Accuracy of Rotator Cuff Tears and Tendinosis Diagnoses on Shoulder Ultrasound Performed by a Short-experienced Operator

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1 ORIGINAL ARTICLE Accurcy of Rottor Cuff Ters nd Tendinosis Dignoses on Shoulder Ultrsound Performed y Short-experienced Opertor Hrshd Arvind Vnjre, Jyoti Pnwr Deprtment of Rdiology, Christin Medicl College nd Hospitl, CMC, Id Scudder Rod, Vellore , Tmil Ndu, Indi Astrct Corresponding Author: Hrshd Arvind Vnjre, Deprtment of Rdiology, Christin Medicl College nd Hospitl, CMC, Id Scudder Rod, Vellore , Tmil Ndu, Indi. E-mil: hrshdcmc2002@gmil.com Received: 07-My-2018 Accepted: 29-My-2018 Pulished: 06-June-2018 Ojective: The ojective of the study ws to ssess the ccurcy of ultrsound exmintion for the dignosis of rottor cuff ter nd tendinosis performed y short experienced opertor, compred to mgnetic resonnce imging (MRI) results. Method: A totl of 70 sujects suspected to hve rottor cuff ter or tendinosis nd plnned for shoulder MRI were included in the study. Shoulder ultrsound ws performed either efore or fter the MRI scn on the sme dy. Ultrsound opertor hd short experience in performing n ultrsound of the shoulder. Ultrsound findings were correlted to MRI findings. Results: Sensitivity, specificity, positive predictive vlue, negtive predictive vlue, nd ccurcy for the dignosis of tendinosis were 58%, 84%, 63%, 80%, nd 75%, respectively, nd it ws 68%, 91%, 73%, 88%, nd 85%, respectively, for the dignosis of rottor cuff ter. Conclusions: Sensitivity for dignosing rottor cuff ter or tendinosis ws moderte ut hd higher negtive predictive vlue. Thus, the ultrsound opertor with short experience in performing shoulder ultrsound hd moderte sensitivity in dignosing tendinosis or ters; however, could exclude them with confidence. Keywords: Opertor experience, Rottor cuff, Ter, Ultrsound R INTRODUCTION Rottor cuff ter is common prolem in the generl popultion, [1-4] nd it cn e ssocited with significnt moridity. [5] Mgnetic resonnce imging (MRI) is good tool to dignose rottor cuff ters. [6,7] With the rpid development of ultrsound technology such s MHz liner rry rod-ndwidth trnsducers, etter penetrtion of the ultrsound em, nd improvement of imge Access this rticle online Quick Response Code: Wesite: DOI: / resolution; the sensitivity of ultrsound to dignose rottor cuff ters hs improved significntly nd hs reched nerly to tht of MRI. [6,8] However, opertor skill is considered importnt for performing ny ultrsound study. Ultrsound opertors in studies demonstrting high sensitivity nd specificity of ultrsound in dignosing rottor cuff ters hve hd long experience in performing shoulder ultrsound; which often hs een in yers. [9] There is very limited dt with respect of shorter ultrsound opertor experience in performing shoulder ultrsound. One study showed good sensitivity nd specificity in dignosing rottor cuff ters which incresed through the study s the experience of the opertor incresed. [10] The current study ws plnned to ssess the ccurcy of ultrsound opertor with shorter experience in performing shoulder ultrsound to dignose rottor cuff tendinosis or ter. This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution-NonCommercil-Shre Alike 4.0 License, which llows others to remix, twek, nd uild upon the work non commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. Americn Journl of Sonogrphy (9) 1

2 Vnjre nd Pnwr: Shoulder USG with short opertor experience METHODS Ultrsound criteri for rottor cuff pthology [11] Ultrsound opertor The ultrsound opertor ws rdiology resident who hd completed 2 yers trining in generl rdiology. The resident performed shoulder ultrsound on 2 norml sujects nd 20 clinicl cses with rottor cuff normlities. At the sme sitting, the contrlterl shoulder ws lso evluted using ultrsound (most of which were norml). After performing the ultrsound, MRI findings of the suject were reviewed the sme dy. This ws done over 1 month durtion. Selection nd description of prticipnts The study ws pproved y the Institutionl Review Bord. All ptients suspected to hve rottor cuff ter nd plnned for MRI of the shoulder presenting consecutively to the rdiology deprtment