Ultrasound in Med. & Biol., Vol. 36, No. 12, pp.

1981–1989, 2010
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doi:10.1016/j.ultrasmedbio.2010.09.001

d Original Contribution

DETECTION AND QUANTIFICATION OF ROTATOR CUFF TEARS

WITH ULTRASONOGRAPHY AND MAGNETIC RESONANCE
IMAGING – A PROSPECTIVE STUDY IN 77 CONSECUTIVE PATIENTS
WITH A SURGICAL REFERENCE

PETRI SIPOLA,* LEA NIEMITUKIA,* HEIKKI KRÖGER,y IMKE HÖFLING,y and URHO VÄÄTÄINENy
* Department of Clinical Radiology, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland; and
y
Department of Orthopaedics, Traumatology and Hand Surgery, University of Eastern Finland and Kuopio University Hospital,
Kuopio, Finland

(Received 19 May 2010; revised 23 August 2010; in final form 5 September 2010)

Abstract—The aim of this study was to compare the accuracy of ultrasonography (US) and magnetic resonance
artrography (MRA) for the detection and measurement of rotator cuff tears, using surgical findings as a standard.
A total of 77 consecutive patients with suspected rotator cuff tears were prospectively studied with US and MRA.
Rotator cuff tears were identified by US with sensitivity, specificity, positive predictive and negative predictive
values of 92%, 45%, 91% and 50%, respectively, and by MRA with values of 97%, 82%, 97% and 82%, respec-
tively. US was not reliable for differentiating between partial and full thickness tears. US and MRA underestimated
the tear sizes by an average of 15 mm and 4 mm, respectively. Our results suggest that US could be used as
a screening test to confirm a suspected rotator cuff tear. In patients with negative findings, an MRA should be
considered for substantiation. (E-mail: petri.sipola@kuh.fi). Ó 2010 World Federation for Ultrasound in Medi-
cine & Biology.
Key Words: Rotator cuff, Ultrasonography, Magnetic resonance imaging, Sensitivity and specificity.

INTRODUCTION Few studies to date have compared the accuracy of

US and MRI for identifying tears of the RC or quantifying
Rotator cuff (RC) disorders accounts for about 10% of all
the size of the tears, and those studies that have been con-
shoulder pain (Meislin et al. 2005). Imaging should be
ducted previously have presented conflicting results
able to confirm a RC tear and evaluate its extent and
(Nelson et al. 1991; Martin-Hervas et al. 2001; Teefey
size. Magnetic resonance imaging (MRI) is an accurate
et al. 2004; Fotiadou et al. 2008). Therefore, the aim of
method for diagnosing tears and assessing sizes (de
the present study is to compare the accuracy of US and
Jesus et al. 2009), but it is quite expensive. In addition,
MRA for the detection and measurement of RC tears
many institutes have long waiting lists for MRI, and it
using surgical findings as the standard in a prospective
is generally not as readily available as ultrasonography
study setting.
(US), both of which factors may cause delays in patient
treatment. Moreover, MRI is sometimes contraindicated
in some patients, such as those with claustrophobia and MATERIALS AND METHODS
most patients with pacemakers. US is an alternative
We studied patients admitted to Kuopio University
imaging method, but it has shown variable results in the
Hospital with signs and symptoms of RC tears. The Kuo-
diagnosis of RC tears (de Jesus et al. 2009). The inconsis-
pio University Hospital Institutional Review Board
tency of accuracy has discouraged many practitioners in
approved the study protocol, and informed consent was
the use of shoulder US as a diagnostic tool in rotator
obtained from all patients. Inclusion criteria were acute
cuff pathology.
or chronic shoulder pain and suspicion of RC disease.
Patients who had undergone conservative treatment,
including physiotherapy for at least 3 months, without
Address correspondence to: Petri Sipola, Department of Clinical
Radiology, Kuopio University Hospital, Puijonlaaksontie 2, FI-70210 sufficient symptom relief were recommended for surgery.
Kuopio, Finland. E-mail: petri.sipola@kuh.fi We prospectively enrolled 79 consecutive patients.

