OROAJ.MS.ID.556126

Abstract

Background: Rotator cuff injuries are a common cause of shoulder pain and functional impairment, requiring accurate diagnosis for effective clinical decision-making. This study evaluates the reliability of ultrasound (US) compared to magnetic resonance imaging (MRI) in diagnosing rotator cuff injuries and examines their impact on therapeutic and surgical decisions.
Methodology: This retrospective study, conducted at EMMS Nazareth Hospital (2020-2023), included 46 patients with shoulder pain and suspected rotator cuff injuries. Each patient underwent both ultrasound (US) and magnetic resonance imaging (MRI). The diagnostic performance of US was compared to MRI, assessing sensitivity, specificity, and clinical outcomes, including surgical decisions based on imaging results.
Results: The results show that US has high sensitivity (80%), making it an effective initial screening tool, particularly in environments where MRI is less accessible or cost prohibitive. However, the low specificity of US (20%) indicates a tendency for false positives, necessitating MRI confirmation in ambiguous cases. These findings highlight the importance of using US alongside MRI to optimize clinical decision-making, balancing diagnostic accuracy, cost, and accessibility. The combined use of these modalities can improve patient care, reduce unnecessary surgical interventions, and enhance healthcare resource utilization.
Conclusion: Ultrasound (US) proves to be a cost-effective and sensitive tool for the initial screening of rotator cuff injuries, especially in settings with limited resources. However, its low specificity necessitates the use of magnetic resonance imaging (MRI) to confirm uncertain diagnoses. The combined use of US and MRI improves diagnostic accuracy, ensuring more reliable treatment decisions and reducing the likelihood of unnecessary surgical interventions. This dual-modality approach enhances patient care, optimizes therapeutic outcomes, and allows for more efficient allocation of healthcare resources.

Keywords:Rotator cuff injuries; Ultrasound diagnosis; MRI confirmation; Shoulder injury imaging; Diagnostic sensitivity

Background

The shoulder joint’s complexity and overlapping symptoms with other shoulder pathologies make it challenging to accurately diagnose rotator cuff injuries. This diagnostic uncertainty often necessitates the use of reliable imaging modalities. Among the most utilized are ultrasound (US) and magnetic resonance imaging (MRI), both of which present distinct advantages and limitations. US is favored for its real-time imaging capabilities, cost-effectiveness, and absence of radiation, making it a widely accessible diagnostic tool. However, the US is also operator-dependent, which can result in variability in the quality and interpretation of images [1]. MRI, on the other hand, offers excellent soft tissue contrast and multiplanar imaging capabilities, making it particularly effective for detailed assessments of rotator cuff injuries. Although MRI is highly accurate, its cost and limited accessibility in certain settings are notable disadvantages [2,3].

Numerous studies have compared the diagnostic accuracy of US and MRI in evaluating rotator cuff injuries. Some findings suggest that US can be comparable to MRI in detecting full-thickness rotator cuff tears, although it is generally less reliable for partial-thickness tears and smaller lesions [4]. The study by Ganesh et al. [5] highlighted that US is highly accurate for diagnosing full-thickness tears, while MRI remains the superior tool for comprehensive evaluations. These findings suggest that the US can serve as a cost-effective initial diagnostic modality, particularly in settings where MRI is less accessible, but MRI should be used to confirm uncertain cases or more complex injuries.

Given these insights, the choice between US and MRI has important implications for clinical decision-making. While MRI is often regarded as the gold standard for soft tissue injuries, US may be sufficient in certain cases where cost and accessibility are major concerns. Clinical guidelines advocate a stepwise approach to diagnosing rotator cuff injuries, beginning with a clinical examination followed by imaging studies such as US or MRI, depending on the clinical context [6]. The rationale for this research is to evaluate the clinical prioritization of US compared to MRI in diagnosing rotator cuff injuries, with a focus on determining the therapeutic approach, including the necessity for surgery. This study aims to assess whether US can serve as a viable alternative to MRI for guiding treatment decisions. By exploring the concept of diagnostic satisfaction-where clinicians may rely solely on US findings for treatment decisions-this research also aims to provide insights into optimizing healthcare resource allocation, while maintaining high standards of patient care [7].

