Is Ultrasound Accurate to Diagnose Shoulder Pathology?
Abstract & Commentary
Synopsis: Ultrasound was 100% sensitive and 96% accurate in diagnosing full-thickness rotator cuff tears, but much less effective at diagnosing partial-thickness cuff tears or ruptures of the biceps tendon.
Source: Teefey SA, et al. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 2000;82:498-504.
Teefey and associates performed ultrasonography prior to shoulder arthroscopy in 100 consecutive patients and presented their findings. This was a retrospective study that was developed to determine the performance of high-resolution ultrasonography compared with the arthroscopy examination. The study was specifically designed to detect and characterize rotator cuff tears and biceps tendon pathology. They point out that ultrasonography is popular in a number of centers across the United States but, in general, magnetic resonance imaging (MRI) continues to be the gold standard.
One hundred consecutive shoulders in 98 patients underwent preoperative ultrasonography, and this was followed by an arthroscopic procedure. During the arthroscopic procedure, 65 shoulders were identified to have a full-thickness rotator cuff tear, and 15 with a partial-thickness cuff tear. There was an associated diagnosis of frozen shoulder syndrome in 12, and arthritis of the acromioclavicular (AC) joint in two, a superior labral anteroposterior (SLAP) tear in one, and calcific bursitis in another.
Specific attention was focused on the presence of a full vs. partial rotator cuff tear and the status of the biceps tendon—whether it was ruptured or dislocated. The ultrasonography was capable of identifying the full-thickness rotator cuff tears in all patients, which represented a sensitivity of 100%. The overall accuracy was 96% in light of three false positives, and in 86% of the shoulders, the actual size of the tear was able to be determined. A partial-thickness tear was identified by ultrasound and confirmed at the time of arthroscopy in only 10 of 15 shoulders. In addition, five of six biceps dislocations as well as seven of 11 ruptures of the biceps tendon were identified.
Teefey et al conclude that ultrasonography is highly accurate for identifying full-thickness rotator cuff tears and dislocations of the biceps tendon, but less sensitive for detecting partial-thickness rotator cuff tears and full ruptures of the biceps tendon.
COMMENT BY JAMES P. TASTO, MD
This is an important paper in light of the increasing sophistication with ultrasonography and the higher resolutions now available. This is also a paper that has far-reaching socioeconomic effects. Should ultrasonography be able to come up to the level of MRIs, it certainly would provide the sports medicine physician with a more cost-efficient diagnostic tool before embarking upon an arthroscopic or conservative program for the patient. There have been a number of studies that are referenced in this article dating back to the mid-1980s, some of which have shown a high level of sensitivity and specificity. However, only a few have correlated their findings with arthroscopic procedures, and most have focused on rotator cuff tears only. The evaluation of the status of the biceps tendon remains a difficult problem both for the clinician as well as by identification with MRI scans.
On three of the patients, a partial-thickness tear was identified on ultrasonography but the rotator cuff was found to be normal at the time of the arthroscopy. In light of the fact that Teefey et al did not have the ability to section this area, it certainly remains possible that these tendons had intrinsic partial tears that were not visible on either the bursal or the glenohumeral side. Teefey et al did not address the issues of labral disruptions, SLAP tears, and Bankart lesions. These, of course, are important elements in the differential of shoulder pain; however, at this stage, they appear to be more appropriately diagnosed with an intra-articular gadolinium-enhanced MRI. This technique is gaining increased acceptance because of the better resolution of the images and enhanced sensitivity.
When one orders a diagnostic test it is important to try to select the appropriate diagnostic tool while maintaining cost-effectiveness and appropriate use of resources. It remains difficult to find an institution with a skilled ultrasonographer on the radiology staff. This is probably the most limiting factor at this stage preventing the widespread use of this technology. It requires not only a skilled technician to perform the test but also a highly trained radiologist to interpret it.
In the future it would be nice to have portable, high-resolution ultrasonography units available for office use. However, this paper demonstrates that ultrasound is still best used to diagnose full-thickness rotator cuff tears and dislocations of the biceps tendon. Partial-thickness cuff tears, biceps tendon ruptures, and labral pathology are better diagnosed by MR arthrogram or arthroscopy.
References
1. Brenneke SL, Morgan CJ. Evaluation of ultrasonography as a diagnostic technique in the assessment of rotator cuff tendon tears. Am J Sports Med 1992;20:287-289.
2. Quinn SF, et al. Rotator cuff tendon tears: Evaluation with fat-suppressed MR imaging with arthroscopic correlation in 100 patients. Radiology 1995;195:497-500.
3. van Holsbeeck MT, et al. US depiction of partial-thickness tear of the rotator cuff. Radiology 1995;197:443-446.
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