1981
1982 Ultrasound in Medicine and Biology
Two patients had medical conditions that prevented
the planned operation; consequently, the operation for
these patients was performed more than 12 months
after the imaging studies and patients were excluded
from the study. Accordingly, the final study population
consisted of 77 patients (40 male and 37 female patients).
The average age was 57 y (range: 42 to 76 y). Of the 77
patients, right and left shoulders were surgically treated
in 53 (69%) and 24 (31%) patients, respectively. All
patients underwent a US study. Of the 77 patients, two
(3%) could not undergo MRA due to claustrophobia.
MRI was performed without an intra-articular contrast
agent in seven patients; three of these patients were
unwilling to receive an injection of contrast agent and
four had not been properly identified as study participants
when the imaging was done.
Imaging and image analysis
US and MRA were carried out within 3 h of each
other. First, the MRI was performed without a contrast
agent. Patients were then examined with US. After that,
a contrast agent was injected with US guidance. Finally,
a second MRI was performed with a contrast agent. Inter-
pretation of MRI was done using MR images before and
after contrast agent simultaneously.
US was performed with an Aloka SSD-500 scanner
fitted to a high frequency (7.5 MHz) linear array trans-
ducer (Aloka Co., Ltd., Tokyo, Japan). Tissue harmonic
imaging was not used. US was performed by three radiol-
ogists, each with more than 10 y experience in shoulder
US and all of whom were blinded to the MRI findings.
The transducer was applied directly to skin lubricated
with gel. Focus was adjusted according to the depth of
the target tissue. Imaging was performed on the long
and short axes of the tendon. The probe was set perpen-
dicular to the tendon surface and the angle of the probe
and tendon was changed to fill hypoechoic areas caused
by an anisotropic effect.
The subscapularis (SSC), supraspinatus (SSP), and
infraspinatus (ISP) tendons were assessed. The SSC was
evaluated with the forearm rotated externally. The SSP
was evaluated with the arm on the ipsilateral side. In
addition, the SSP was assessed with the hand behind
the patient’s back (Crass position) or on the waist (modi-
fied Crass position) for better exposure of the tendon
from underneath the acromion (Crass et al. 1987; Ferri
et al. 2005), when the patient could assume these
positions. To make the ISP more accessible, the patient
placed the ipsilateral hand across the chest on top of the
contralateral shoulder.
US findings were analyzed during the examination
by the radiologist who performed the examination. A
tear was diagnosed when a hypoechoic area was detected
that could not be altered in appearance or position by
Volume 36, Number 12, 2010
changing the probe angle and/or hand position. Tendon
volume loss on the bursal side was also interpreted as
a tear. A full‑thickness tear was diagnosed when the hy-
poechoic area or volume loss extended from the bursal
surface to the articular surface of the tendon. Otherwise,
the tear was diagnosed as a partial-thickness tear. Tear
size was determined by measuring the maximal antero-
posterior diameter of the hypoechoic area on still images.
MRA was performed on a Siemens Vision 1.5 T
scanner (Siemens AG, Erlangen, Germany) equipped
with a flexible surface coil. Slice thicknesses were
3 mm in all sequences. The following MRI sequences
were performed: an oblique coronal T1-weighted spin-
echo (SE) repetition time/echo time ([TR]/[TE]), 650
ms/20 ms; a T2-weighted fat-saturated dual-echo fast
spin-echo (FSE), 3500/16; an oblique sagittal T2-
weighted dual-echo FSE, 3500/16, 98; an axial T2*-
weighted gradient echo two-dimensional FLASH, 580/15,
flip angle 15 ; and a T1-weighted fat‑saturated SE, 800/
20. For artrography, 1 mL gadopentetate dimeglumine
(Magnevist; Berlex Laboratories, Wayne, NJ, USA) in
a concentration of 469.01 mg/mL was diluted in 250
mL of saline; 10 to 20 mL was then injected with US
guidance into the glenohumeral joint using a posterior
approach (Koivikko and Mustonen 2008).
After the imaging studies, the patients were returned
to the MRI unit, and we obtained T1-weighted fat-satu-
rated SE 800/20 images in the sagittal oblique, coronal
oblique and axial planes, and T2-weighted FSE 4500/96
images in the coronal oblique plane. We acquired the
T1-weighted images without contrast to compare signal
intensity before and after the administration of a contrast
agent. In four patients studied without contrast agent, the
sequences were variable (not shown).
All MRA images were interpreted by one radiologist
who had 1 y of experience in musculoskeletal MRI at the
beginning of the study. In MRI analysis, a partial-
thickness tear was diagnosed when a sharply delineated
region in the cuff displayed increased signal intensity
that communicated with either the articular or bursal
surface of the RC on a T2-weighted MRI. A full-
thickness tear displayed increased signal intensity that
extended through the full thickness of the cuff substance
on T2-weighted images.
