostic data were extracted from articles that met the inclusion/exclusion criteria. A network meta-analysis was performed using an arm-based model to pool the absolute sensitivity and specificity, relative sensitivity and specificity, and diagnostic odds ratio as well as the superiority index for ranking the probability of these techniques.

RESULTS

A total of 144 studies involving 14,059 patients (14,212 shoulders) were included in this network meta-analysis. For the detection of full-thickness (FT) tears, partial-thickness (PT) tears, or any tear, MRA had the highest sensitivity, specificity, and superiority index. For the detection of any tear, MRI had better performance than US (sensitivity: 0.84 vs 0.81, specificity: 0.86 vs 0.82, and superiority index: 0.98 vs 0.22, respectively). With regard to FT tears, MRI had a higher sensitivity and superiority index than US (0.91 vs 0.87 and 0.67 vs 0.28, respectively) and a similar specificity (0.88 vs 0.88, respectively). The results for PT tears were similar to the detection of FT tears. A sensitivity analysis was performed by removing studies involving only 1 arm for FT tears, PT tears, or any tear, and the results remained stable.

CONCLUSION

This network meta-analysis of diagnostic tests revealed that high-field MRA had the highest diagnostic value for detecting any tear, followed by low-field MRA, high-field MRI, high-frequency US, low-field MRI, and low-frequency US. These findings can help guide clinicians in deciding on the appropriate imaging modality.

Method Comparison for Detection and Measurement of Rotator Cuff Tears: Office-based Bedside Ultrasonography by a Single Physiatrist versus Imaging Center-based Ultrasonography by Two Expert Musculoskeletal Radiologists

INTRODUCTION

There is increasing interest among physiatrists in using bedside ultrasonography to assess rotator cuff tears.

OBJECTIVE

To conduct a method comparison between ultrasonography performed by a single physiatrist at bedside and two validated expert musculoskeletal radiologists at an imaging center.

DESIGN

Prospective, blinded comparison study.

SETTING

Academic outpatient clinic and imaging center.

PATIENTS

Seventy-two unilateral shoulders were scanned. Inclusion criteria included pain or weakness with rotator cuff testing and compliance with repeat ultrasonography.

INTERVENTIONS

Ultrasonography performed by the physiatrist was done at bedside during the patient's clinical visit, while the radiologists' scan was performed afterwards in an imaging center. The radiologists trained the physiatrist who was performing the scans.

MAIN OUTCOME MEASUREMENTS

The primary outcome was integrity of the rotator cuff (intact, partial tear, full tear). When a posterior cuff (supraspinatus, infraspinatus, teres minor) tear was detected, measurements of length, width, and distance from the biceps tendon were taken.

RESULTS

With use of the radiologists' scan as a criterion standard, bedside ultrasonography performed by the physiatrist for detection of posterior cuff tears had a percent perfect agreement of 72.2% for categorization as no tear, partial tear, or full tear. When evaluating dichotomously for presence of a full tear, sensitivity was 82.1% and specificity was 93.9%. Seven (18%) full-thickness tears were missed, and all were essentially small (<15 mm). When physiatrist and radiologist measurements were compared, the mean ± standard deviation (SD) difference in length was 3.4 ± 4.7 mm, width was 2.7 ± 6.7 mm, and distance to the biceps tendon was -0.8 ± 7.5 mm.

CONCLUSIONS

Office-based bedside ultrasonography is a reasonable modality to rule out medium/large full-thickness posterior cuff tears. However, physicians should be aware that a percentage of small full-thickness tears can be missed. Further imaging should be considered in suspected partial tears and full tears that may be appropriate for surgical repair.

The Value of Percutaneous Shoulder Puncture with Contrast-enhanced Ultrasound in Differentiation of Rotator Cuff Tear Subtypes: A Preliminary Prospective Study

Imaging tests perform relatively well in the detection of rotator cuff tears (RCTs), exhibiting high sensitivity and specificity, mainly among larger full-thickness tears (tear width >1 cm). However, these tests are relatively less accurate in the detection of small full-thickness tears and partial-thickness tears. The purpose of this study was to determine the feasibility of percutaneous ultrasound-guided tendon lesionography (PUTL) using the SonoVue and the value of percutaneous shoulder puncture via contrast-enhanced ultrasound (CEUS)-a combination of percutaneous ultrasound-guided subacromial bursography (PUSB) and PUTL-in the detection of RCT subtypes. Conventional ultrasound (US), CEUS and magnetic resonance imaging (MRI) were performed and prospectively evaluated in 97 patients who had undergone arthroscopy because of suspected RCTs. The rates of detection of the various subtypes of RCTs using CEUS, PUSB, PUTL, US and MRI were evaluated. The RCT subtype detection rate via CEUS was significantly higher than the rates via US and MRI (96.9%, 74.2% and 76.3%, respectively), as were the detection rates for small full-thickness tears combined with partial-thickness tears (98.2%, 60.0% and 61.8%, respectively). The detection rate with PUSB was significantly higher than those with US and MRI in assessing full-thickness tears combined with bursal-side partial-thickness tears (93.9%, 65.3% and 65.3%, respectively). The detection rate with PUTL was significantly higher than those with US and MRI in assessing the corresponding subtypes (100.0%, 69.2% and 76.9%, respectively). On the basis of our findings, we consider PUTL a tolerable and feasible procedure. Percutaneous shoulder puncture using CEUS can be an effective alternative method with better diagnostic performance than US and MRI for the detection of RCT subtypes.

Quantitative diagnosis of rotator cuff tears based on sonographic pattern recognition

The lifetime prevalence of shoulder pain is nearly 70% and is mostly attributable to subacromial disorders. A rotator cuff tear is the most severe form of subacromial disorders, and most occur in the supraspinatus. For clinical examination, shoulder ultrasound is recommended to detect supraspinatus tears. In this study, a computer-aided tear classification (CTC) system was developed to identify supraspinatus tears in ultrasound examinations and reduce inter-operator variability. The observed cases included 89 ultrasound images of supraspinatus tendinopathy and 102 of supraspinatus tear from 136 patients. For each case, intensity and texture features were extracted from the entire lesion and combined in a binary logistic regression classifier for lesion classification. The proposed CTC system achieved an accuracy rate of 92% (176/191) and an area under receiver operating characteristic curve (Az) of 0.9694. Based on its diagnostic performance, the CTC system has promise for clinical use.