The primary objective of this research is to evaluate the sensitivity and specificity of US compared to MRI for diagnosing rotator cuff tears, determining the diagnostic accuracy of US relative to MRI. The objective Dary objective is to investigate the feasibility of using the US as a standalone diagnostic tool for treatment decision-making, particularly regarding conservative versus surgical interventions. This aspect will examine whether US findings can sufficiently inform clinical decisions without requiring additional MRI imaging, potentially providing significant cost-saving benefits [8,9]. Patients included in this study will have exhibited clinical indications of a rotator cuff tear, such as shoulder pain, weakness, or limited range of motion. Additionally, all patients must have undergone both US and MRI examinations, followed by shoulder arthroscopy, ensuring surgical confirmation of rotator cuff tears for comparison with imaging findings [10].

Methods

A retrospective cohort study was conducted at EMMS Nazareth Hospital, analyzing the ultrasound (US) and MRI reports of patients who underwent rotator cuff tear repair surgery between 2020 and 2023. The study involved a cohort of 44 patients who underwent both US and MRI examinations of the shoulder, followed by shoulder arthroscopy for rotator cuff tear repair. The study included all patients who underwent initial surgeries for rotator cuff tear repair during this period, excluding revision surgeries. My role in the study involved reviewing the medical records of enrolled patients, analyzing their US and MRI results, and examining surgical reports from shoulder arthroscopy. I processed and compared the diagnostic accuracy of US and MRI with the surgical findings, drawing conclusions about the reliability and utility of US as a diagnostic tool for rotator cuff tears, particularly in guiding treatment decisions.

Results

This study aimed to assess the sensitivity and specificity of ultrasound (US) compared to MRI for diagnosing rotator cuff tears, evaluating whether US could serve as a standalone diagnostic tool for guiding treatment decisions, potentially avoiding the need for MRI. The study involved (46) participants, with an evenly split gender distribution of (23) males and (23) females, and an average age of (M = 54.76, SD = 10.15). The purpose was to determine if the US alone could adequately identify patients needing conservative or surgical treatment, thus offering a cost-effective approach to diagnosis in the healthcare system.

The primary findings demonstrated that the US has high sensitivity, meaning it effectively detects a significant portion of true positive cases when compared to MRI. Specifically, US exhibited a sensitivity rate of (80%), correctly identifying (80%) of patients diagnosed with rotator cuff tears by MRI. However, the study also revealed that the US has low specificity, at only (20%), indicating a higher rate of false positives. This means that while the US is reliable for identifying patients with rotator cuff injuries, it may over-diagnose some cases, classifying them as positive when MRI results are negative. Therefore, although US can serve as an effective initial screening tool, its lower specificity suggests that MRI may still be necessary to confirm ambiguous diagnoses, particularly in more complex cases.

Moreover, a correlation analysis between US and MRI results showed a moderate positive correlation, with a correlation coefficient of (r = 0.6). This indicates that while there is some level of agreement between the results of the two diagnostic methods, they do not perfectly align. MRI remains the more reliable modality for diagnosing rotator cuff injuries, especially in cases where US results are positive but clinical symptoms are not definitive. This moderate correlation reinforces the importance of selecting the appropriate diagnostic tool based on the clinical context and complexity of each case. In addition to the correlation analysis, a logistic regression was conducted to evaluate the impact of US results on the likelihood of a positive MRI diagnosis. The results demonstrated a statistically significant relationship between the two modalities, with the logistic regression coefficient for the US showing a strong positive effect (β = 1.3773, p = .006). A positive US result was shown to significantly increase the odds of a positive MRI diagnosis. The p-value of less than (p < .001) indicated strong statistical significance, while the (95% CI [0.393, 2.361]) confirmed the reliability of these findings.

Thus, while US results are positively associated with MRI outcomes, it remains essential to verify US diagnoses with MRI to ensure accuracy. The logistic regression analysis demonstrated that positive US results significantly increase the likelihood of positive MRI findings, as illustrated in Figure 1. This finding highlights a moderate but statistically significant correlation between the two diagnostic methods, suggesting that the US can be reliably used as a preliminary screening tool for rotator cuff injuries. The red dashed line in Figure 1 illustrates the logistic regression fit, showing that US results tend to align with MRI outcomes, particularly in cases where US detects a tear. This relationship emphasizes US’s value in initial screenings, particularly in healthcare settings where MRI is not immediately available or is too costly.

