Shoulder joint is an elegant anatomic structure. Its range of motion exceeds all other joints, yet under most circumstances it is stable. The shoulder joint relies upon a variety of structures for stability, including the osseous glenoid, the fibrous labrum, the joint capsule, the glenohumeral ligaments, and various muscles around the shoulder (1).

The rotator cuff consists of the supraspinatus, infraspinatus, subscapularis and teres minor muscles and tendons. At the distal aspect of the rotator cuff, tendons splay out and interdigitate, forming a common continuous insertion on the greater and lesser tuberosity of the humerus(2). The rotator cuff is a functional- anatomic unit rather than four unrelated tendons, and injury to one component may have an influence on other regions of the rotator cuff.

The pre-requisites for normal cuff functioning are strong, healthy, intact cuff muscles and tendons, normal capular laxity, smooth coracoacromial arch and normal bursae. Disorders of this complex mechanism are the most common source of shoulder problem (3).

Arthrography is quite accurate in detecting complete tears but it is an invasive procedure with some associated risk and discomfort. In addition, it is insensitive to partial tears involving superficial surface or substance of the cuff. The diagnosis of partial tears, however, is important because many orthopedic surgeons will operate before it progresses to full thickness tear. The relative ease with which they are seen on MRI suggests that MRI may have a role in their diagnosis (5).

Although non-invasive, MRI is considerably more expensive than ultrasonography and will probably not replace it as a screening procedure for those trained in its use. For those cases in which the ultrasonography yields indeterminate results or in those institutions in which no one is trained in sonography of the shoulder, MRI may be a useful screening test. The major disadvantages of MRI are the long examination time, high cost and possibility of study being unsuccessful in very large or claustrophobic patients (9).

Ultrasonography is effective for detecting tears of the rotator cuff. The size of the tears can be classified and the findings used as a basis for management decisions. Ultrasonography can also reveal the presence of other abnormalities that may mimic rotator cuff tear including tendinosis, calcific tendinitis, sub-acromial sub-deltoid bursitis, greater tuberosity fracture (10).

Ultrasonography of rotator cuff is quick and painless. There is no risk of infection and in contrast to arthrography there is no discomfort following the procedure. The simplicity, rapidity, low cost and accuracy of the examination make it especially attractive as a screening and pre-surgical staging study (1).

MRI and Ultrasonography have replaced the arthrography for evaluating the integrity of rotator cuff. MRI has become the ―gold standard‖ for detecting both subtle and obvious internal derangement and assessing overall joint structure. Arthrography can be performed in those cases in which ultrasound and MRI are not definitive (6). Both diagnostic ultrasound and magnetic resonance imaging (MRI) are used for investigation of the presence and severity of rotator cuff lesions. There is no consensus as to which is the more accurate and cost-effective study (11).

Thus, in our study, 50 patients with clinically suspected rotator cuff injury will be subjected to Ultrasonography and MRI, USG findings will be correlated with MRI findings in rotator cuff injuries.

AIMS- to study various types of rotator cup pathology, diagnosis and management- single center study also to determine the efficacy of USG in detecting rotator cuff pathology in comparison to MRI.

Source of Data:

The source of data for the study is patients from the Department of orthopedics Shri Rawatpura Sarkar Institute of Medical Sciences and Research, Atal Nagar Nawa Raipur, Chhattisgarh from January 2024- January 2025. The study was a prospective study, in those patients who had been referred for USG, clinically suspicious of rotator cuff pathology selected according to the inclusion and exclusion criteria, and additional MRI of the shoulder joint was done following that. Findings of both MRI and USG were compared and evaluated.

Inclusion Criteria:

• Clinically suspected to have rotator cuff pathology

Exclusion Criteria:

• Patient contraindicated to MRI
• Shoulder joint fracture in X-ray.
• Patient not willing or uncooperative for study.-
• Previous history of surgery.
• Previous history of recurrent shoulder dislocation.
• Patient who did not undergo any one of the imaging modality.