Supraspinatus muscle elasticity measured with real time shear wave ultrasound elastography correlates with MRI spectroscopic measured amount of fatty degeneration

BACKGROUND

Fatty Degeneration (FD) of the rotator cuff muscles influences functional and anatomical outcome after rotator cuff repair. The MRI based estimation of fatty degeneration is the gold standard. There is some evidence that Ultrasound elastography (EUS) can detect local differences of tissue stiffness in muscles and tendons. Shear-wave elastography (SWE) was evaluated to determine the extent to which shear wave velocity was associated with measures of fatty degeneration. MRI-spectroscopic fat measurement was used as a reference to quantify the amount of fat in the muscle belly.

METHODS

Forty-two patients underwent SWE of the supraspinatus muscles at its thickest diameter. After ultrasound evaluation an MRI-spectroscopic fat measurement of the supraspinatus muscle was performed using the SPLASH-technique. A gel filled capsule was used to locate the measured area in the MRI. The values of shear wave velocity (SWV) measured with SWE and spectroscopic fat measurement were correlated statistically using Pearson's correlation test.

RESULTS

Correlation of the fat amount measured with MRI-spectroscopy and the SWV measured with SWE was ρ =0.82. Spectroscopic measured fat ratio of the supraspinatus muscle ranged from 0% to 77.41% and SWV from 1.59 m/s to 5.32 m/s. In 4 patients no sufficient SWE could be performed, these individuals showed a larger diameter of the overlying soft tissue. SWV measured with SWE showed a good correlation with MRI spectroscopic fat amount of the supraspinatus muscle.

CONCLUSION

These preliminary data suggest that SWE may be a sufficient tool in detecting and estimating the amount of fatty degeneration in the supraspinatus muscle in real time. Large overlying soft tissue may be a limitation in performing sufficient EUS. Ethical Committee Approval: Nr: 156/14 Date 12th August 2014.

LEVEL OF EVIDENCE

III.

Characterization of Rotator Cuff Tears: Ultrasound Versus Magnetic Resonance Imaging

Ultrasound and magnetic resonance imaging (MRI) are both capable of diagnosing full-thickness rotator cuff tears. However, it is unknown which imaging modality is more accurate and precise in evaluating the characteristics of full-thickness rotator cuff tears in a surgical population. This study reviewed 114 patients who underwent arthroscopic repair of a full-thickness rotator cuff tear over a 1-year period. Of these patients, 61 had both preoperative MRI and ultrasound for review. Three musculoskeletal radiologists evaluated each ultrasound and MRI in a randomized and blinded fashion on 2 separate occasions. Tear size, retraction status, muscle atrophy, and fatty infiltration were analyzed and compared between the 2 modalities. Ultrasound measurements were statistically smaller in both tear size (P=.001) and retraction status (P=.001) compared with MRI. The 2 image modalities showed comparable intraobserver reliability in assessment of tear size and retraction status. However, MRI showed greater interobserver reliability in assessment of tear size, retraction status, and atrophy. Independent observers are more likely to agree on measurements of the characteristics of rotator cuff tears when using MRI compared with ultrasound. As tear size increases, the 2 image modalities show greater differences in measurement of tear size and retraction status. Additionally, compared with MRI, ultrasound shows consistently low reliability in detecting subtle, but clinically important, degeneration of the soft tissue envelope. Although it is inexpensive and convenient, ultrasound may be best used to identify a tear, and MRI is superior for use in surgical planning for larger tears. [Orthopedics. 2017; 40(1):e124-e130.].

Biceps sheath fluid on shoulder ultrasound as a predictor of rotator cuff tear: analysis of a consecutive cohort

BACKGROUND

Ultrasound provides evaluation of rotator cuff disease with accuracy comparable to that of magnetic resonance imaging. Fluid in the sheath of the long head of the biceps tendon (LHB), identified on ultrasound scan, has been associated with disease of the rotator cuff, LHB, and glenohumeral joint. Prior literature has compared ultrasound findings only with arthrography, and results have been conflicting. Arthroscopy remains the reference standard in assessing accuracy of imaging modalities. We present the first study investigating the significance of fluid in the LHB on ultrasound in predicting subsequent rotator cuff disease identified on arthroscopy.

METHODS

Records were reviewed of 175 patients undergoing ultrasound and subsequent arthroscopy under 1 shoulder surgeon. Experienced musculoskeletal radiologists and sonographers performed ultrasound. Ultrasound examination and operating records were collected and analyzed. Data were analyzed using descriptive statistics, correlation, and logistic regression modeling.

RESULTS

Highly significant correlation (P < .001; ρ = 0.354) was found between fluid in the LHB sheath and rotator cuff tears on arthroscopy. Statistically significant but weak correlation (P < .05; rho = 0.187) was found between fluid in the LHB sheath and both biceps tendon disease and glenohumeral joint disease. Fluid around the LHB was shown to increase the likelihood of having rotator cuff tear (odds ratio, 2.641; 95% confidence interval, 1.229-5.674) and biceps tendon disease (odds ratio, 2.698; 95% confidence interval, 1.216-5.987).

CONCLUSION

This is the first report identifying significant correlation between fluid in the LHB sheath identified on ultrasound and subsequent rotator cuff disease identified at arthroscopy. We recommend routine reporting of fluid in the LHB sheath as it is likely to improve the accuracy of detecting rotator cuff and biceps tendon diseases.

Computer-Aided Diagnosis of Different Rotator Cuff Lesions Using Shoulder Musculoskeletal Ultrasound

The lifetime prevalence of shoulder pain approaches 70%, which is mostly attributable to rotator cuff lesions such as inflammation, calcific tendinitis and tears. On clinical examination, shoulder ultrasound is recommended for the detection of lesions. However, there exists inter-operator variability in diagnostic accuracy because of differences in the experience and expertise of operators. In this study, a computer-aided diagnosis (CAD) system was developed to assist ultrasound operators in diagnosing rotator cuff lesions and to improve the practicality of ultrasound examination. The collected cases included 43 cases of inflammation, 30 cases of calcific tendinitis and 26 tears. For each case, the lesion area and texture features were extracted from the entire lesions and combined in a multinomial logistic regression classifier for lesion classification. The proposed CAD achieved an accuracy of 87.9%. The individual accuracy of this CAD system was 88.4% for inflammation, 83.3% for calcific tendinitis and 92.3% for tears. Cohen's k was 0.798. On the basis of its diagnostic performance, clinical use of this CAD technique has promise.

Correlation of findings in clinical and high resolution ultrasonography examinations of the painful shoulder

Objective

High resolution ultrasonography is a non-painful and non-invasive imaging technique which is useful for the assessment of shoulder pain causes, as clinical examination often does not allow an exact diagnosis. The aim of this study was to compare the findings of clinical examination and high resolution ultrasonography in patients presenting with painful shoulder.