However, the study also highlights that the US, while highly sensitive, tends to have lower specificity. Specifically, the sensitivity of US was found to be 80%, indicating that it effectively identifies true positive cases of rotator cuff tears. This high sensitivity makes the US a valuable tool for initial diagnosis, particularly in identifying patients who need further evaluation or treatment. In contrast, the specificity of US was reported to be low at only 20%, meaning that there is a significant risk of false positives. This limitation indicates that while the US can detect the presence of tears, it may overestimate their occurrence, as some patients who tested positive on US were found to have no injury when confirmed by MRI. The findings suggest that in ambiguous or more complex cases, MRI should be used to confirm US findings to ensure accurate diagnosis and avoid unnecessary treatments (as demonstrated in Figure 2 in Appendix).





In Figure 2 (Appendix), the distribution of US and MRI results is shown, indicating that most of the positive US’S results corresponded to positive MRI results, further supporting the high sensitivity of US. However, due to its low specificity, clinicians are advised to use MRI as a follow-up modality, especially when US results are positive, but the clinical symptoms do not fully match the imaging findings. The study’s findings also align with previous literature, which consistently identifies MRI as the gold standard for diagnosing soft tissue injuries like rotator cuff tears. MRI offers superior imaging resolution, allowing for the detection of partial-thickness tears and smaller, more complex lesions that US might miss. Figure 3 (In Appendix) presents an MRI image showing a partial tear of the supraspinatus tendon, a common injury in the shoulder’s rotator cuff. Partial tears can result from overuse, trauma, or degenerative changes and often lead to pain and limited shoulder movement. MRI helps in assessing the tear’s size and location for treatment planning.

In contrast, Figure 4 (In Appendix) displays an ultrasound image showing a partial tear of the supraspinatus tendon. While ultrasound can effectively visualize the tendon, it may not always provide the detail needed to detect more subtle injuries like partial tears. However, ultrasound remains valuable for real-time, dynamic assessment of tendon function and morphology, often serving as a useful tool for the initial evaluation of shoulder pain and suspected rotator cuff injuries.

Discussion

The findings of this study align with prior research that compares the diagnostic accuracy of ultrasound (US) and magnetic resonance imaging (MRI) in detecting rotator cuff injuries. The US is often recognized for its cost-effectiveness and accessibility, making it a valuable initial screening tool, especially in settings where access to MRI is limited [5,8]. Additionally, the dynamic imaging capabilities of US allow clinicians to assess tendon function in real-time, which is particularly useful in diagnosing shoulder injuries. However, the literature also highlights that the US is operator-dependent, meaning that the quality and interpretation of the images can vary significantly based on the technician’s experience [1,3,4]. This variability is one reason for discrepancies in diagnostic accuracy, particularly when dealing with partial-thickness tears or smaller lesions.

Jacobson et al. [4] found that while US is highly effective in diagnosing full-thickness rotator cuff tears, it tends to be less reliable when identifying partial tears or smaller, more complex injuries [4]. This observation is supported by research indicating that US, despite its advantages, often shows lower specificity, leading to an increased rate of false positives [3]. This underscores the need for more precise diagnostic tools, such as MRI, especially in cases where clinical symptoms do not conclusively match the imaging findings. Relying solely on US can result in over-diagnosis, which in turn may lead to unnecessary treatments, including surgery [6,9].

MRI, on the other hand, is widely regarded as the gold standard for imaging soft tissue injuries, particularly rotator cuff tears [5,8]. It provides excellent soft tissue contrast and allows for detailed visualization of structures like tendons, muscles, and bones. MRI’s ability to detect both partial and full-thickness tears, as well as small lesions and degeneration, is unparalleled compared to [2,4,9]. Research consistently shows that MRI’s diagnostic accuracy surpasses that of US, especially in complex cases, making it the preferred modality when the clinical decision involves potential surgical intervention [3]. Given these insights, the combined use of US and MRI, as suggested in this study, follows a logical diagnostic pathway. US, with its affordability and dynamic capabilities, serves well as a preliminary tool. However, in cases where US findings are ambiguous or do not align with the patient’s clinical presentation, MRI should be used to confirm the diagnosis [2,3]. This dual-modality approach, recommended in both clinical guidelines and the literature, ensures that patients receive an accurate diagnosis while minimizing unnecessary procedures [5,7].

References

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