Parameters studied:

Principal parameters- Rotator cuff tendons

1. Supraspinatus
2. Infraspinatus
3. Teres minor
4. Subscapularis

The present study was carried out to describe role of USG and magnetic resonance imaging of rotator cuff pathologies. Fifty patients who were found to have rotator cuff disease during the study period fulfilling the inclusion and the exclusion criteria were included in study.

Out of 50 patients in MRI, 43 patients (86%) had abnormal supraspinatus tendon, in which 19 (38%) had tendinosis, 3 (6%) were complete tear and 21 (42%) were partial tear.

While in USG, 40 (80%) patients had abnormal supraspinatus tendon, in which 18 (36%) had tendinosis, 3(6%) were complete tear and 19 (38%) were partial tear. Out of 50 patients in MRI 20 patients (40%) had abnormal subscapularis tendon, in which 14 (28%) were tendinosis and partial tear constituted 6 (12%) cases.

Table 1: MRI finding Subscapularis

While in USG 19 (38%) patients had abnormal subscapularis tendon, in which 14 (28%) were tendinosis and partial tear constituted 5(10%) of the cases. Out of 50 patients MR detected 6 cases (12%) of abnormal infraspinatus tendon, in which 5 (10%) of them were partial tear (10%) and 1 (2%) was tendinosis.

USG detected 4 (8%) cases of abnormal infraspinatus tendon in which 3 (6%) were partial tear and 1(2%) was tendinosis.

In our study, no teres minor pathology was found. Of 43 abnormal cases Supraspinatus tendon in MRI, USG had detected 40 cases. Among 7 normal cases in MRI, all cases were diagnosed as normal by USG.

Among 24 cases of Supraspinatus tear in MRI, 3 cases are complete tear and among 7 cases of intra-substance partial tear, 2 cases of intra-substance partial tear are not detected by USG. Complete or full thickness tear is more frequent in supraspinatus in most of the literature. Of 20 abnormal cases of subscapularis tendon in MRI, USG had detected 19 cases. Fisher Exact Test test was significant. Among 6 tendon tear on MRI, all were partial tears which were detected on USG. Out of 6 partial tear on MRI 5 were detected on USG, 1 articular surface partial tear was missed on USG. Of 6 abnormal cases of infraspinatus tendon in MRI, USG had detected 4 cases. Among 44 normal cases in MRI, all cases were diagnosed as normal in USG. Among 1 case of intra-substance Infraspinatus tendinosis in MRI, it was detected on USG. Among 5 cases of Infraspinatus tear, 1case of intra-substance partial tear & bursal surface partial tear each is not detected by USG. Sensitivity, Specificity measures 100 %, 100%, respectively.

There was no significant correlation between joint effusion and degree of joint effusion with rotator cuff pathology in our study. Pathology of the rotator cuff is the most common problem of the shoulder joint and accurate diagnosis is essential for appropriate management ⁽⁴⁷⁾. Ultrasonography and MRI are successful imaging modalities for both rotator cuff and non-rotator cuff disorders. This study is conducted to compare the results obtained after the evaluation of the rotator cuff injuries of the shoulder joint by Ultrasonography and Magnetic Resonance Imaging.

This is a prospective study of 50 patients who presented with shoulder pain. A history and clinical examination were done initially, following which USG examination of the affected shoulder was done, and finding were compared with shoulder MRI.

Supraspinatus –

Of 43 abnormal cases of Supraspinatus tendon in MRI, USG had detected 40 cases. Among 7 normal cases supraspinatus tendon in MRI, all cases were diagnosed as normal by USG. Sensitivity, Specificity 93.8%, 100%, respectively. Fisher Exact Test was 0.0001 i.e. significant.

In our study, 24 (55.8%) patients in MRI had tear of supraspinatus tendon, in which articular surface partial tear constituted 9 (37%) cases. While in USG, 22 (55%) patients had tear of supraspinatus tendon, in which bursal surface partial tear constituted 9 (40%) cases.

In a study conducted by Zhang et al (11), the sensitivity of US diagnosis was 93.4 % (31/33), and specificity is 75% (3/4) and concluded that, high frequency ultrasound in the diagnosis of rotator cuff tears injuries has a high sensitivity and specificity. High frequency ultrasound can be used as a routine method to diagnose rotator cuff tears injuries. Our study shows sensitivity near equal to study done by Zhang et al (11), while specificity is high when compared to it.