Methods

Non-interventional observational study of 100 adult patients suffering from unilateral shoulder pain. Exclusion criteria were shoulder fractures, prior shoulder joint surgery and shoulder injections in the past month. The physicians performing the most common clinical shoulder examinations were blinded to the results of the high resolution ultrasonography and vice versa.

Results

In order to detect pathology of the m. supraspinatus tendon, the Hawkins and Kennedy impingement test showed the highest sensitivity (0.86) whereas the Jobe supraspinatus test showed the highest specificity (0.55). To identify m. subscapularis tendon pathology the Gerber lift off test showed a sensitivity of 1, whereas the belly press test showed the higher specificity (0.72). The infraspinatus test showed a high sensitivity (0.90) and specificity (0.74). All AC tests (painful arc II^a, AC joint tenderness^b, cross body adduction stress test^c) showed high specificities (^a0.96, ^b0.99, ^c0.96). Evaluating the long biceps tendon, the palm up test showed the highest sensitivity (0.47) and the Yergason test the highest specificity (0.88).

Conclusion

Knowledge of sensitivity and specificity of various clinical tests is important for the interpretation of clinical examination test results. High resolution ultrasonography is needed in most cases to establish a clear diagnosis.

Imaging of the Rotator Cuff With Optical Coherence Tomography

This study evaluated the utility of optical coherence tomography (OCT) in imaging porcine and human rotator cuff (RTC) tissue, analyzed its effectiveness in identifying clinical pathology, and correlated these findings with histologic examination. Twelve human cadaveric and 6 porcine shoulders were evaluated. Six-millimeter-wide bone sections were harvested from the proximal humerus of each specimen, with each containing the entire enthesis of the respective RTC tendon, as well as 2 cm of tendon medial to the enthesis. Only the supraspinatus tendon was evaluated in the human specimens, whereas the enthesis of multiple RTC tendons were evaluated in the porcine model. All specimens were imaged using OCT and correlated with histologic evaluation. Optical coherence tomography evaluation of macroscopically healthy tissue consistently showed an easily identifiable banding pattern (birefringence) in contrast to a disorganized, homogeneous appearance in grossly diseased tissue. Optical coherence tomography was more effective for qualitative evaluation of RTC tissue, identification of bursal-sided RTC tears, and localization of calcific deposits, whereas intrasubstance tendon delaminations and partial articular-sided tendon avulsion lesions were relatively more difficult to identify. Optical coherence tomography correlated well with histologic evaluation in all specimens. Optical coherence tomography provides high-resolution, subsurface imaging of rotator cuff tissue in real-time to a depth of up to 4 mm with excellent correlation to histology in a cadaveric model. Optical coherence tomography could be an effective adjunctive tool for the identification and localization of rotator cuff pathology. The use of OCT in arthroscopic shoulder surgery potentially provides a minimally invasive modality for qualitative assessment of rotator cuff pathology. This may allow for a decrease in soft tissue dissection, improved qualitative assessment of cuff tissue, and improved patient outcomes.

Dedicated training program for shoulder sonography: the results of a quality program reverberate with everyone

OBJECTIVES

The purpose of this study was to define and report on the effect of a comprehensive musculoskeletal sonography training program to improve accuracy (sensitivity and specificity) for the diagnosis of rotator cuff tears in relatively inexperienced operators.

METHODS

Before the training program was implemented, radiologists (n = 12) had a mean of 2 years (range, <1-12 years) of experience performing and interpreting musculoskeletal sonography. Pre- and post-training shoulder sonographic results were compared to surgical reports or, in their absence, to shoulder magnetic resonance imaging or computed tomographic arthrographic results if within 2 months of the sonographic examination. A total of 82 patients were included in the pre-training group (January 2010-December 2011), and 50 patients were included in the post-training group (January 2012-June 2013). The accuracy, sensitivity, specificity, and positive and negative predictive values were determined for the presence or absence of supraspinatus and infraspinatus tendon tears.

RESULTS

After implementation of the training program, the sensitivity of sonography for detecting full-thickness rotator cuff tears increased by 14%, and the sensitivity for detecting partial-thickness rotator cuff tears increased by 3%.

CONCLUSIONS

Quality improvement programs and acquisition standardization along with ongoing, focused case conferences for the entire care team increased the sensitivity of shoulder sonography for diagnosing both full- and partial-thickness rotator cuff tears, independent of the years of operator experience.

Use of ultrasonography as a diagnostic and therapeutic tool in sports medicine

Ultrasonography has many important advantages over other imaging modalities and many important applications in sports medicine. This article presents an evidence-based discussion of the use of ultrasound technology to diagnose and treat common musculoskeletal disorders, with emphasis on the shoulder, elbow, hip, knee, and foot and ankle. Topics include basic principles, scan artifacts, the appearance of musculoskeletal structure characteristics and pathologies, and various diagnostic and therapeutic applications in sports medicine.

Clinics in diagnostic imaging. 148. Bursal-sided partial-thickness supraspinatus tendon tear

Rotator cuff injury comprises a continual spectrum of lesions ranging from tendinopathy, which may progress to partial- or full-thickness tear. This progression may be influenced by the interplay of extrinsic and intrinsic factors. We describe the case of a 29-year-man who presented with right shoulder pain for one year. His initial magnetic resonance (MR) arthrogram showed supraspinatus tendinopathy. Subsequent MR arthrogram, obtained after a road traffic accident, showed a bursal-sided partial-thickness tear of the supraspinatus tendon. In view of his worsening clinical symptoms, surgery was performed ten months later, revealing a full-thickness rotator cuff tear near the tendon insertion, with a tight subacromial space and bony protuberance of the humeral head. The pathogenesis of rotator cuff injuries, the roles of different imaging modalities in the diagnosis of rotator cuff injuries, as well as the advantages and limitations of various radiological modalities, are discussed.

Shoulder ultrasound: What you need to know

Shoulder ultrasound is consistently used in the assessment of rotator cuff and is as accurate as magnetic resonance imaging in the detection of rotator cuff tear. It can be used as a focused examination providing rapid, real-time diagnosis, and treatment in desired clinical situations. This article presents a simplified approach to scanning and image-guided intervention, and discusses common sonographically apparent shoulder pathologies.