were included in the study fter informed consent. The shoulder ultrsound ws performed just efore or immeditely fter the shoulder MRI scn, nd the ultrsound opertor ws linded to the MRI scn findings. Ptients who refused to prticipte in the study were excluded from the study. This study ws done over 6 months durtion. Tendinosis (Figures 1-3) Chrcterized y heterogeneous, ill-defined, nd hypoechoic re in the tendon with vrile chnge in the clier (enlrged/thinned) without tendon defect. Prtil thickness tendon ter (Figure 4) Chrcterized y well-defined hypoechoic or nechoic normlity tht disrupt the tendon fiers: Interstitil ter: Within the tendon sustnce tht does not extend to the ursl or rticulr surfce. Articulr ter: Extends to the rticulr surfce. Bursl ter: Extends to the ursl surfce. Full thickness ter (Figure 5) Chrcterized y well-defined hypoechoic or nechoic normlity tht disrupts the hyperechoic tendon fiers Technicl informtion Siemens ACUSON S2000 ultrsound mchine with 5 14 MHz rnge ultrsound trnsducer ws used for performing shoulder ultrsounds. MRI of the shoulder ws done in Philips Achiev 3.0T MRI scnner. Protocol for performing n ultrsound of shoulder: The study ws explined to the sujects who were mde to sit on rotting chir. Sujects were mde to perform routine mneuvers within comfortle limits; such s externl nd internl rottion of rm nd extreme internl rottion of the rm such tht the hnd extended towrd the contrlterl shoulder lde. Sequence of ssessment: First iceps tendon ws ssessed with elow t 90 flexion. The forerm ws kept in supintion. Suscpulris ws ssessed with the rm in externl rottion nd elow t 90 flexion. The forerm ws kept in supintion. Suprspintus ws ssessed fter keeping the rm in internl rottion such tht the hnd extended towrd the contrlterl shoulder lde. For ssessment of infrspintus, plm of the hnd touched the front of the opposite shoulder. Figure 1: A 53-yer-old mle with left shoulder pin, dignosed to hve suprspintus tendinosis. Imge () T2 (ft suppressed) sgittl section showing hyperintensity nd swelling involving the suprspintus tendon (rrow). Imge () Gryscle ultrsound short xis view showing heterogeneous echotexture of the suprspintus tendon (rrow). Figure 2: A 41-yer-old mle with right shoulder pin, dignosed to hve full thickness ter of suprspintus tendon with infrspintus tendinopthy chnges. Imge () T2 (ft suppressed) sgittl section showing focl full-thickness ter (rrowhed) involving suprspintus tendon with surrounding edem. The infrspintus tendon (rrow) shows swelling nd hyperintensity suggestive of tendinopthy chnges. Imge () Gryscle ultrsound short xis view shows suprspintus tendon ter (rrowhed) with infrspintus tendinopthy chnges (rrow). Americn Journl of Sonogrphy (9) 2

3 Vnjre nd Pnwr: Shoulder USG with short opertor experience nd extend from the rticulr to the ursl surfce of the tendon. MRI of the shoulder Figure 3: A 47-yer-old mle with right shoulder pin, dignosed to hve suscpulris tendinosis. Imge () T2 (ft suppressed) sgittl section showing swelling nd edem involving the suscpulris tendon (rrow). Imge () Gryscle ultrsound short xis view with ulk nd heterogeneous suscpulris tendon (rrow). The following sequences were cquired in ccordnce with the institutionl protocol: i. Proton density weighted (PDW) xil SPAIR (ft suppressed). ii. T2W SPAIR coronl. iii. T2W SPAIR sgittl. iv. PDW coronl. v. PDW sgittl. vi. T1W xil. MRI scns were reported y two musculoskeletl rdiologist with 5 nd 10 yers of experience. Figure 4: A 47-yer-old mle with right shoulder pin, dignosed to hve rticulr surfce prtil thickness ter of the right suprspintus tendon. Imge () T2 (ft suppressed) sgittl section showing focl re of hyperintensity involving the rticulr surfce of the suprspintus tendon (rrow) suggestive of smll rticulr surfce ter. Imge () Gryscle ultrsound short xis view showing corresponding focl hypoechoic re (rrow). RESULTS A totl numer of sujects included in the study were 70. Fifty-five were men nd 15 were women. Averge ge of the sujects ws 39.6 yers (±12.6 yers). Averge ge for men ws 38.3 yers (±12.6 yers) nd for women it ws 44.4 yers (±12 yers). Right shoulder ws evluted in 45 sujects while left shoulder ws evluted in 