Accuracy of Diagnostic Ultrasound in Patients With Suspected Subacromial Disorders: A Systematic Review and Meta-Analysis

doi:10.1016/j.apmr.2010.07.017

Archives of Physical Medicine and Rehabilitation

Volume 91, Issue 10, October 2010, Pages 1616-1625

https://doi.org/10.1016/j.apmr.2010.07.017 Get rights and content

Abstract

Ottenheijm RP, Jansen MJ, Staal JB, van den Bruel A, Weijers RE, de Bie RA, Dinant G-J. 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.

Section snippets

Search Strategy

A well conducted systematic review on this topic was published in 2003, using a search strategy comparable to ours.¹⁷ This review was based on a search from 1985 to October 2001. We updated this review by using its reference list and conducting a new search, incorporating the methods recommended in the Cochrane Handbook on Systematic Reviews of Diagnostic Tests.²² Two reviewers (M.J.J., R.P.O.) searched the bibliographic databases of PubMed and Embase from 2001 up to June 9, 2010, with a set of

Study Selection and Characteristics

Our search strategy yielded 137 records. Figure 1 summarizes the flow of records through the review. Of the 114 excluded records, 18 were duplicates, and 56 were rejected on the basis of the title or abstract. Of the remaining records, 8 provided insufficient data, and 32 were excluded for other reasons: other populations, other target condition, US not used as index test, US transducer frequencies less than 7.5MHz, or arthrography as a reference standard.

Twenty-three studies thus met the

Statement of Main Results

To our knowledge, this is the first time a systematic review has examined the accuracy of US to diagnose the full spectrum of subacromial disorders. Our comprehensive review identified data for tendinopathy, calcifying tendonitis, subacromial bursitis, and partial-thickness and full-thickness tears. The results indicate that in a secondary care setting in patients in whom conservative treatment has failed, US has a high diagnostic accuracy for most of these disorders.

Tests with high sensitivity

Conclusions

In order to achieve appropriate treatment decisions, we strongly recommend the use of US in patients in whom conservative treatment has failed, to rule full-thickness tears in or out, to rule in partial-thickness tear, and to a lesser extent to diagnose tendinopathy, subacromial bursitis, and calcifying tendonitis. The diagnostic accuracy of US in patients with acute complaints remains to be determined.

Suppliers

Acknowledgments

We thank Frank Buntinx, MD, PhD for his methodologic advice, and Jan Klerkx for linguistic advice.