Longitudinal analysis of effects of operator experience on accuracy for ultrasound detection of supraspinatus tears

BACKGROUND

Magnetic resonance imaging (MRI) is highly accurate in diagnosing full-thickness rotator cuff tears but has the limitations of high cost and patient-based inconveniences. Diagnostic ultrasound of the rotator cuff has become popular, but its accuracy is operator dependent. We hypothesized that the incremental learning associated with initiation of shoulder ultrasonography in the orthopedic office setting could be quantified.

MATERIALS AND METHODS

Ultrasound was performed by 2 surgeons in different patient populations each consisting of 200 patients within the clinical setting. Analysis of the operator learning curves based on sensitivity, specificity, positive predictive value, negative predictive value, and κ agreement scores was performed with MRI used as the reference standard.

RESULTS

Surgeon 1 detected 67 (ultrasound) of 72 (MRI) full-thickness supraspinatus tears, and surgeon 2 detected 92 (ultrasound) of 95 (MRI) full-thickness tears. Agreement between ultrasound and MRI improved with increasing number of ultrasounds performed. The maximal rate of increase in sensitivity occurred by the 50th ultrasound for both surgeons. The maximal rate of increase in specificity occurred by the 75th ultrasound for both surgeons. Overall accuracy to detect full-thickness supraspinatus tears plateaued after 100 ultrasounds.

CONCLUSIONS

The majority of learning to detect full-thickness supraspinatus tears by ultrasound occurred in the surgeons' first 50 cases. The ability to accurately distinguish a normal supraspinatus tendon by ultrasound took longer, occurring within the first 75 cases. The majority of learning before accuracy plateaued occurred within the first 100 ultrasounds. The recommended operator experience necessary to evaluate the supraspinatus tendon before clinical application was 100 ultrasounds.

LEVEL OF EVIDENCE

Level I, Diagnostic Study.

Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement

The Society of Radiologists in Ultrasound convened a panel of specialists from a variety of medical disciplines to reach a consensus about the recommended imaging evaluation of painful shoulders with clinically suspected rotator cuff disease. The panel met in Chicago, Ill, on October 18 and 19, 2011, and created this consensus statement regarding the roles of radiography, ultrasonography (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography. The consensus panel consisted of two co-moderators, a facilitator, a statistician and health care economist, and 10 physicians who have specialty expertise in shoulder pain evaluation and/or treatment. Of the 13 physicians on the panel, nine were radiologists who were chosen to represent a broad range of skill sets in diagnostic imaging, different practice types (private and academic), and different geographical regions of the United States. Five of the radiologists routinely performed musculoskeletal US as part of their practice and four did not. There was also one representative from each of the following clinical specialties: rheumatology, physical medicine and rehabilitation, orthopedic surgery, and nonoperative sports medicine. The goal of this conference was to construct several algorithms with which to guide the imaging evaluation of suspected rotator cuff disease in patients with a native rotator cuff, patients with a repaired rotator cuff, and patients who have undergone shoulder replacement. The panel hopes that these recommendations will lead to greater uniformity in rotator cuff imaging and more cost-effective care for patients suspected of having rotator cuff abnormality.

Ultrasound assessment of asymmetric hypertrophy of the rectus abdominis muscle and prevalence of associated injury in professional tennis players

OBJECTIVE

To assess rectus abdominis (RA) thickness and injury prevalence using ultrasound in a group of professional tennis players. Observations with regard to muscle fiber repair is described. We likewise studied the potential link between RA volume asymmetry and the risk of muscle strain.

MATERIALS AND METHODS

The degree of asymmetry between the different RA slices was assessed using ultrasound in 61 professional tennis players. The history of RA injury in these tennis players was likewise studied, taking into account the following factors: dominant vs non-dominant arm, history of RA strains, duration thereof and number of recurrences. Ultrasound examination was performed with an 8- to 12-MHz linear multi-frequency transducer.

RESULTS

Ultrasound revealed the presence of fibrous scar tissue in the RA muscle in 18 cases (29.5%). In all instances, the lesion was located in the RA on the side of the nondominant arm. In 16 of the cases, the lesion was infra-umbilical and L2 was affected in two cases. The mean maximum width of the fibrous repair tissue was 9 mm (range 5-16). The mean distance between the umbilicus and the scar was 5.8 cm (range 2.9-11.4). Statistical study of the ultrasound measurements obtained for the different slices revealed statistically significant differences between the different depths and according to arm dominance.

CONCLUSIONS

In the series studied, the prevalence of RA muscle lesion in professional tennis players was 29.5%. Asymmetric hypertrophy of the RA muscle appears to constitute a risk factor for suffering an injury in this location.

Diagnostic performance and reliability of ultrasonography for fatty degeneration of the rotator cuff muscles

BACKGROUND

Diagnostic evaluation of rotator cuff muscle quality is important to determine indications for potential operative repair. Ultrasonography has developed into an accepted and useful tool for evaluating rotator cuff tendon tears; however, its use for evaluating rotator muscle quality has not been well established. The purpose of this study was to investigate the diagnostic performance and observer reliability of ultrasonography in grading fatty degeneration of the posterior and superior rotator cuff muscles.

METHODS

The supraspinatus, infraspinatus, and teres minor muscles were prospectively evaluated with magnetic resonance imaging (MRI) and ultrasonography in eighty patients with shoulder pain. The degree of fatty degeneration on MRI was graded by four independent raters on the basis of the modified Goutallier grading system. Ultrasonographic evaluation of fatty degeneration was performed by one of three radiologists with use of a three-point scale. The two scoring systems were compared to determine the diagnostic performance of ultrasonography. The interobserver and intraobserver reliability of MRI grading by the four raters were determined. The interobserver reliability of ultrasonography among the three radiologists was determined in a separate group of thirty study subjects. The weighted Cohen kappa, percentage agreement, sensitivity, and specificity were calculated.

RESULTS

The accuracy of ultrasonography for the detection of fatty degeneration, as assessed on the basis of the percentage agreement with MRI, was 92.5% for the supraspinatus and infraspinatus muscles and 87.5% for the teres minor. The sensitivity was 84.6% for the supraspinatus, 95.6% for the infraspinatus, and 87.5% for the teres minor. The specificity was 96.3% for the supraspinatus, 91.2% for the infraspinatus, and 87.5% for the teres minor. The agreement between MRI and ultrasonography was substantial for the supraspinatus and infraspinatus (kappa = 0.78 and 0.71, respectively) and moderate for the teres minor (kappa = 0.47). The interobserver reliability for MRI was substantial for the supraspinatus and infraspinatus (kappa = 0.76 and 0.77, respectively) and moderate for the teres minor (kappa = 0.59). For ultrasonography, the interobserver reliability was substantial for all three muscles (kappa = 0.71 for the supraspinatus, 0.65 for the infraspinatus, and 0.72 for the teres minor).

