Evaluation of Symptomatic Supraspinatus Tendon

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Radiography (2002) 8, 235–240

doi:10.1016/radi.2002.0382

Evaluation of the symptomatic supraspinatustendon—a comparison of ultrasound and

arthroscopyK. M. Venu, FRCS, Specialist Registrar in Orthopaedics*

D. C. Howlett, MRCP, FRCR, Consultant Radiologist†

R. Garikipati, FRCS, SHO in Orthopaedics*

H. J. Anderson, FRCR, Consultant Radiologist†

and A. V. Bonnici, FRCS, Orthopaedic Consultant*

*Department of Orthopaedics and †Department of Radiology, Eastbourne General Hospital,

King’s Drive, Eastbourne, BN21 2UD, U.K.

Purpose: A prospective study was undertaken to determine the accuracy of ultrasound compared with arthroscopy in the evaluation of the symptomatic supra-spinatus tendon, and to identify whether ultrasound diagnosis was helpful inpre-operative planning.Methods: A total of 276 consecutive patients with shoulder impingement symp-toms underwent ultrasound examination of the supraspinatus tendon. Of thesepatients, 41 proceeded to open or arthroscopic surgical procedure on clinicalgrounds, and in this group direct comparison with ultrasound findings was made.Results: There was full correlation between ultrasound and arthroscopy in thediagnosis of a normal supraspinatus tendon, full-thickness tear, tendinopathy and

tendon rupture. There was some discrepancy between the two techniques. Twopatients with partial thickness tear on ultrasound had a full thickness tear atarthroscopy. Ultrasound was able to identify intra-substance partial thickness tears inthree patients with supraspinatus tendon said to be normal at arthroscopy. Ultra-sound helped plan the surgical approach and operative time needed in cases of supraspinatus tendon rupture and full thickness tear.Conclusion: In this study ultrasound was effective in the evaluation of thesymptomatic supraspinatus tendon, and was also able to diagnose intra-tendinouslesions not visible at arthroscopy.

2002 The College of Radiographers. Published by Elsevier Science Ltd. All rights reserved.

(Received 3 May 2001;

revised 28 May 2002;

accepted 16 July 2002)

INTRODUCTIONRotator cuff tears involving the supraspinatustendon (SST) are commonly seen in clinical practiceand are often associated with sub-acromialimpingement type pain. Imaging plays an import-ant role in the diagnosis of such lesions, as it

is often not possible to clinically differentiate afull-thickness tear (FTT) from a partial thicknesstear (PTT) or tendinopathy. Accurate pre-operative diagnosis also helps to plan operativetreatment. A variety of modalities have been usedto image the rotator cuff, including computerizedtomography (CT), magnetic resonance imaging(MRI) and arthrographic techniques.

Ultrasound (US) evaluation of rotator cuff hasbeen shown to be accurate for the diagnosis of rotator cuff tears [1 – 7]. As a technique it is widely

Correspondence should be addressed to: Mr K. M. Venu,

47 Speranza Street, Plumstead, London SE18 1NX, U.K. Tel:

(00)44 (0) 20 88548416; E-mail: [email protected]

1078–8174/02/040235+06 $30.00/0 2002 The College of Radiographers. Published by Elsevier Science Ltd. All rights reserved.



available, non-invasive and well tolerated. In thisstudy, we have compared the ability of US toidentify and differentiate SST pathologies, whencompared with the findings at arthroscopy.

MATERIALS AND METHODS

A total of 276 consecutive patients with clinicalsupraspinatus impingement syndrome were evalu-ated by US over a two-year period, from June 1997to June 1999. Of these, 41 proceeded to arthro-scopic decompression, debridement or open repairof the tendon on clinical grounds. In this group,24 were male, 17 female and the mean age was57 years (range 34–79).

Two radiologists experienced in shoulder ultra-

sound performed the US examinations in allpatients using a linear array 5–10 MHz transducer,with the shoulder internally rotated to visualize theSST. Clinical data and plain radiographs were avail-able at the time of performing the US examination.Conventional longitudinal and transverse views of the SST were obtained. In our institution, the bicepstendon is routinely scanned as part of a shoulderexamination, although these findings were notrecorded for the purpose of this study. The otherrotator cuff tendons are not routinely examined.