On MRA images, a partial‑thickness tear was diag-
nosed when the contrast agent entered the cuff substance
without reaching the subacromial bursa. A full-thickness
tear was diagnosed when the contrast agent was detected
on the MR image throughout the full thickness of the RC
and/or when the contrast agent was detected in the suba-
cromial bursa. The tear size was measured as the maximal
anteroposterior size of the increased signal intensity on
T2-weighted images or the maximal concentration of
the contrast agent within the substance of the RC on
 Comparison of US with MRA to detect and measure rotator cuff tears d P. SIPOLA et al.
MRA images. The higher value was selected to represent
the maximal tear size.
Surgery
Surgery was performed by three experienced ortho-
paedic surgeons. Of the 77 patients in the study, the
mini-open operation technique was performed in 27
(36%) and the arthroscopic technique was performed in
50 (64%). The size and type (partial/full thickness) of
tendon tear was determined and measured from anterior
to posterior and from lateral to medial dimensions. Any
involved tendons were also identified. Intraoperatively,
a sterile ruler or a calibrated arthroscopic probe was
used to define both the anteroposterior and the mediolat-
eral size of the tear. The anteroposterior size was used
for statistical analysis.
Statistical analysis
Data are presented as the mean 6 1 standard devia-
tion, the mean 1 range, or the number (n) and percent of
the total (%). The paired sample t-test and the Wilcoxon
signed-rank test were used to analyze differences
between the imaging methods in measurements of tear
size. The Spearman rank correlation coefficient was
used for correlation analyses. Statistical analysis was per-
formed with SPSS for Windows (version 17.0; SPSS,
Inc., Chicago, IL, USA). Statistical significance was set
at a p value less than 0.05.
RESULTS
The clinical characteristics of the patients are shown
in Table 1. Of the 77 patients, the diagnosis at surgery was
a full-thickness tear of the RC in 58 (75%), a partial-
Table 1. Clinical characteristics of patients with
a suspected rotator cuff tear
Mean or n (%)
N 5 77
Pain duration (m)* 21
Symptoms (no. patients)y
Pain at heavy work 2/72 (3)
Pain at light work 28/72 (39)
Pain at rest 42/72 (58)
Range of motion ( )
Flexionz 128
Elevationx 114
Internal rotation{ 61
External rotation{ 56
Etiology of suspected tear (no. patients)
Traumatic 17/77 (22)
Degenerative 60/77 (78)
* Data were not obtained in 6 (8%) patients.
y Data were not obtained in 5 ((7%) patients.
z Data were not obtained in 6 (8%) patients.
x Data were not obtained in 7 (9%) patients.
{ Data were not obtained in 13 (17%) patients.
1983
thickness tear in 8 (19%) and no tear in 11 (14%) patients.
The mean time between imaging and surgery was 2.3
months (range: 0 to 9.5 months). The tear locations are
shown in Table 2. The SSP tendon was the only tendon
involved in more than half the cases, and it was involved
in combination with other tendons in 65 (99%) of 66 total
cases.
Figure 1 depicts US and MRA findings in RC
tendons that are shown to be normal via arthroscopy.
Table 3 shows the RC cuff findings on US, MRA and
during surgery. Table 4 shows the diagnostic accuracy
of US, and Table 5 shows the diagnostic accuracy of
MRA. US had a high positive predictive value for RC
tear (Fig. 2). Of the 10 partial-thickness tears assessed
by US, six (60%) were identified as full-thickness tears
during surgery. Of the cases that showed no detectable
tear on US, half displayed a RC tear in surgery, usually
a full-thickness tear (Fig. 3).
MRA was highly sensitive for detecting tears (sensi-
tivity 5 97%), but less sensitive (sensitivity 5 88%) for
the diagnosis of full-thickness tears. The specificity of
MRA was considerably higher than that of US (Figs. 4
and 5). The post-test probability of detecting a RC tear
after a normal MRA was considerably lower than after
US (18% vs. 50%).
Patients were additionally divided into two groups
based on body mass index (BMI) as follows: group 1
had a BMI that ranged from 18.1 to 28.2 kg/m2 and group
2 had a BMI between 28.3 to 40.6 kg/m2. No significant
differences in diagnostic accuracy between these groups
were found.
In 47 patients, a full-thickness tear was correctly
detected on both US and MRA. These patients were
selected for a comparison of tear size measurements.
The RC tear sizes in US, MRA and surgery were, respec-
tively, 25 6 9 mm (range: 4 to 48 mm), 36 6 13 mm
(range: 11 to 65 mm) and 40 6 15 mm (range: 10 to
70 mm). Accordingly, US and MRA underestimated the
Range average tear size by 15 mm (p , 0.001) and 4 mm
(p , 0.05), respectively (Fig. 6).
2–144
Table 2. Tear location in patients discovered during
surgery for a rotator cuff tear
40–180
35–180 Tendon type n (%) n 5 65*
20–95
0–95 SSP 37 (57)
SSP and ISP 14 (22)
SSP and SSC 9 (14)
SSP, ISP and SSC 4 (6)
ISP 1 (2)
SSP 5 supraspinatus tendon; ISP 5 infraspinatus tendon; SSC 5 sub-
scapularis tendon.
* In one patient with a partial-thickness tear, the tear location was not
recorded.
1984 Ultrasound in Medicine and Biology Volume 36, Number 12, 2010