CONCLUSIONS

The diagnostic performance of ultrasonography in identifying and grading fatty degeneration of the rotator cuff muscles was comparable with that of MRI. Ultrasonography can be used as the primary diagnostic imaging modality for fatty changes in rotator cuff muscles.

Reproducibility of sonographic measurement of thickness and echogenicity of the plantar fascia

BACKGROUND

To evaluate the intra- and interrater reliability of ultrasonographic measurements of the thickness and echogenicity of the plantar fascia.

METHODS

Eleven patients (20 feet), who complained of inferior heel pain, and 26 volunteers (52 feet) were enrolled. Two sonographers independently imaged the plantar fascia in both longitudinal and transverse planes. Volunteers were assessed twice to evaluate intrarater reliability. Quantitative evaluation of the echogenicity of the plantar fascia was performed by measuring the mean gray level of the region of interest using Digital Imaging and Communications in Medicine viewer software.

RESULTS

Sonographic evaluation of the thickness of the plantar fascia showed high reliability. Sonographic evaluations of the presence or absence of hypoechoic change in the plantar fascia showed surprisingly low agreement. The reliability of gray-scale evaluations appears to be much better than subjective judgments in the evaluation of echogenicity. Transverse scanning did not show any advantage in sonographic evaluation of the plantar fascia.

CONCLUSIONS

The reliability of sonographic examination of the thickness of the plantar fascia is high. Mean gray-level analysis of quantitative sonography can be used for the evaluation of echogenicity, which could reduce discrepancies in the interpretation of echogenicity by different sonographers. Longitudinal instead of transverse scanning is recommended for imaging the plantar fascia.

Reliability of sonographic assessment of tendinopathy in tennis elbow

OBJECTIVE

To assess the reliability and compute the minimum detectable change using sonographic scales to quantify the extent of pathology and hyperaemia in the common extensor tendon in people with tennis elbow.

MATERIALS AND METHODS

The lateral elbows of 19 people with tennis elbow were assessed sonographically twice, 1-2 weeks apart. Greyscale and power Doppler images were recorded for subsequent rating of abnormalities. Tendon thickening, hypoechogenicity, fibrillar disruption and calcification were each rated on four-point scales, and scores were summed to provide an overall rating of structural abnormality; hyperaemia was scored on a five point scale. Inter-rater reliability was established using the intraclass correlation coefficient (ICC) to compare scores assigned independently to the same set of images by a radiologist and a physiotherapist with training in musculoskeletal imaging. Test-retest reliability was assessed by comparing scores assigned by the physiotherapist to images recorded at the two sessions. The minimum detectable change (MDC) was calculated from the test-retest reliability data.

RESULTS

ICC values for inter-rater reliability ranged from 0.35 (95% CI: 0.05, 0.60) for fibrillar disruption to 0.77 (0.55, 0.88) for overall greyscale score, and 0.89 (0.79, 0.95) for hyperaemia. Test-retest reliability ranged from 0.70 (0.48, 0.84) for tendon thickening to 0.82 (0.66, 0.90) for overall greyscale score and 0.86 (0.73, 0.93) for calcification. The MDC for the greyscale total score was 2.0/12 and for the hyperaemia score was 1.1/5.

CONCLUSION

The sonographic scoring system used in this study may be used reliably to quantify tendon abnormalities and change over time. A relatively inexperienced imager can conduct the assessment and use the rating scales reliably.

Surgeon-operated ultrasonography in a one-stop shoulder clinic

INTRODUCTION

Nearly 1 in 40 of the population seeks medical advice related to a shoulder problem every year. The majority pertain to rotator cuff pathology. Prior to intervention in such patients it is imperative to define whether the tendons are intact or torn. Ultrasonography has become an essential adjunct to clinical assessment in diagnosing rotator cuff tears. This study was designed to investigate if a surgeon using a portable ultrasonography machine in a one-stop shoulder clinic could significantly reduce the time a patient waited from initial outpatient presentation to the end of the treatment episode (be it surgery, injection or conservative management).

METHODS

A total of 77 patients were allocated to one of two groups: Group A, consisting of 37 patients who were assessed and had ultrasonography as outpatients, and Group B, consisting of 40 patients who were assessed and referred for departmental ultrasonography where appropriate. Three clear outcome groups were defined: those who required surgical repair, those who had irreparable tears and those who declined surgery.

RESULTS

For all outcomes (surgery, irreparable tears and conservative treatment), the patients in Group A all completed their clinical episodes significantly quicker than those in Group B (p<0.02). As well as the time saving benefits, there was a substantial financial saving for Group A. By performing ultrasonography in the outpatients department, those patients avoided the requirement of departmental imaging (£120) and subsequent follow-up appointments (£73) to discuss results and management, resulting in a saving of nearly £200 per patient.

CONCLUSIONS

The use of a portable ultrasonography machine by an orthopaedic surgeon can significantly reduce the time to treatment and the financial cost for patients with rotator cuff tears.

Diagnostic accuracy of ultrasound for rotator cuff tears in adults: a systematic review and meta-analysis

AIM

To determine the diagnostic accuracy of ultrasound to detect partial and complete thickness rotator cuff tears based on all available clinical trials.

MATERIALS AND METHODS

An electronic search of databases registering published and unpublished literature was conducted. All diagnostic accuracy studies that directly compared the accuracy of ultrasound (the index test) to either arthroscopic or open surgical findings (the reference test) for rotator cuff tear were included. The methodological quality of each included study was assessed using the QUADAS form. When appropriate, pooled sensitivity and specificity analysis was conducted, with an assessment of the summary receiver operating characteristic (ROC) curve for each analysis.

RESULTS

Sixty-two studies assessing 6007 patients and 6066 shoulders were included. Ultrasonography had good sensitivity and specificity for the assessment of partial thickness (sensitivity 0.84; specificity 0.89), and full-thickness rotator cuff tears (sensitivity 0.96; specificity 0.93). However, the literature poorly described population characteristics, assessor blinding, and was based on limited sample sizes. The literature assessing transducer frequency was particularly small in size.

CONCLUSION

Ultrasonography is an appropriate radiological technique for the assessment of rotator cuff tears with an acceptable sensitivity and specificity. The diagnostic test accuracy of ultrasound is superior for the detection of full-thickness compared to partial-thickness cuff tears. Further study assessing the effect of transducer frequency is warranted.

A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks

BACKGROUND

The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ).