For the purpose of the study, the appearances of the SST on ultrasound were classified into 5 cat-egories (ultrasound and equivalent arthroscopicimages are included):

Normal tendon (Fig. 1a & 1b) Tendinopathy (Fig. 2a & 2b) Partial thickness tear (Fig. 3) Full thickness tear Rupture (Fig. 4a & 4b)

Diagnostic criteria for the classification:

Tendinopathy may be diagnosed if the tendon isseen to be thickened and of patchy and oftendecreased echogenicity.

A PTT was diagnosed in the presence of ahypo-or hyperechoic tendon defect, not involv-ing the full thickness of the tendon. This can bean intra-substance partial-thickness tear notinvolving the tendon surface.

A FTT was diagnosed if the hypo or hyperechoictendon defect involved the full thickness of thetendon.

Rupture was diagnosed if the tendon was absentwith often only the retracted proximal tendonvisualized.

Initially all patients received a course of shoulder physiotherapy and a variable numberof sub-acromial steroid injections as first line of management. The decision to proceed to arthro-scopy was made on clinical grounds. The indicationfor surgery was failure of clinical improvement withconservative measures within one year of the onsetof symptoms. The surgeon knew the US diagnosisprior to surgery and accordingly, the pre-operativeplanning was made. All patients underwentshoulder joint arthroscopy and bursoscopy. All

Figure 1 (a) Longitudinal US of a normal left SST.

Hypoechoic humeral head cartilage lies inferiorly (arrows)

with a line of increased echogenicity superiorly represent-

ing deltoid muscle fascia (curved arrow). (b) Bursoscopic

image of a normal SST (arrow).

236 VENU ET AL.



patients underwent an arthroscopic subacromialdecompression or rotator cuff debridement. Those

patients with a full thickness tear or tendon rupturewere treated with an open repair following arthro-scopic decompression. In this group, pre-operativesonographic diagnosis helped plan the surgicalprocedure and allocation of appropriate theatretime.

A single surgeon performed all the operations.The average time to surgery from the time of USwas 6 months. The state of the SST was noted atthe time of surgery and comparison was then madewith the US findings.

RESULTS

The results are summarized in Table 1. It can beseen that there is a discrepancy between the USand arthroscopic findings in five patients in the PTTgroup. In three of these patients where US diag-nosed intra-substance partial tear, arthroscopy wasnormal. Two patients with PTTs at ultrasound hadFTTs at the time of surgery.

DISCUSSION

Rotator cuff disorders are commonly associatedwith impingement syndrome, which can result fromoutlet and non-outlet factors. Outlet factors suchas the shape and slope of the acromion and promi-nence of the acromio-clavicular joint are commoncauses of impingement. Non-outlet factors are less

frequently seen and include prominence of thegreater tuberosity, loss of humeral head depres-sors, loss of gleno-humeral fulcrum, lesions of theacromion and thickened sub-acromial bursa or cuff [8]. The rotator cuff may impinge against thecoraco-acromial arch leading to a microtraumaticprocess, giving rise to tears commonly affectingthe supraspinatus tendon [9]. Infraspinatus, sub-scapularis, and teres minor tendons are much lesscommonly involved [10, 11]. Tears can rangefrom partial or intra-substance tears to complete

Figure 2 (a) Longitudinal US of a right SST, whichis thickened and of diffusely abnormal echotexture

containing multiple poorly defined hypoechoic foci.

The appearances are consistent with tendinopathy.

(b) Bursoscopic image showing irregular and frayed

appearance on the bursal surface of the SST consistent with

tendinopathy (arrow).

Figure 3 Longitudinal US of a left SST, which contains a

focal hypoechoic intra-tendinous lesion (callipers) not

involving the bursal or articular aspects. This is consistent

with an intra-substance partial tear and was not visualized at

arthroscopy.

EVALUATION OF THE SYMPTOMATIC SST—A COMPARISON OF US AND ARTHROSCOPY 237



rupture of the tendon. They can involve the bursal,articular or both surfaces.Accurate diagnosis is necessary to plan the man-

agement of rotator cuff tears. Surgical treatment isadvocated if conservative measures fail. In our unit,the gleno-humeral joint and the subacromial spaceare initially assessed arthroscopically and either asubacromial decompression or open tendonrepair performed depending on type of cuff lesion.Most surgeons prefer to treat SST tendinopathy,intra-substance tear and PTT by arthroscopic

sub-acromial decompression to control impinge-ment, with or without debridement of thetendon. Some authors prefer to convert a PTT toFTT and repair the tendon directly [12]. Opensurgery is carried out for FTT, if the tendon isthought to be repairable without tension. Accuratepre-operative diagnosis helps plan the surgicalapproach and allows allocation of appropriatetheatre time.