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For patients with rotator cuff tear (RCT), the contra-lateral shoulders have higher risk of RCT than general population. It has been proved by several previous studies. The focus of this study is to obtain the data of contra-lateral rotator cuff tear in Chinese population, and to find the rules of contra-lateral rotator cuff tear through statistical analysis.
From March 2016 to January 2020, patients who underwent shoulder arthroscopic surgery were included in the study, we conduct bilateral shoulder ultrasound before surgery, patients information collection include gender, age, occupation and whether received contra-lateral rotator cuff surgery within 1–3 years. The above information was statistically analyzed.
According to the inclusion and exclusion criteria, 401 patients were included. The incidence of contra-lateral rotator cuff tear was 24.3%, 5.58% of them underwent contra-lateral rotator cuff repair surgery within 3 years. The degree of contra-lateral rotator cuff tear was positively correlated with the degree of the primary side; Patients with full-thickness rotator cuff tear were more likely to have contra-lateral rotator cuff tear than patients with partial rotator cuff tear. For patients with supraspinatus tendon tear, the contra-lateral rotator cuff tear risk increases, For patients with subscapularis muscle tear, the contra-lateral rotator cuff tear risk doesn't increases. Contra-lateral rotator cuff tear is related to age, the risk of contra-lateral rotator cuff tear is higher in elderly patients.
The contra-lateral RCT data obtained in our study was 24.3%, significantly lower than that of previous studies. The reasons may include ethnic variation, lifestyle, and proportion of heavy physical labor. The condition of contra-lateral rotator cuff is closely related to affected side rotator cuff tear.
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While ultrasound has become a preferred tool for musculoskeletal imaging, differing ultrasound findings that have been reported in patients with adhesive capsulitis can create confusion and misconceptions. This systematic review was aimed at summarizing all the ultrasound features currently described in the literature and providing a critical analysis of the sources to allow the readers to make a well-informed decision on the reliability of these features in the diagnosis of this condition. Databases were searched for original studies up to August 2021. Twenty-three studies were included. The QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool was used to assess the quality of each selected article. Fourteen ultrasound features were identified. A quality analysis of all ultrasound features was performed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework. All studies exhibited considerable heterogeneity in investigated ultrasound features and methodologies employed; therefore, meta-analysis was not considered to be appropriate. Hence, narrative synthesis was performed. The overall quality of each ultrasound outcome was found to be of “low” to “very low” level, and the generalisability of the results was also thought to be limited. Cautious interpretation and clinical correlation are recommended while applying these ultrasound features in clinical practice.
An interexaminer agreement and reliability study on cadavers with musculoskeletal ultrasound of the shoulder performed by physiotherapists and radiologists compared with dissection
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A cross-sectional inter-examiner agreement and reliability study on fresh frozen cadaver shoulders.
Musculoskeletal ultrasound (MSU) is frequently used by physical therapists and radiologists to improve specific diagnosis in rotator cuff related pathology. The evaluation of the rotator cable seems to be important as stabilizing structure when cuff tears occur.
To evaluate the inter-examiner agreement and reliability of MSU of the shoulder to detect rotator cuff-pathology and the involvement of the rotator cable in comparison to “dissection”.
Physical therapists, a radiologist and an orthopedic surgeon (dissection) investigated 40 fresh frozen cadaver shoulders in order to detect shoulder pathology including rotator cable involvement. Examiners were blinded to each other's findings.
We found a strong and significant agreement between the raters: PTs, the radiologist and the dissector in this cadaver study for all rotator cuff, the long head of the biceps pathologies and in detecting abnormalities of the rotator cable. The kappa value was substantial to (almost) perfect agreement for all diagnostic outcome categories.
This study shows that among a limited group of physical therapists, one radiologist and a dissector a strong level of agreement with kappa values from substantial to (almost) perfect in finding subacromial pathology.
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A cross-sectional inter-examiner agreement and reliability study among physical therapists in primary care.
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To estimate the inter-examiner agreement and reliability in physical therapists using MSU for patients with shoulder pain.
Physical therapists performed diagnostic MSU in 62 patients with shoulder pain. Both physical therapists were blinded to each other's results and patients were not informed about the test results. We calculated the overall inter-examiner agreement, specific positive and negative inter-examiner agreement, and inter-examiner reliability (Cohen's Kappa's).
Overall agreement for detecting RC ruptures ranged from 61.7% to 85.5% and from 43.9% to 91.4% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures. Overall agreement for other pathology than ruptures related to SAPS, ranged from 72.6% to 93.6% and from 77.3% to 96% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures and 52.5%–83.3% for other pathology than ruptures related to SAPS. Reliability values varied from substantial for any thickness ruptures to moderate for partial thickness ruptures and fair for full thickness tears. Moreover, reliability was fair for cuff tendinopathy. The reliability for AC arthritis and no pathology found was fair and moderate. There was substantial agreement for the calcifying tendinopathy.
Physical therapists using MSU agree on the diagnosis of cuff tendinopathy and on the presence of RCT in primary care, but agree less on the absence of pathology.
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Citation Excerpt :
Previous investigations have reported alterations in asymptomatic shoulders using ultrasound (US)20,23,28,29,31,39,46,51,52 and MRI.6,9,18,25,32,33,41,43 The most common findings included partial- and full-thickness tears of the SST and IST tendons with a prevalence ranging from 2% to 95%.7,10,18,24,26,29,30,32-34,42,44,51,52 These past studies focused on describing alterations in only the SST and IST tendons or presented a grouped prevalence of all rotator cuff tendons, hindering a detailed evaluation of which tendons were affected.
Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms.
We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined.
Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon's findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51).
Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.
Does the outcome of diagnostic ultrasound influence the treatment modalities and recovery in patients with shoulder pain in physiotherapy practice? Results from a prospective cohort study
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There is an increased tendency to use diagnostic ultrasound to aid the diagnostic strategy and target treatment. It is a relatively cheap and accessible imaging technique but the implications for practice and patients are unknown.
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Participants (n = 389) with a new episode of shoulder pain were assessed at baseline and followed for 6, 12 and 26 weeks. Diagnostic work-up, including the use of DUS, and treatment strategies were reported by the therapists at 3, 6 and 12 weeks.
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Review article (meta-analysis)Accuracy of Diagnostic Ultrasound in Patients With Suspected Subacromial Disorders: A Systematic Review and Meta-Analysis

Abstract

Objective

Data Sources

Study Selection

Data Extraction

Data Synthesis

Conclusions

Section snippets

Search Strategy

Study Selection and Characteristics

Statement of Main Results

Conclusions

Acknowledgments

Man Ther

Pain

Aust J Physiother

Physiotherapy

Best Prac Res Clin Rheumatol

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Eur J Ultrasound

Orthop Clin North Am

J Clin Epidemiol

J Clin Epidemiol

Clin Imaging

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

Incidence and prevalence of complaints of the neck and upper extremity in general practice

Ann Rheum Dis

Subacromial impingement syndrome

J Bone Joint Surg Am

Impingement lesions

Clin Orthop Rel Res

The painful shoulder: can consultants agree?

Br J Rheumatol

Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement

Ann Rheum Dis

Rehabilitation of the rotator cuff: an evaluation-based approach

J Am Acad Orthop Surg

The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review

Health Technol Assess

Sonography of the rotator cuff: analysis of interobserver variability

AJR Am J Roentgenol

US of the shoulder: non-rotator cuff disorders

Radiographics

Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis

AJR Am J Roentgenol

Handbook for DTA reviews

Development and validation of methods for assessing the quality of diagnostic accuracy studies

Health Technol Assess

The detection of full thickness rotator cuff tears using ultrasound

J Bone Joint Surg Br

Diagnostic accuracy of shoulder ultrasound performed by a single operator

Australas Radiol

Review article (meta-analysis)
Accuracy of Diagnostic Ultrasound in Patients With Suspected Subacromial Disorders: A Systematic Review and Meta-Analysis