METHODS

Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks.

RESULTS

In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05).

CONCLUSIONS

Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.

Shoulder ultrasonography versus arthroscopy for the detection of rotator cuff tears: analysis of errors

PURPOSE

To compare shoulder ultrasonography with arthroscopy for detecting specific rotator cuff tears.

METHODS

96 shoulders in 56 men and 34 women aged 28 to 65 (mean, 42) years with rotator cuff problems underwent a shoulder ultrasonography by a single radiologist, and then a shoulder arthroscopy by a single surgeon. The ultrasonographic and arthroscopic findings were compared with regard to tendon-specific tears and disparities in diagnosis.

RESULTS

For detection of supraspinatus tendon tears, ultrasonography attained a sensitivity of 89%, specificity of 43%, positive predictive value of 76%, and negative predictive value of 100%. For detection of subscapularis tendon tears, ultrasonography attained a sensitivity of 30%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 78%. Sensitivity, specificity, and predictive values were good in larger full-thickness tears, but were significantly reduced in sub-centimetre and partial-thickness tears, particularly of the subscapularis tendon.

CONCLUSIONS

Surgeons should be aware of the potential disparities between ultrasonographic and arthroscopic findings and be prepared to adjust the surgical procedure during arthroscopy.

Ultrasound detection of rotator cuff tears: observer agreement related to increasing experience

OBJECTIVE

Ultrasound of the rotator cuff is considered to be operator-dependent with its accuracy being related to the operator's level of experience. This study was conducted to test the hypothesis that ultrasound performed by operators with different levels of experience will give nonreproducible results.

SUBJECTS AND METHODS

Two radiologists, one general radiologist with no experience in musculoskeletal ultrasound and one experienced musculoskeletal radiologist, independently performed ultrasound on 200 shoulders in 183 consecutive patients. Agreement was assessed. Cohen's kappa values with standard errors were calculated. In 71 patients the ultrasound findings could be related to surgical findings.

RESULTS

The diagnoses of full-thickness and partial-thickness rotator cuff tears were made with agreements of 98% (κ-value: 0.95 [standard error, 0.03]) and 90% (κ-value: 0.79 [0.05]), respectively. Agreement for full-thickness tears was constant; the agreement for partial-thickness tears improved from 80% to 98% in the last quarter of the study period. Based on the 71 patients who underwent shoulder surgery, sensitivity, specificity, and accuracy for detecting full-thickness tears by the experienced and general radiologists were 94%, 94%, and 94% and 89%, 91%, and 90%, respectively. Sensitivity, specificity, and accuracy for detecting partial-thickness tears by the experienced and general radiologists were 100%, 32%, and 57% and 84%, 35%, and 53%, respectively.

CONCLUSION

The hypothesis that ultrasound of the shoulder is operator-dependent and related to experience was refuted. In this study, there was excellent agreement for the detection of rotator cuff tears, which only slightly improved with the increasing experience of the general radiologist. Accuracy of rotator cuff tear detection was high and in accordance with the results in the literature.

Accuracy of diagnostic ultrasound in patients with suspected subacromial disorders: a systematic review and meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of ultrasound for detecting subacromial disorders in patients presenting in primary and secondary care settings.

DATA SOURCES

Medline and Embase were searched on June 9, 2010. In addition, the reference list of 1 systematic review and all included articles were searched to identify relevant studies.

STUDY SELECTION

Two reviewers independently selected the articles evaluating the accuracy of ultrasound for detecting subacromial disorders from the title and abstracts retrieved by the literature search. Selection criteria were ultrasound frequency greater than or equal to 7.5MHz as index test, surgery, magnetic resonance imaging and/or radiography as reference standards, and subacromial disorders as target conditions.

DATA EXTRACTION

Two reviewers independently extracted the data on study characteristics and results to construct 2 by 2 tables and performed a methodologic quality assessment.

DATA SYNTHESIS

Twenty-three studies were included: 22 reported on full-thickness rotator cuff tears, 15 on partial-thickness tears, 3 on subacromial bursitis, 2 on tendinopathy, and 2 on calcifying tendonitis, respectively. For full-thickness tears, pooled sensitivity of ultrasound was .95 (95% confidence interval, .90-.97), and specificity .96 (.93-.98). For partial-thickness tears, pooled sensitivity was .72 (.58-.83), and specificity .93 (.89-.96). Statistical pooling was not possible for the other disorders. For subacromial bursitis, sensitivity ranged from .79 to .81, and specificity from .94 to .98. For tendinopathy, sensitivity ranged from .67 to .93, specificity from .88 to 1.00. Sensitivity for calcifying tendonitis was 1.00 in both studies, with specificity ranging from .85 to .98.

CONCLUSIONS

We strongly recommend ultrasound in patients for whom conservative treatment fails, to rule in or out full-thickness tears, to rule in partial-thickness tears, and to a lesser extent to diagnose tendinopathy, subacromial bursitis, and calcifying tendonitis. These results can help physicians tailor treatment.

Location and initiation of degenerative rotator cuff tears: an analysis of three hundred and sixty shoulders

BACKGROUND

It has been theorized that degenerative rotator cuff tears most commonly involve the supraspinatus tendon, initiating at the anterior portion of the supraspinatus insertion and propagating posteriorly. The purposes of this study were to determine the most common location of degenerative rotator cuff tears and to examine tear location patterns associated with various tear sizes.

METHODS

Ultrasonograms of 360 shoulders with either a full-thickness rotator cuff tear (272) or a partial-thickness rotator cuff tear (eighty-eight) were obtained to measure the width and length of the tear and the distance from the biceps tendon to the anterior margin of the tear. Tears were grouped on the basis of their size (anteroposterior width) and extent (partial or full-thickness). Each tear was represented numerically as a column of consecutive numbers representing the tear width and distance posterior to the biceps tendon. All tears were pooled to graphically represent the width and location of the tears within groups. Frequency histograms of the pooled data were generated, and the mode was determined for each histogram representing various tear groups.

RESULTS

The mean age (and standard deviation) of the 233 subjects (360 shoulders) was 64.7 +/- 10.2 years. The mean width and length of the tears were 16.3 +/- 12.1 mm and 17.0 +/- 13.0 mm, respectively. The mean distance from the biceps tendon to the anterior tear margin was 7.8 +/- 5.7 mm (range, 0 to 26 mm). Histograms of the various tear groups invariably showed the location of 15 to 16 mm posterior to the biceps tendon to be the most commonly torn location within the posterior cuff tendons. The histograms of small tears (a width of <10 mm) and partial-thickness tears showed similar distributions of tear locations, indicating that the region approximately 15 mm posterior to the biceps tendon may be where rotator cuff tears most commonly initiate.