Shoulder arthrography is a useful diagnosticprocedure and can reliably detect full-thicknesstears and, at times, partial thickness tears on theinferior (joint) surface of the cuff [13 – 15]. It cannotdetect intra-substance tears, tendinopathy orpartial-thickness tears affecting the bursal surfaceof the cuff. Diagnostic accuracy is increased withCT or MR arthrography. Arthrography however

is an invasive procedure and is associated withcomplications [13, 14].

Noninvasive imaging techniques for the evalu-ation of rotator cuff pathology have considerablyimproved over the past decade. Plain radiographicfindings include narrowing of the acromio-humeralspace, decalcification of the greater tuberosity andreversal of the normal convexity of the inferiorsurface of the acromion, but these appearances arenot specific in the diagnosis of rotator cuff tears[16]. MR imaging of the shoulder has been found to

be accurate in diagnosing FTTs, but the results arevariable with PTTs [1, 17, 18]. MR examination hasadvantages over plain arthrography or US in thatthe former technique provides information of thewhole rotator cuff, the glenohumeral and acromio-clavicular joints. It also gives information about thepresence of significant fatty degeneration of therotator cuff muscles, which may preclude a majorrotator cuff tear repair. It has been shown in someearly studies the limitations of the clinical utility of MR due to the frequent occurrence of ‘abnormal’

Figure 4 (a) Longitudinal US demonstrates rupture of

right SST with distal tendon remnant demonstrated

(arrow). The proximal tendon has retracted out of field of

view. (b) Arthroscopic image of a ruptured SST with

retraction. The retracted segment is held with forceps

(arrow).

Table 1 Summary of results

US findings

Correlation at

arthroscopy

Normal 13 13Tendinopathy 11 11PTT 7 2

FTT 7 7Rupture 3 3

TOTAL 41 36

238 VENU ET AL.



signal in the rotator cuff in asymptomatic individuals[19]. However, in a recent study by Wright et al ., itwas suggested that either fast spin echo inversionrecovery (FSEIR) images or fast-spin echo (FSE)fat-saturated images with TE greater than 66 beused to facilitate the differentiation of fluid signal

from intermediate increased signal intensity in rota-tor cuff imaging in order to refine the normalvariability of the rotator cuff’s signal [20]. The costfactor and limited availability mean that MRI is notthe first line of investigation in many centres.

Ultrasound as a technique is attractive. It is safe,widely available and well tolerated. Since Seltzeret al . described the sonographic appearances of tears of the rotator cuff in 1979; there have beenseveral other studies supporting the usefulness of this investigation [21]. It has been shown thatoperator skills and equipment specifications play animportant role in obtaining accurate sonographicresults [22]. US has been found to be accurate indiagnosing FTTs, but not reliable in detecting PTTs[5 – 7]. Dynamic US studies have also been per-formed to diagnose sub-acromial impingement[6, 7]. Sonographic changes in the biceps tendon,which accompany a lesion of the cuff, are wellunderstood [5]. Some authors have described direct

correlation between the diameter of the bicepstendon and the extent of tears [5, 23]. Ultrasoundcan reliably detect biceps tendon abnormalities

including dislocation, rupture, and tendinitis.Our results showed that US was very accurate in

diagnosing the normal tendon, tendinopathy, FTTsand ruptures of the SST. However only two out of seven cases in the PTT group were correlated atsurgery. Three of these patients had a focal intra-substance tear diagnosed at US, but the supra-spinatus tendon appeared normal at arthroscopy.Intra-substance tears are often not visible atarthroscopy but are readily diagnosed by ultra-sound. The diagnosis of intra-substance tears is

important, as they may be responsible for continu-ing symptoms following normal arthroscopy. In theremaining two patients said to have PTT at US, FTTwas found at surgery. It is likely that during 6months from the time of US to surgery, the PTTmay have progressed to FTT.

CONCLUSION

Our study demonstrated that US is effective inevaluating the symptomatic SST. Ultrasound is

accurate in identifying the normal tendon,tendinopathy, FTT and SST rupture and is also ableto diagnose intra-substance tears of the SST notvisualized during arthroscopy. US is a usefulmethod of pre-operative assessment in sympto-matic SST to plan the operative approach and for

allocation of theatre time.

ACKNOWLEDGEMENT

The authors would like to thank Nick Taylor for hishelp to prepare the illustrations.

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Evaluation of Symptomatic Supraspinatus Tendon