Pain related to rotator cuff abnormalities: MRI findings without clinical significance

Shoulder impingement: various risk factors for supraspinatus tendon tear: A case group study

A total of 680 cases of monolateral shoulder pain and functional impairment were included, and Chi-Squared tests was incorporated to test for possible associations.No relation between impingement syndrome and potential risk factors was found, such as presence of down slopping (P = .083), presence of ossification acromiale (P  = .102), presence of calcific tendinitis (P  = .144), types of acromion (I [P = .600], II [P = .536], III [P = .633] and IV [P = .832]) and grade of acromioclavicular degenerative changes (mild [P = .077], moderate [P = .111], and severe [P = .700]). However, a significant relationship was uncovered between impingement syndrome and risk factors such as gender (X2 = 7.004, df = 1, P = .08) (where females were more prone), history of shoulder dislocation (X2 = 19.440, df = 1, P = .001), presence of supraspinatus tendon tear or tendinopathy (X2 = 69.344, df = 1, P = .001) and supraspinatus complete tear (X2 = 13.593, df = 1, P = .001). A significant relationship was found between the type of supraspinatus pathology and factors such as gender (female more prone) (X2 = 34.719, df = 3, P = .01), presence of down slopping (X2 = 57.765, df = 3, P = .01), history of shoulder dislocation (X2 = 148.880, df = 3, P = .001), type III of the acromion (X2 = 12.979, df = 3, P = .005), presence of acromioclavicular generative changes mild (X2 = 76.408, df = 3, P = .001) and moderate (X2 = 29.697, df = 3, P = .001), and acromiohumeral distance of ≤3 mm (X2 = 18.915, df = 3, P = .001), 3.1 to 6 mm (X2 = 13.212, df = 3, P = .004), and 9.1-12 mm (X2 = 15.066, df = 3, P = .002). Overall, the Magnetic Resonance Imaging results yielded high sensitivity for detecting full-thickness supraspinatus tears.Considering the findings, this study may help radiologists understand the salient risk factors and identify which factors are mainly responsible for supraspinatus tendon tears and the respective grade of tear (articular partial, bursal partial, complete, or tendinopathy).

Incidental Flexor Carpi Radialis Tendinopathy on Magnetic Resonance Imaging

Background: Wrist pain is often nonspecific. Magnetic resonance imaging (MRI) is regularly obtained to evaluate wrist pain. Variations and pathophysiology identified on MRI may not account for patient's clinical symptoms. This study aims to quantify the prevalence of flexor carpi radialis (FCR) tendinopathy on MRI and the coexistence of trapeziometacarpal (TMC) or scaphotrapeziotrapezoid (STT) osteoarthritis. Methods: Using an institutional research database, we identified 3631 adult patients who obtained an MRI of the wrist during a 15-year period. Text search in the radiology reports identified 302 patients with possible FCR signal abnormalities. After reviewing the medical records, 98 patients were identified with FCR tendinopathy. Furthermore, medical records were used to identify pain located on the volar radial part of the wrist. In the absence of a documented examination consistent with FCR tendinopathy, we considered any signal change in the FCR incidental. Results: We identified 55 patients (55%) with incidental FCR tendinopathy. In a bivariate analysis, we found FCR signal changes on the MRI were associated with older age, white race, clinically suspected FCR tendinopathy, volar-radial sided wrist pain, and TMC and STT arthritis. Using multivariable logistic regression to account for confounding, older age and volar-radial sided wrist pain were independently associated with FCR signal changes on MRI. Conclusions: Signal changes in the FCR are infrequent and often incidental (asymptomatic) or associated with peritrapezial osteoarthritis.

The Prevalence of Triangular Fibrocartilage Complex Signal Abnormalities on Magnetic Resonance Imaging Relative to Clinical Suspicion of Pathology

PURPOSE

To determine the prevalence of triangular fibrocartilage complex (TFCC) signal changes in patients undergoing magnetic resonance imaging (MRI) of the wrist and its relationship to a clinical suspicion of TFCC pathology. The secondary purpose was to study factors that are associated with TFCC signal changes.