Fig. 1. Arthroscopically proven normal rotator cuff tendons. (a) Long- and (b) short-axis sonographic views, (c) oblique
coronal and (d) oblique sagittal T2-weighted magnetic resonance images, and (e) oblique coronal and (f) trans-
verse T1-weighted fat-saturated magnetic resonance images after injection of intra-articular contrast agent show
homogeneous tendons.

In both methods, underestimation was higher in
large tears than small tears (Figs. 7 and 8). Tear size
overestimation was rare. Of the 77 patients in our study,
US overestimated the tear size by at least 10 mm in only
one (2%) patient. In contrast, MRA overestimated the
tear size by at least 10 mm in seven patients (15%; p ,
0.05). Patient body weight and BMI were associated
with the difference between MRA and surgery in tear
size estimations (r 5 .291, p ,0.05 and r 5.313, p ,
0.05, respectively). There was no correlation between
 Comparison of US with MRA to detect and measure rotator cuff tears d P. SIPOLA et al. 1985

Table 3. Comparison of US and MRI data in the Table 5. Diagnostic accuracy of magnetic resonance
diagnosis of rotator cuff tears artrography in the detection of rotator cuff tears
Operative diagnosis No tear vs. full- or No full-thickness
partial-thickness tear vs. full-thickness
Full-thickness Partial-thickness No tear, tear N 5 75 tear N 5 75
tear, n 5 58 tear, n 5 8 n 5 11
Sensitivity, mean or n (%) 62/64 (97) 50/57 (88)
Diagnosis with US, 48 (62) 6 (8%) 3 (4) Specificity, mean or n (%) 9/11 (82) 17/18 (94
n (%) 6 (8) 1 (1) 3 (4) PPV, mean or n (%) 62/64 (97) 50/51 (98)
4 (5) 1 (1) 5 (7) NPV, mean or n (%) 9/11 (82) 17/24 (71)
Accuracy, mean or n (%) 71/75 (95) 67/75 (89)
Diagnosis with MRA, (n 557*) (n 5 7y) (n 5 11)
n (%) 50 (67) 1 (1) 0 (0) PPV 5 positive predictive value; NPV 5 negative predictive value.
6 (8) 5 (7) 2 (3)
1 (1%) 1 (1) 9 (12)
for detecting tears, particularly partial-thickness tears
US 5 ultrasonography; MRA 5 magnetic resonance artrography.
* In one patient with a full-thickness tear, MRA was not performed.
(Nelson et al. 1991; Martin-Hervas et al. 2001). In a
y In one patient with a partial-thickness tear, MRAwas not performed. more recent studies with a surgical reference, US and
MRI were shown to have comparable accuracy for
anthropometric measurements and the difference between identifying (Teefey et al. 2004; Fotiadou et al. 2008)
US and surgery tear size estimations. and measuring (Teefey et al. 2004) the size of full- and
partial-thickness RC tears. To the best of our knowledge,
DISCUSSION the current study is the second largest in the literature to
Main findings date that compares the accuracy of US and MRI with
We found that US had a high positive predictive a surgical reference. Our findings are concordant with
value for diagnosing a RC tear and that MRA was a recent meta‑analysis, which showed that MRA was
a more specific method for detecting a tear. Both the most sensitive and the most specific technique for
methods, particularly US, underestimated the tear size diagnosing both full- and partial-thickness RC tears
of large tears. In contrast, US usually did not overestimate (de Jesus et al. 2009).
tear size, but overestimations were not uncommon with We did not find a difference in diagnostic accuracy