Subscapularis -

In MRI 20 (40%) patients had abnormal Subscapularis tendon, in which articular surface tendinosis constituted 7 (14%) cases. While in USG, 19 (38%) patients had abnormal Subscapularis tendon, in which 1 case of intra-substance tendinosis was diagnosed as articular surface tendinosis. Sensitivity, Specificity 95.65%, 100% respectively. Fisher Exact Test was 0.0001, significant.

In the study conducted of 70 patients conducted by Nabetani Y., et al, (12), the diagnostic accuracy, sensitivity and specificity of US is 94.3%, 94.3 % and 95.8% when the intraoperative findings were regarded as a gold standard.

Infraspinatus –

Among 6 abnormal cases of Infraspinatus tendon in MRI, USG had detected 5 cases. While one intra-substance & one bursal surface partial tear was not detected in USG.

Among 45 normal cases of Infraspinatus tendon in MRI, all cases were diagnosed normal in USG. Sensitivity, Specificity 77.77%, 100%, respectively. Fisher Exact Test was 0.0001, significant.

Tendinosis - Supraspinatus

Among 19 cases of Supraspinatus tendinosis on MRI, one intra-substance tendinosis was missed by USG. Sensitivity, Specificity 95%, 100% respectively. Fisher Exact Test was 0.000021, significant.

In meta- analysis conducted by Ottenheijm RE., et al (13), for tendinopathy, sensitivity ranged from 0.67 to 0.93, specificity from 0.88 to 1.00, which is same compared to our study.

Subscapularis tendinosis –

Among 14 cases of Subscapularis tendinosis, all were detected on USG but an intra-substance tendinosis was diagnosed as articular surface tendinosis on USG.

Sensitivity, Specificity, 100%, 97.3% respectively. Fisher Exact Test was 0.00013, significant.

Infraspinatus Tendinosis –

MRI detected 1 intra-substance tendinosis which was detected on USG as well.

Sensitivity, Specificity, 100%, 100% respectively.

Supraspinatus tear –

Among 24 cases of Supraspinatus tear in MRI, 3 cases are complete tear and are detected by USG. Among 7 cases of intra-substance partial tear 2 cases were missed by USG. Complete or full thickness tear is more frequent in supraspinatus in most of the literature. Sensitivity, Specificity, 92.30 %, 100% , respectively. Fisher Exact Test was 0.0001, significant.

In a study conducted by Ok JH, et al (14) in 51 patients, the sensitivity of USG for detecting partial thickness tears is 45.5% and that of full thickness tears was 80.0%. The specificity of USG for detecting partial thickness tears is 45.1% and for full thickness tears was 82.4% and Kappa coefficient is 0.47, which is less in compared to our study, however similar to our study sensitivity and specificity of complete tear is more in compared to partial tear.

Subscapularis tear –

Among 6 cases of Subscapularis tear in MRI, one articular surface partial tear was missed on USG. Sensitivity, Specificity, 88.89%, 100% respectively. Fisher Exact Test is 0.00001, significant.

Cochrane Database systemic review (15) done on 20 studies of people with suspected rotator cuff tears (1147 shoulders), of which six evaluated MRI and US (252 shoulders), or MRI and US (127 shoulders) in the same people shows rotator cuff tears, the summery sensitivity and specificity 91% (95% CI 83% to 95%) and 85% (95% CI 74% to 92%) respectively for US (13 studies, 854 shoulders).

Infraspinatus tear –

Among 6 cases of Infraspinatus tear 1 case each of bursal surface partial tear & intra-substance partial tear are missed by USG. Sensitivity, Specificity, 75%, 100% respectively. Fisher Exact Test was 0.0001, significant.

In a prospective study conducted Sipola et al (16) in 77 patients, Sensitivity, Specificity, PPV, NPV of USG is 92 %, 45%, 91% and 50% respectively.