25 sujects. (Tle 1) descries true positive nd negtive nd flse positive nd negtive ultrsound studies with respect to MRI. Suscpulris Of the 24 sujects dignosed with tendinosis on MRI, ultrsound detected 11 sujects. Prtil thickness ter ws dignosed in 13 sujects on MRI of which ultrsound detected 3 sujects. No suject ws dignosed with complete thickness ter on MRI. Suprspintus Figure 5: A 37-yer-old femle with difficulty in lifting her right rm, dignosed to hve suprspintus full-thickness ter. Imge () T2 (ft suppressed) coronl section showing full thickness ter involving the suprspintus tendon (rrow) t its insertion site with retrction of the tendon. Imge () Gryscle ultrsound long xis view showing loss of ttchment of the suprspintus tendon to its insertion site with hypoechoic re extending into the tendon (rrow). Of the 42 sujects dignosed with tendinosis on MRI, ultrsound detected 35 sujects. 35 sujects were dignosed to hve ny ter (oth prtil nd full thickness) on MRI of which 31 were identified on ultrsound. Between complete nd prtil thickness ter, ultrsound dignosed 5 of the 12 complete ters nd 18 of the 19 prtil ters s compred to MRI. Infrspintus Of the 15 sujects with tendinosis, 4 were dignosed on ultrsound. Four of the 8 sujects were identified with tendon ter on ultrsound s compred to MRI. Americn Journl of Sonogrphy (9) 3

4 Vnjre nd Pnwr: Shoulder USG with short opertor experience Biceps Of the 8 sujects dignosed with tendinosis, 2 were dignosed on ultrsound. No ter ws found involving iceps tendon. to the tendon. The resulting intr-tendinous hypoechoic ppernce my simulte tendon ter/tendinosis which my e mistken for pthology. This would cuse over or underestimtion of ctul pthology y n inexperienced ultrsound opertor. DISCUSSION At present, there is indequte dt with regrd to the numer of ultrsound required for n opertor to e le to dignose rottor cuff ter with confidence. One study which ssessed 2 opertors recommended t lest 100 shoulder ultrsound efore the opertors reched plteu for their skills to dignose suprspintus ters. [12] In our study, the ultrsound opertor with limited experience in performing shoulder ultrsound (2 norml sujects [4 shoulders] nd 20 ptients [40 shoulder]) could dignose rottor cuff tendinosis with sensitivity, specificity, positive predictive vlue, negtive predictive vlue, nd ccurcy t 58%, 84%, 63%, 80%, nd 75%, respectively, nd rottor cuff ter t 68%, 91%, 73%, 88%, nd 85%, respectively. Tle 1: Asolute vlues (s used in 2 2 tles) Ultrsound versus MRI Tendinosis nd tendon ters involving suscpulris tendon were repetedly missed. This my e ttriuted to norml strited pttern of the tendon [13] nd effects of nisotropy, n rtifct which occurs when the proe is not held prllel The results suggest tht lthough sensitivity nd specificity for dignosing rottor cuff ters nd tendinosis for ultrsound opertor with limited experience is moderte, except for suprspintus tendinosis nd ters where the sensitivity ws modertely good (83% for tendinosis nd 89% for ter); the negtive predictive vlues hve een good (Tles 2 nd 3). This suggests tht n inexperienced ultrsound opertor cn exclude rottor cuff ter nd tendinosis with more confidence thn dignosing them. The suject selection hs een confounding fctor in this study. All the sujects enrolled in the study hd high pretest proility for rottor cuff ters or tendinosis (this confounding fctor is present in most of the investigtions used in hospitl setup). Thus, the estimtes for sensitivity nd positive predictive vlues my e flsely rised. If the sme opertor ws to perform shoulder ultrsound in generl popultion with lower pretest proility the sensitivity of the test my e lower. However, in such cse the negtive predictive vlues would e higher thn estimted y this study. Muscle tendons n True positive () Flse positive () Flse negtive (c) True negtive (d) Tendinopthy chnges Biceps Suscpulris Suprspintus Infrspintus Tendinopthy chnges involving ny tendon Ter Suscpulris Suprspintus Infrspintus Ter involving ny tendon Deciml vlues in percentges rounded off to the nerest integer. MRI: Mgnetic resonnce imging Tle 2: Tendinosis Ultrsound versus MRI Sttisticl mesures Asolute vlues (%) Suscpulris Suprspintus Infrspintus Biceps All comined Sensitivity 11/24 (46) 35/42 (83) 4/15 (27) 2/8 (25) 52/89 (58) Specificity 38/46 (83) 12/25 (48) 45/52 (87) 56/59 (95) 151/182 (84) Positive predictive vlue 11/19 (58) 35/48 (73) 4/11 (36) 2/5 (40) 52/83 (63) Negtive predictive vlue 38/51 (75) 12/19 (63) 45/56 (80) 56/62 (90) 151/188 (80) Accurcy 49/70 (70) 47/67 (70) 49/67 (73) 58/67 (87) 203/271 (75) Deciml vlues in percentges rounded off to the nerest integer. MRI: Mgnetic resonnce imging Americn Journl of Sonogrphy (9) 4