contrast-enhanced MRA. Patient obesity did not influ- between the high and low BMI groups, although the
ence the overall accuracy of imaging tests, but it reduced difference between MRA and surgery tear size measure-
the accuracy of MRA in tear size detection. Our results ments was associated with BMI and body weight. This
indicate that US can be used to confirm a RC tear. observation is consistent with previous findings that
However, US cannot reliably determine the tear extension obesity reduced the diagnostic value of MRI (Nelson
(partial- or full-thickness tear). MRA can provide a reli- et al. 1991). In the current study, obesity may not
able estimate of tear extension and can enable measure- have influenced the accuracy of US because we used
ment of the tear size more accurately than US. The a relatively low frequency probe. The high frequency
reliability of MRA in the detection of tear size is reduced transducer, however, may improve the sensitivity to
in obese patients. detect tears, especially partial-thickness tears (Fotiadou
et al. 2008).
Comparison of findings to previous studies The SSP tendon is a key location for a RC tear. It was
Previous studies that compared the accuracy of US involved in 98% of tears. To diagnose a RC tear accu-
and MRI produced controversial results. In two older rately, special attention should be paid to the SSP tendon.
studies, US was found to be less sensitive than MRI In contrast, when no tears are detected in the SSP tendon,
it is highly probable that the patient has no RC tear. In our
Table 4. Diagnostic accuracy of ultrasonography in the study, an isolated SSC tear was not found in any patients.
detection of rotator cuff tears Indeed, tears of the SSC tendon have rarely been reported
and have usually been associated with trauma (Gerber
No tear vs. full- or No full-thickness
partial-thickness tear vs. full-thickness and Krushell 1991).
tear, N 5 77 tear, N 5 77 Our finding that US can be considered the imaging
modality of choice for the initial detection of full- and
Sensitivity, mean or n (%) 61/66 (92) 48/58 (83)
Specificity, mean or n (%) 5/11 (45) 10/19 (53) partial-thickness RC tears in patients with a history and
PPV, mean or n (%) 61/67 (91) 48/57 (84) clinical findings that do not suggest any other intra-
NPV, mean or n (%) 5/10 (50) 10/20 (50) articular disorder is in concordance with previous studies
Accuracy, mean or n (%) 66/77 (86) 58/77 (75)
(Farin et al. 1995; Teefey et al. 2004; Fotiadou et al.
PPV 5 positive predictive value; NPV 5 negative predictive value. 2008).
1986 Ultrasound in Medicine and Biology Volume 36, Number 12, 2010

Fig. 2. (a) Long-axis (b) and short-axis sonographic views of the left supraspinatus (SSP) tendon show absence of
tendons. (c) Corresponding oblique coronal and (d) oblique sagittal T2-weighted magnetic resonance images show
absence of tendon related to a massive rotator cuff tear. The medial retraction (arrow in c) of the stump of the SSP tendon
is seen. In ultrasonography and magnetic resonance imaging, a full-thickness tear of 30 and 55 mm, respectively, were
diagnosed. Surgery revealed a full-thickness tear of the SSP and infraspinatus tendons measuring 60 mm.

