Elsevier

Clinical Radiology

Volume 66, Issue 11, November 2011, Pages 1036-1048
Clinical Radiology

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

https://doi.org/10.1016/j.crad.2011.05.007Get rights and content

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An electronic search of databases registering published and unpublished literature was conducted.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.

Introduction

Rupture of the rotator cuff is a major cause of shoulder pain and associated functional disability,1, 2 with partial thickness tears a relatively common source of shoulder pain.3 Up to 70% of all shoulder pain is attributable to disorders of the rotator cuff.4, 5 Clinical examination is frequently considered difficult and unreliable as the location of shoulder pain is considered a poor indictor of its origin.6 Accordingly, radiological investigation is often required to confirm diagnosis.1, 7 The differential diagnosis of shoulder pathologies is further complicated as a number of different lesions, such as shoulder impingement syndrome and instability, can present with similar signs and symptoms.8, 9 As the diagnosis is important for determining treatment pathways, particularly differentiating between partial and full-thickness tears, an accurate diagnosis is required to ensure that the optimal management strategy is selected for these patients.1, 6, 10 In particular, accurate measurement of the size and location of rotator cuff tears is essential for effective preoperative planning.11

X-ray arthrography, magnetic resonance imaging (MRI), and ultrasonography have all been used to image the rotator cuff.1, 2, 8 Both X-ray arthrography and MRI can provide useful findings to assess the integrity of the rotator cuff but arthrography is an invasive procedure and may not be able to identify the size of the tear, and MRI is still relatively expensive and time-consuming.1 In comparison ultrasound is less expensive, less time-consuming, and permits a dynamic evaluation. Furthermore the portability of ultrasound means that the integrity of the rotator cuff can be assessed in geographically isolated locations or by a surgeon/radiologist during a clinic session to allow the efficient planning of treatment to be initiated.12

The first studies using ultrasound to detect rotator cuff tears were presented in the late 1970s.13 As the technology in high-frequency real-time ultrasound has developed, a number of studies have now been published assessing the diagnostic accuracy of ultrasound to detect partial or complete rotator cuff tear. Although some authors have suggested that there is little issue about the use of ultrasound for the diagnosis of full-thickness rotator cuff tears, there is greater controversy regarding the use of ultrasound for the diagnosis of partial-thickness tears.3, 14, 15 Three previous systematic reviews have been undertaken to assess the sensitivity of ultrasound for detecting these injuries.16, 17, 18 However, these studies only assessed English language publications, and either did not or made only limited attempts to assess sources of unpublished literature. Therefore, these findings may have been impacted by selection and publication biases. To address this, the purpose of the present study was to perform a systematic review of all literature to determine the diagnostic accuracy of ultrasound to detect partial and complete-thickness rotator cuff tears, based on all available clinical trials.

Section snippets

Eligibility criteria

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 tears were included. All cadaveric and animal studies were excluded. No language restrictions were enforced. Studies based on patient age or methodological quality were not excluded. Studies that reported the diagnosis accuracy of either complete or partial tear were included, although these lesions were

Search result

In total, the search strategy identified 212 citations. On removing duplicates, the titles and abstracts indicated 82 papers were potentially eligible. Once the full texts of these citations were reviewed, 62 studies were deemed appropriate and fully satisfied the eligibility criteria for inclusion in the final review. The full results of the search strategy are presented in a PRISMA flowchart (Fig 1).

Methodology appraisal

The findings of the critical appraisal based on the QUADAS tool, is presented in Table 2. This

Discussion

The findings of this study indicate that although the diagnostic accuracy of ultrasound is acceptable for detecting rotator cuff tears, full-thickness rotator cuff tears are better detected by ultrasound compared to partial-thickness rotator cuff tears. The results of this analysis indicate that 7.5 MHz transducers may be better able to detect each type of rotator cuff tear, and that diagnostic accuracy was highest when ultrasonography was undertaken and reported by a musculoskeletal

Acknowledgements

The authors thank the library staff at the University of East Anglia’s library for their assistance in gathering the papers used in this systematic review. The authors also thank all corresponding authors who reviewed the findings of the search strategy of the present study.

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