CONCLUSIONS

Degenerative rotator cuff tears most commonly involve a posterior location, near the junction of the supraspinatus and infraspinatus. The patterns of tear location across multiple tear sizes suggest that degenerative cuff tears may initiate in a region 13 to 17 mm posterior to the biceps tendon.

Relationship of tear size and location to fatty degeneration of the rotator cuff

BACKGROUND

Fatty degeneration of the rotator cuff muscles may have detrimental effects on both anatomical and functional outcomes following shoulder surgery. The purpose of this study was to investigate the relationship between tear geometry and muscle fatty degeneration in shoulders with a deficient rotator cuff.

METHODS

Ultrasonograms of both shoulders of 262 patients were reviewed to assess the type of rotator cuff tear and fatty degeneration in the supraspinatus and infraspinatus muscles. The 251 shoulders with a full-thickness tear underwent further evaluation for tear size and location. The relationship of tear size and location to fatty degeneration of the supraspinatus and infraspinatus muscles was investigated with use of statistical comparisons and regression models.

RESULTS

Fatty degeneration was found almost exclusively in shoulders with a full-thickness rotator cuff tear. Of the 251 shoulders with a full-thickness tear, eighty-seven (34.7%) had fatty degeneration in either the supraspinatus or infraspinatus, or both. Eighty-two (32.7%) of the 251 full-thickness tears had a distance of 0 mm between the biceps tendon and anterior margin of the tear. Ninety percent of the full-thickness tears with fatty degeneration in both muscles had a distance of 0 mm posterior from the biceps, whereas only 9% of those without fatty degeneration had a distance of 0 mm. Tears with fatty degeneration had significantly greater width and length than those without fatty degeneration (p < 0.0001). Tears with fatty degeneration had a significantly shorter distance posterior from the biceps than those without fatty degeneration (p < 0.0001). The distance posterior from the biceps was found to be the most important predictor for supraspinatus fatty degeneration, whereas tear width and length were found to be the most important predictors for infraspinatus fatty degeneration.

CONCLUSIONS

Fatty degeneration of the rotator cuff muscles is closely associated with tear size and location. The finding of this study suggests that the integrity of the anterior supraspinatus tendon is important to the development of fatty degeneration. Patients with full-thickness tears that extend through this area may benefit from earlier surgical intervention if fatty degeneration has not already occurred. Additionally, the findings suggest the importance of secure fixation and healing of the anterior aspect of the supraspinatus with surgical repair.

Detection of partial-thickness supraspinatus tendon tears: is a single direct MR arthrography series in ABER position as accurate as conventional MR arthrography?

PURPOSE

The purpose of this study was to retrospectively evaluate sensitivity and specificity of a single magnetic resonance (MR) arthrography series in abduction external rotation (ABER) position compared with conventional MR arthrography for detection of supraspinatus tendon tears, with arthroscopy as gold standard, and to assess interobserver variability.

MATERIALS AND METHODS

Institutional review board approval was obtained; informed consent was waived. MR arthrograms of 250 patients (170 men and 80 women; mean age, 36 years) were retrospectively and independently evaluated by three observers. Oblique coronal T1-weighted fat-suppressed images, proton density, and T2-weighted images and axial T1-weighted images and oblique sagittal T1-weighted fat-suppressed images were analyzed to detect supraspinatus tendon tears. Separately, a single T1-weighted fat-suppressed oblique axial series in ABER position was evaluated. Both protocols were scored randomly without knowledge of patients' clinical history and arthroscopy results. Tears were subclassified, based on articular surface integrity and extension (Lee classification). Interobserver agreement was assessed by kappa statistics for all patients. Ninety-two of 250 patients underwent arthroscopy; sensitivity and specificity of ABER and conventional MR arthrography were calculated and compared using paired McNemar test.

RESULTS

Weighted kappa values of ABER and conventional MR arthrography were 0.48-0.65 and 0.60-0.67, respectively. According to arthroscopy, 69 of 92 patients had an intact cuff, and 23 patients had a cuff tear (16 partial thickness and seven full thickness). There were no statistically significant differences between ABER and conventional MR arthrography regarding sensitivity (48-61% and 52-70%, respectively) and specificity (80-94% and 91-95%).

CONCLUSION

Sensitivity and specificity of a single T1-weighted series in ABER position and conventional MR arthrography are comparable for assessment of rotator cuff tears.

Musculoskeletal ultrasound: focused impact on MRI

OBJECTIVE

This article will compare and contrast image interpretation, accuracy, observer variability, economic impact, and education with regard to musculoskeletal ultrasound and MRI because these factors will influence the growth of musculoskeletal ultrasound and the impact on MRI.

CONCLUSION

The use of musculoskeletal ultrasound continues to grow and there are a number of factors that impact MRI. The development of less expensive portable ultrasound machines has opened the market to nonradiologists, and applications for musculoskeletal ultrasound have broadened. Selective substitution of musculoskeletal ultrasound for MRI can result in significant cost saving to the health care system. Although this change could decrease the use of MRI, issues related to accuracy, variability, education, and competence must be addressed.

Detection of rotator cuff tears: the value of MRI following ultrasound

OBJECTIVE

To evaluate the need for additional magnetic resonance imaging (MRI) following ultrasound (US) in patients with shoulder pain and/or disability and to compare the accuracy of both techniques for the detection of partial-thickness and full-thickness rotator cuff tears (RCT).

METHODS

In 4 years, 5,216 patients underwent US by experienced musculoskeletal radiologists. Retrospectively, patient records were evaluated if MRI and surgery were performed within 5 months of US. US and MRI findings were classified into intact cuff, partial-thickness and full-thickness RCT, and were correlated with surgical findings.

RESULTS

Additional MR imaging was performed in 275 (5.2%) patients. Sixty-eight patients underwent surgery within 5 months. US and MRI correctly depicted 21 (95%) and 22 (100%) of the 22 full-thickness tears, and 8 (89%) and 6 (67%) of the 9 partial-thickness tears, respectively. The differences in performance of US and MRI were not statistically significant (p = 0.15).

CONCLUSIONS

MRI following routine shoulder US was requested in only 5.2% of the patients. The additional value of MRI was in detecting intra-articular lesions. In patients who underwent surgery, US and MRI yielded comparably high sensitivity for detecting full-thickness RCT. US performed better in detecting partial-thickness tears, although the difference was not significant.