In a meta-analysis study conducted by Ottenheijm RP., et al (13),partial- thickness tears, pooled sensitivity of ultrasound was 0.72 (0.58-0.83), and specificity 0.93 (0.89-0.96), which is similar to our study.

Teres Minor –

In a study conducted (76) on 2436 shoulder MRI examinations for a period of 67-months period from September 1996 to April 2002. MRI findings of Teres minor abnormality were seen in 0.8% only among the study population. No teres minor pathology was found in our study.

In a retrospective study conducted Rutten MJ et al (17) , in 5216 patients for past 4 years, US correctively depicted 22 (100%) of the 22 full-thickness tears, 6 (67%) of the 9 partial-thickness tears. Detection of complete tear by USG in good in compare to partial thickness tears which is similar to our study.

There was no significant correlation between joint effusion or degree of joint effusion with rotator cuff pathology in our study which is contradictory to the study done by Arsalan G et al (18). It was concluded in this study that fluid in the bursa (subacromial / sub deltoid), joint effusion had strong association with rotator cuff tears. The specificity and PPV for rotator cuff tears increases when both bursal and joint fluid were present, and careful evaluation of rotator tendons is a warranted to rule out tears in presence of joint effusion or bursal effusion.

In a study conducted by Hollister et al (19), the sonographic finding of intra-articular fluid alone (without bursal fluid) has both a low sensitivity and a low specificity for the diagnosis of rotator cuff tears. However, the finding of fluid in the sub acromial and sub deltoid bursa, especially when combined with a joint effusion, is highly specific and has a very high PPV for associated rotator cuff tear; however in our study there is no significant association between sub acromial- sub deltoid bursal effusions with rotator cuff tears.

Similar results were also found in the study by Gringer et al, (20) who reviewed 1831 MRI over 2 years. They suggested sub coracoid bursa efusions is not an incidental finding but may be associated with rotator cuff and rotator interval tears.

USG and MRI are complementary imaging modalities for evaluation of abnormalities of the shoulder joint. The primary role of USG is evaluation of rotator cuff pathologies. However, MRI provides comprehensive evaluation of the shoulder joint.

Though operator dependent, a well performed USG can effectively serve as a primary diagnostic method and screening of all painful shoulder joints because it is economic, fast, dynamic and widely available. Sound anatomical knowledge of the rotator cuff on USG, awareness of artifacts and practice is a prerequisite for this procedure.

MRI has lesser artifacts, good soft tissue resolution but has limitations of being time consuming, costly, static and not widely available. However MRI is excellent in evaluation of labral, capsular or ligamentous pathologies.

In our study, USG examination had excellent specificity (88 to 100%), PPV (84 to 100%), better NPV (87 to 96%) and fair sensitivity (66 to 95%) as compared MRI for diagnosing rotator cuff pathologies. It is equal to MRI in diagnosing and quantifying joint effusion and acromio-clavicular degenerative changes. USG scores over MRI in diagnosing calcific tendinosis. MRI was better in evaluation of partial rotator cuff tear as compared

to USG.

USG can be used as a first line screning investigation for a case of shoulder joint pain to rule out rotator cuff pathologies; however it was found

poor in detecting partial tears. USG cannot completely replace MRI in evaluation of rotator cuff pathology as partial tear of rotator cuff, which was the most common rotator cuff pathology in our study, was not as effectively diagnosed on USG compared to MRI.

