Rotator cuff tear
Rotator cuff tears are one of the most common causes of shoulder pain mostly in older patients.
Prevalence of tear increases with age. Most significant findings are impingement and "arc of pain" sign (pain during descent of abducted arm) 1. Supraspinatus weakness, night pain and weakness of external rotation (seen in infraspinatus tear) are also seen.
Important causes of rotator cuff tear include:
- trauma (acute, chronic repetitive)
- subacromial impingement
- tendon degeneration
A modification of the original Codman classification system published in 1930:
- full thickness rotator cuff tear (FTRCT)
- complete cuff tear: full thickness as well as full width tear
- vertical with a connection from joint to bursa, not involving the whole breath of tendon
- partial thickness rotator cuff tear (PTRCT)
- bursal surface tear
- articular surface tear
- intratendinous tear / central tears: not in communication with the joint surface or with the bursal surface of the tendon 7; also known as tendon delamination or interstitial tear; if the gap is filled with fluid then it is called cleavage tear of the rotator cuff tendon
Exact features depend on the type of tear, general features include
- may show a decreased acromiohumeral interval
- <6 mm on true AP shoulder radiograph
- <2 mm on an 'active abduction' view
- may show decreased supraspinatus opacity and decreased bulk due to atrophy, may be seen in chronic cases (on an 'outlet view')
- humeral subluxation superiorly may be seen in late cases
- may show features of acromial impingement -
- spur formation on the undersurface of acromioclavicular joint
- acromion with an inferolateral tilt (type III acromion) seen on outlet view i.e. modified 'Y' view
- secondary degenerative changes - sclerosis, subchondral cysts, osteolysis, and notching or pitting of greater tuberosity
In the hands of a good radiologist, ultrasound may have up to 90% sensitivity and specificity. It can also reveal other mimics like tendinosis, calcific tendinitis, subacromial subdeltoid bursitis, greater tuberosity fracture and adhesive capsulitis.
Full-thickness tears extend from bursal to the articular surface, while partial thickness tears are focal defects in the tendon that involve either the bursal or articular surface. Full-thickness appear on ultrasound as hypoechoic/anechoic defects in the tendon. Due to the fluid replacing tendon, cartilage shadow gets accentuated giving a 'double cortex' or 'cartilage interface sign'. Also, due to the defect, overlying peribursal fat dips down into the tendon gap, creating a 'sagging peribursal fat' sign 1.
Direct signs are:
- non-visualization of supraspinatus tendon
- hypoechoic discontinuity in tendon
Indirect signs are:
- double cortex sign
- sagging peribursal fat sign
- muscle atrophy
Secondary associated signs are:
- cortical irregularity of greater tuberosity
- shoulder joint effusion
- fluid along biceps tendon
- fluid in the axillary pouch and posterior recess
Complete tears are easier to diagnose on MRI than full-thickness tear 2 . Hyperintense signal area within the tendon on T2W, fat-suppressed and GRE sequences, usually corresponding to fluid signal is seen.
Partial tears are extending to either bursal or articular surface, and sometimes intrasubstance. Retraction of tendinous fibers from the distal insertion into the greater tuberosity may also be considered partial tear.
Complete tears extend from articular to bursal surface, most commonly in supraspinatus tendon. The presence of tendon defect filled with fluid is most direct sign of rotator cuff tear. Tendon retraction may also be present, which can be graded using the Patte classification. Indirect signs on MRI are - subdeltoid bursal effusion, medial dislocation of biceps, fluid along biceps tendon, and diffuse loss of peribursal fat planes. Muscle atrophy and fatty replacement is seen in chronic cases and can be graded using the Goutallier classification 6. Chronic tears have degenerative changes at acromioclavicular joint, acromioclavicular joint cysts, as well as intramuscular cysts.
MR arthrography may enhance the detection of rotator cuff tears, especially complete tears.
General imaging differential considerations include
- calcific tendinitis
- subacromial subdeltoid bursitis
- greater tuberosity fracture
- adhesive capsulitis
- supraspinatus tendinitis
- 1. Moosikasuwan JB, Miller TT, Burke BJ. Rotator cuff tears: clinical, radiographic, and US findings. Radiographics. 25 (6): 1591-607. doi:10.1148/rg.256045203 - Pubmed citation
- 2. Stoller DW, Fritz RC. Magnetic resonance imaging of impingement and rotator cuff tears. Magn Reson Imaging Clin N Am. 1993;1 (1): 47-63. - Pubmed citation
- 3. Kaplan P. Musculoskeletal MRI. W B Saunders Co. (2001) ISBN:0721690270. Read it at Google Books - Find it at Amazon
- 4. Haaga JR, Boll D. CT and MRI of the whole body. Mosby. (2009) ISBN:0323053750. Read it at Google Books - Find it at Amazon
- 5. Tuite MJ, Turnbull JR, Orwin JF. Anterior versus posterior, and rim-rent rotator cuff tears: prevalence and MR sensitivity. Skeletal Radiol. 1998;27 (5): 237-43. Pubmed citation
- 6. Goutallier D, Postel JM, Bernageau J et-al. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin. Orthop. Relat. Res. 1994; (304): 78-83. Pubmed citation
- 7. Guerini H, Fermand M, Godefroy D et-al. US appearance of partial-thickness supraspinatus tendon tears: Application of the string theory. Pictorial essay. J Ultrasound. 2012;15 (1): 7-15. doi:10.1016/j.jus.2011.12.001 - Free text at pubmed - Pubmed citation
- 8. Bergin D, Parker L, Zoga A et-al. Abnormalities on MRI of the subscapularis tendon in the presence of a full-thickness supraspinatus tendon tear. AJR Am J Roentgenol. 2006;186 (2): 454-9. doi:10.2214/AJR.04.1723 - Pubmed citation
- 9. Morag Y, Jacobson JA, Miller B et-al. MR imaging of rotator cuff injury: what the clinician needs to know. Radiographics. 2006;26 (4): 1045-65. Radiographics (full text) - doi:10.1148/rg.264055087 - Pubmed citation