Management of massive and irreparable rotator cuff tears

Massive rotator cuff tears pose a distinct clinical challenge for the orthopaedist. In this review, we will discuss the classification, diagnosis, and evaluation of massive rotator cuff tears before discussing various treatment options for this problem. Nonoperative treatment has had inconsistent results and proven unsuccessful for chronic symptoms while operative treatment including debridement and partial and complete repairs have had varying degrees of success. For rotator cuff tears that are deemed irreparable, treatment options are limited. The use of tendon transfers in younger patients to reconstruct rotator cuff function and restore shoulder kinematics can be useful in salvaging this difficult problem.

Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs

BACKGROUND

Normative data are essential to the evaluation of shoulder function. The purposes of this study were to establish a normative database of isometric shoulder strength measured in asymptomatic individuals verified to have intact rotator cuffs and to determine the effect of asymptomatic rotator cuff tears on shoulder strength.

METHODS

Two hundred and thirty-seven volunteers with no shoulder pain or history of shoulder injury were screened with ultrasonography bilaterally for rotator cuff tears and then underwent isometric strength measurements for abduction in the scapular plane and external rotation. Statistical analysis was performed to evaluate the effect of age, body habitus, hand dominance, and the presence of a rotator cuff tear on shoulder strength.

RESULTS

Of the 237 volunteers, forty-one were found to have a torn rotator cuff in at least one shoulder. The prevalence of rotator cuff tears was 0% for the subjects between forty and forty-nine years old; 10%, between fifty and fifty-nine years old; 20%, between sixty and sixty-nine years old; and 40.7% for those seventy years old or older. Both abduction strength and external rotation strength in the male subjects showed an age-dependent decrease, whereas only abduction strength showed an age-dependent decrease in the female subjects. In multiple regression analysis, age and weight were the most important predictors of abduction strength and external rotation strength, respectively. In the shoulders with a large-to-massive full-thickness rotator cuff tear, abduction strength was significantly decreased (p = 0.007). Additionally, the ratio of abduction strength to external rotation strength was significantly decreased in the shoulders with a large-to-massive full-thickness tear compared with the shoulders with an intact rotator cuff (p < 0.001).

CONCLUSIONS

There is a high prevalence of rotator cuff tears in elderly asymptomatic individuals. Asymptomatic shoulders with a large-to-massive full-thickness rotator cuff tear have significantly decreased abduction strength. When there is a substantial decrease in abduction strength in relation to external rotation strength, the presence of an asymptomatic full-thickness tear should be suspected in that shoulder. Previous studies establishing normative values for isometric shoulder strength may have been skewed by the presence of asymptomatic rotator cuff tears in elderly subgroups.

Sonography of the painful shoulder: role of the operator's experience

OBJECTIVE

The aim of our study was to determine the role of the operator's experience in the sonographic evaluation of the painful shoulder and to validate assumptions about its technical performance in routine practice.

MATERIALS AND METHODS

Two radiologists, respectively standard and expert sonographic operators, independently and prospectively scanned 65 patients with clinical suspicion of rotator cuff lesion. Magnetic resonance arthrography was the reference standard.

RESULTS

The sensitivity of the expert ultrasound operator was 95.3% for full-thickness rotator cuff tears (41/43), 70.6% for partial-thickness tears (12/17), 64.3% for intratendinous tears (9/14), 100% for abnormality of the long head of biceps tendon (seven of seven), 88.9% for supraspinatus tendinosis (16/18), 96.4% for subacromial bursa abnormalities (53/55), and 91.7% for acromioclavicular joint osteoarthritis (33/36). The two sonographic operators were in very good agreement about full-thickness rotator cuff tears (kappa = 0.90), supraspinatus tendinosis (kappa = 0.80), abnormalities of the long head of biceps tendon (kappa = 0.84), subacromial bursa abnormalities (kappa = 0.89), and acromioclavicular osteoarthritis (kappa = 0.81). The agreement was only moderate for partial-thickness tears (kappa = 0.63) and intratendinous tears (kappa = 0.57).

CONCLUSIONS

Our results show that in moderately experienced hands as in experts' hands, sonography has a low level of interobserver variability for full-thickness rotator cuff tears. Considering partial-thickness and intratendinous rotator cuff tears, our data suggest that interobserver variability is higher.

The detection of full thickness rotator cuff tears using ultrasound

We have examined the accuracy of 143 consecutive ultrasound scans of patients who subsequently underwent shoulder arthroscopy for rotator-cuff disease. All the scans and subsequent surgery were performed by an orthopaedic surgeon using a portable ultrasound scanner in a one-stop clinic. There were 78 full thickness tears which we confirmed by surgery or MRI. Three moderate-size tears were assessed as partial-thickness at ultrasound scan (false negative) giving a sensitivity of 96.2%. One partially torn and two intact cuffs were over-diagnosed as small full-thickness tears by ultrasound scan (false positive) giving a specificity of 95.4%. This gave a positive predictive value of 96.2% and a negative predictive value of 95.4%. Estimation of tear size was more accurate for large and massive tears at 96.5% than for moderate (88.8%) and small tears (91.6%). These results are equivalent to those obtained by several studies undertaken by experienced radiologists. We conclude that ultrasound imaging of the shoulder performed by a sufficiently-trained orthopaedic surgeon is a reliable time-saving practice to identify rotator-cuff integrity.

The pathogenesis and surgical treatment of tears of the rotator cuff

This review discusses the pathogenesis and surgical treatment of tears of the rotator cuff.

Ultrasonography of symptomatic rotator cuff tears compared with MR imaging and surgery

PURPOSE

To compare the accuracy of ultrasonography and magnetic resonance imaging in the detection of rotator cuff tears.

MATERIALS AND METHODS

Ninety-six patients with clinically suspected rotator cuff pathology underwent ultrasonography and magnetic resonance imaging of the shoulder. The findings in 88 patients were compared with arthroscopy or open surgery.

RESULTS

Full-thickness tear was confirmed in 57 cases, partial-thickness tear in 30 cases and degenerative changes without tear in 1. In all 57 cases of full-thickness tear and in 28 out of 30 cases of partial-thickness tear the supraspinatus tendon was involved. The accuracy in the detection of full-thickness tears was 98 and 100% for ultrasonography and magnetic resonance imaging, respectively. The accuracy in the detection of bursal or articular partial-thickness tears was 87 and 90% for ultrasonography and magnetic resonance imaging, respectively.

CONCLUSIONS

In experienced hands ultrasonography should be considered as an accurate modality for the initial investigation of rotator cuff, especially supraspinatus, tears.