1. Wiener SN, Seitz WH, Jr. Sonography of the shoulder in patients with tears of the rotator cuff: accuracy and value for selecting surgical options. AJR American journal of roentgenology. 1993; 160(1):103-7; discussion 9-10.
2. Teefey SA, Middleton WD, Payne WT, Yamaguchi K. Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors. American journal of roentgenology. 2005; 184(6):1768-73.
3. Morag Y, Jacobson JA, Miller B, De Maeseneer M, Girish G, Jamadar D. MR imaging of rotator cuff injury: what clinician needs to know. Radiographics : a review publication of the Radiological Society of North America, Inc. 2006;26(4): 1045-65.
4. Umans HR, Pavlov H, Berkowitz M, Warren RF. Correlation of radiographics and arthroscopic findings with rotator cuff tears and degenerative joint disease. Journal of shoulder and elbow surgery/ American Shoulder and Elbow Surgeons [et al]. 2001;10(5):428-33.
5. Kneeland JB, Middleton WD, Carrera GF, Zeuge RC, Jesmanowicz A, Froncisz W, et al. MR imaging of the shoulder: diagnosis of rotator cuff tears. American journal of roentgenology. 1987; 149(2) : 333-7.
6. de Jesus JO, Parker L, Frangos AJ, Nazarian LN,. Accuracy of MRI , MR arthrography ans ultrasound in diagnosis of rotator cuff tears: a meta-analysis. AJR American journal of roentgenology. 2009;192(6):1701-7.
7. Dinnes J, Loveman E, Mc Intyre L, Waugh N. The effectiveness of diagnostic tests for the assesment of shoulder pain due to soft tissue disorders: a systemic review. Health technology assesment . 2003;7(29):iii, 1-166.
8. Nazarian LN, Jacobson JA, Benson CB, Bancroft LW, Bedi A, McShane JM, et al. Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2013; 267(2):589-95.
9. Burk DL, Karasick D, Kurtz AB, Mitchell DG, Rifkin MD, Miller CL, et al. Rotator cuff tears: prospective comparison of MR imaging with arthrography, sonography and surgery. American journal of roentgenology. 1989; 153(1):87-92.
10. Moosikasuwan JB, Miller TT, Burke BJ. Rotator cuff tears: clinical, radiographic and US findings. Radiographics : a review publication of the Radiological Society of North America, Inc. 2005;25(6):1591-607.
11. Zhang C, Guo L, An N, Liu GH, Zhu YT, Fan LZ. [Application value of the high frequency ultrasound on the diagnosis of rotator cuff tear]. Zongguo gu shang = China Journal of orthopaedics and traumatology. 2013;26(9):784-6.
12. Bencardino JT, Beltran J. MR imaging of the gleno-humeral Radiologic clinic of North America.2006;44(4):489-502,vii.
13. Ottenheijm RE, Jansen MJ, Stall JB, van den Bruel A, Weijers RE, De bie RA, et al. Accuracy of ultrasound in patients with suspected sub- acromial disorders: a systematic review and meta analysis. Archives of Physical Medicine and rehabilitation. 2010;91(10):1616-25.
14. Ok JH, Kim YS, Kim JN, Yoo TW. Learning curve of office – based ultrasonography for rotator cuff tondons tear. Knee surgery, Sports traumatology, arthroscopy: Official Journal of the Esska. 2013;21(7):1593-7.
15. Lenza M, Buchbinder R. Takwoingi Y. Johnston RV, Hanchard NC, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. The Cochrane database of systematic reviews. 2013;9:CD009020.
16. Sipola P, Niemitukia L, Kroger H, Hofling I, Veppatainen U. Detection and qualification of rotator cuff tear with ultrasonography, magnetic resonance imaging- a prospective study in 77 consequetive patients with a surgical reference. Ultrasound in Medicine and Biology.2010;36(12):1981-9.
17. Rutten MG, Spaargaren GJ, van LunTi, de Waal MC, Kiemeney LA, Jager JG. Detection of rotator cuff tear; the value of MRI Ultrasound. European radiology. 2010;20(2):450-7.
18. Beall DP, Williamson EE, Ly JQ, Adkins MC, Emery RL, Jones TP, et al. Associatioon of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the brotator cuff. AJR American Jounal of Roentegenology. 2003;180(3):633-9.
19. Hollister MS, Mack LA, Patten RM, Winter TC, Matsen FA. 3rd Veith RR Association of sonographically detected subacromial/subdeltoid bursal effusion and intraarticular fluid with rotator cuff tear. American journal of Roentgenology. 1995;165(3):605-8.
20. Grainger AJ, Tirman TF, Elliott JM, Kingzett-Tailor A, Steindach LS, Genant HK. MR anatomy of the sub coracoid bursa and the association of sub coracoids effusion with tear of the anterior rotator cuff And the rotator interval. AJR American Jounal of Roentegenology. 2000;174(5):1377-80.