5 Vnjre nd Pnwr: Shoulder USG with short opertor experience Thus, the finl conclusion of the study would remin unchnged tht n ultrsound opertor with limited experience in performing shoulder ultrsound cn exclude rottor cuff ter or tendinosis more confidently thn dignosing them. Limittions This study is limited y single ultrsound opertor which gives us no ide how multiple ultrsound opertors with limited experience would perform in dignosing rottor cuff tendinosis or ter. This study ws done s prt of the rdiology residency ACKNOWLEDGMENT trining progrm (MD in Rdiology), nd the institution is ffilited to Dr. MGR Medicl University, Tmil Ndu, Indi. REFERENCES 1. Ymmoto A, Tkgishi K, Osw T, Yngw T, Nkjim D, Shitr H, et l. Prevlence nd risk fctors of rottor cuff ter in the generl popultion. J Shoulder Elow Surg 2010;19: Ate M, Schivone C, Di Crlo L, Slini V. Prevlence of nd risk fctors for symptomtic rottor cuff ters in postmenopusl women. Menopuse 2014;21: Akr M, Blen G, Brunner M, Seyler TM, Bruckner T, Munzinger J, et l. Prevlence of rottor cuff ter in prplegic ptients compred with controls. J Bone Joint Surg Am 2010;92: Vlkering KP, Stokmn RD, Bijlsm TS, Brohet RM, vn Noort A. Prevlence of symptomtic rottor cuff ruptures fter shoulder trum: A prospective cohort study. Eur J Emerg Med 2014;21: Nkjim D, Ymmoto A, Koyshi T, Osw T, Shitr H, Ichinose T, et l. The effects of rottor cuff Tle 3: Any ter Ultrsound versus MRI Sttisticl mesures Asolute vlues (%) Suscpulris Suprspintus Infrspintus All comined Sensitivity 3/13 (23) 31/35 (89) 4/8 (50) 38/56 (68) Specificity 52/57 (91) 26/32 (81) 59/62 (95) 137/151 (91) Positive predictive vlue 3/8 (38) 31/37 (84) 4/7 (57) 38/52 (73) Negtive predictive vlue 52/62 (84) 26/30 (87) 59/63 (94) 137/155 (88) Accurcy 55/70 (79) 57/67 (85) 63/70 (90) 175/207 (85) Deciml vlues in percentges rounded off to the nerest integer. MRI: Mgnetic resonnce imging ters, including shoulders without pin, on ctivities of dily living in the generl popultion. J Orthop Sci 2012;17: Teefey SA, Middleton WD, Pyne WT, Ymguchi K. Detection nd mesurement of rottor cuff ters with sonogrphy: Anlysis of dignostic errors. AJR Am J Roentgenol 2005;184: Dell Sl SW, Binchini G. Mgnetic resonnce in the study of the pinful shoulder. The surgicl comprison in 30 consecutive cses. Rdiol Med 1996;91: Venu KM, Howlett DC, Grikipti R, Anderson HJ, Bonnici AV. Evlution of the symptomtic suprspintus tendon- comprison of ultrsound nd rthroscopy. Rdiogr Tody 2002;8: Lenz M, Buchinder R, Tkwoingi Y, Johnston RV, Hnchrd NC, Flopp F. Mgnetic resonnce imging, mgnetic resonnce rthrogrphy nd ultrsonogrphy for ssessing rottor cuff ters in people with shoulder pin for whom surgery is eing considered. In: Cochrne Dtse of Systemtic Reviews. John Wiley nd Sons, Ltd.; Aville from: wiley.com/doi/ / cd pu2/ strct. [Lst cited on 2013 Dec 18]. 10. Rutten MJ, Jger GJ, Kiemeney LA. Ultrsound detection of rottor cuff ters: Oserver greement relted to incresing experience. AJR Am J Roentgenol 2010;195:W Jcoson JA. Fundmentls of Musculoskeletl Ultrsound. 2 nd ed. Phildelphi, PA: Elsevier; p Alvekios DA, Dionysin E, Sodl J, Contrers R, Cho Y, Yin EH, et l. Longitudinl nlysis of effects of opertor experience on ccurcy for ultrsound detection of suprspintus ters. J Shoulder Elow Surg 2013;22: Nrsimhn R, Shmse K, Nsh C, Dhingr D, Kennedy S. Prevlence of suscpulris ters nd ccurcy of shoulder ultrsound in pre-opertive dignosis. Int Orthop 2016;40: How to cite this rticle: Vnjre HA, Pnwr J. Accurcy of Rottor Cuff Ters nd Tendinosis Dignoses on Shoulder Ultrsound Performed y Short-experienced Opertor. Am J Sonogr 2018, 1(9) 1-5. Americn Journl of Sonogrphy (9) 5