Fig. 3. (a) In a long-axis sonographic view of the subscapularis (SSC) tendon, no abnormalities were found. (b) Trans-
verse T1-weighted fat-saturated magnetic resonance arthographic image shows that contrast material has extended under
the insertion of the SSC tendon onto the lesser tuberosity (arrows). Surgery revealed a 50-mm full-thickness tear of the
supraspinatus and SSC tendons.
 Comparison of US with MRA to detect and measure rotator cuff tears d P. SIPOLA et al. 1987

Fig. 4. (a) Long-axis sonographic view of left supraspinatus tendon insertion shows a hypoechoic defect (cursor: X and x)
that was interpreted as a full-thickness tear that measured 17 mm. (b) An oblique coronal T2-weighted magnetic reso-
nance (MR) image shows a focal area of increased signal intensity, and an oblique coronal T1-weighted fat-saturated
MR arthographic image obtained after injection of the MR imaging contrast agent shows no abnormalities (c). MR
findings suggest a partial-thickness tear on the bursal side. Surgery revealed a partial-thickness tear of the supraspinatus
tendon.

Fig. 5. (a) Long-axis and (b) short-axis sonographic views of the left supraspinatus (SSP) tendon insertion show a hypo-
echoic defect (cursor: X and x) that was interpreted as full-thickness tear measuring 16 mm. (c) An oblique coronal and (d)
transversal T1-weighted fat-saturated magnetic resonance (MR) arthrogram obtained after injection of the MR imaging
contrast agent show that (c) the contrast material extended under the insertion of the SSP tendon and (d) the subscapularis
tendon. The contrast agent, however, did not communicate with the subdeltoid bursa, which was interpreted as partial-
thickness tears of the tendons. Surgery revealed a partial-thickness tear of the SSP tendon, and no tear in the subscapularis
tendon.
1988 Ultrasound in Medicine and Biology Volume 36, Number 12, 2010

Fig. 6. A typical case showing underestimation of large tear. (a) In a short-axis sonographic view, a 25-mm full-thickness
tear was found (cursor: X and x). (b) In a corresponding oblique sagittal T2-weighted magnetic resonance image,
the measurement of the tear size was 39 mm. The tear measurement sites are marked with X-marks. Surgery revealed
a 50-mm full-thickness tear of the supraspinatus and subscapularis tendons.

Study limitations differences in the predictive accuracy of US and MRA

Currently, more high frequency transducers to
diagnose tendon abnormalities with US are commonly
recommended (Robinson 2009). We could not study
the influence of harmonic imaging for diagnosis of RC
tear (Strobel et al. 2004). We also did not control the
influence of patient positioning to tear size estimates
(Ferri et al. 2005).
CONCLUSIONS
In general, US displayed lower accuracy than MRA
for measuring RC tears. Because we found no marked
(post-test probability of disease: 91% vs. 97%, respec-
tively), US is a suitable method for screening suspected
torn RCs. Given the long waiting lists associated in large
part with the increasing demand for MRI to diagnose
other diseases and the problem that no alternative
imaging methods may be available, our results suggest
that more patients could undergo primary imaging with
US instead of MRI.
However, a negative US finding cannot be used to
rule out the diagnosis of a RC tear. Our findings suggest
that MRI is required to confirm a negative diagnosis in
patients with signs and symptoms of RC tear who have

Fig. 7. Accuracy of ultrasonography (US) tear size measure-
ments compared to the surgical reference. The y-axis shows
the difference between tear sizes measured during surgery
(operation) and by US analysis. Negative numbers indicate
that the US value was an overestimation. The x-axis shows
the range of actual tear sizes measured during the operation.
Each symbol represents one patient.
Fig. 8. Accuracy of magnetic resonance image (MRI) tear size
measurements compared to the surgical reference. The y-axis
shows the difference between tear sizes measured during
surgery (operation) and by MRI analysis. Negative numbers
indicate that the MRI value was an overestimation. The x-axis
shows the range of actual tear sizes measured during the opera-
tion. Each symbol represents one patient.
 Comparison of US with MRA to detect and measure rotator cuff tears d P. SIPOLA et al.
not experienced symptom relief after 3 months of conser-
vative treatment. Also, although open surgery currently is
uncommon due to improved arthroscopic techniques, in
cases where open surgery is considered for a suspected
large tear, MRI should be used to assess the tear size
more accurately. Finally, our study demonstrated that
US was not reliable for differentiating between partial-
and full-thickness tears; therefore, the diagnosis of
a partial-thickness tear based on US alone should be
made with caution.
Acknowledgments—The authors thank Marja-Liisa Sutinen, RN, for
technical assistance.
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