METHODS

In this retrospective study, we looked for any TFCC signal changes in the reports of MRI findings performed during a 3-year period in 1,134 patients. Demographic characteristics, the categorized indications for MRI, and symptoms at the time of the MRI were also retrieved from the medical records. Patients were divided into 6 groups, based on age, to calculate the proportions of TFCC signal changes in the entire cohort and as an incidental finding among patients without a clinical suspicion of TFCC pathology within each age group.

RESULTS

A total of 321 patients (28%) had incidental TFCC signal changes. The prevalence among 18- to 30 year-olds was 19%, and increased to 64% in patients older than 70 years. Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with having TFCC signal changes on MRI in patients who have a low clinical suspicion of TFCC pathology. The rate of incidental TFCC signal changes steadily increases with age.

CONCLUSIONS

The TFCC signal abnormalities on MRI are more common with increasing age in patients with low clinical suspicion of TFCC pathology. At age 70, more than half of all patients will have TFCC signal changes, and more than 90% are present in patients with a low clinical suspicion of TFCC pathology.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Incidental signal changes in the extensor carpi ulnaris on MRI

BACKGROUND

Magnetic resonance imaging (MRI) commonly finds musculoskeletal abnormalities incidental to the reason for ordering the test. The purpose of this study was to determine if the prevalence of extensor carpi ulnaris (ECU) signal changes on MRI varies between patients undergoing upper extremity MRI for assessment of clinically suspected ECU tendinopathy and those undergoing upper extremity MRI for other indications. Our secondary null hypotheses were that the prevalence of ECU signal changes on MRI does not vary based on patient age or sex and that the prevalence of ECU signal changes on MRI does not vary among other indications for MRI.

METHODS

We searched MRI reports of all patients undergoing MRI of the hand, wrist, or arm at our institution between 2001 and 2014 for signal changes in the ECU. The medical record was reviewed to determine the indication for the MRI and the presence of clinically suspected ECU tendinopathy.

RESULTS

ECU signal changes (overall prevalence of 13 %) were more common in patients undergoing MRI for a working clinical diagnosis of ECU tendinopathy or ulnar-sided wrist pain compared to patients evaluated for nonspecific pain and other indications. Age was independently associated with ECU signal changes on MRI. MRI signal changes are uncommonly associated with symptomatic tendinopathy (low positive predictive value).

CONCLUSIONS

ECU signal changes on MRI are common and often asymptomatic.

Magnetic resonance anatomy of the superior part of the rotator cuff in normal shoulders, assessment and practical implication

OBJECTIVES

The superior part of the rotator cuff consists of the anterior (SSa) and posterior (SSp) parts of the supraspinatus tendon, the infraspinatus (IS) tendon plus the articular capsule. An overlap of the distal SSp tendon by the anterior part of the IS one has been anatomically demonstrated; the insertion area of the IS is more anterior than currently believed. The aim of our study was to assess this complex architecture through standard MRI scans.

METHODS

Twenty-five healthy volunteers underwent a shoulder MRI. Three planes T2 fat saturation sequences were read in consensus by two radiologists. The SSa, the SSp, the IS tendons and the articular capsule were assessed for visibility. The patterns of demarcation of each structure from adjacent ones were assessed. The width and the thickness of each tendinous band were measured on sagittal images.

RESULTS

The SSa, the SSp and the IS tendons were distinguishable in all patients. The anterior part of the IS tendon overlapped the SSp tendon to reach a quite anterior insertion into the greater tuberosity of the humerus. The SSa, the SSp and the IS tendons were 6.5-3.4, 15.1-2.8 and 26.8-2.2 mm wide and thick, respectively.

CONCLUSION

MR images of the normal superior rotator cuff are consistent with latest anatomical descriptions. The distal superposition of the IS over the SSp tendon should be considered regarding the linear increased signal areas and the commonly named "partial thickness ruptures" of the superior rotator cuff as well as the fatty infiltration of the IS muscle.

Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered

BACKGROUND

Shoulder pain is a very common symptom. Disorders of the rotator cuff tendons due to wear or tear are among the most common causes of shoulder pain and disability. Magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and ultrasound (US) are increasingly being used to assess the presence and size of rotator cuff tears to assist in planning surgical treatment. It is not known whether one imaging method is superior to any of the others.

OBJECTIVES

To compare the diagnostic test accuracy of MRI, MRA and US for detecting any rotator cuff tears (i.e. partial or full thickness) in people with suspected rotator cuff tears for whom surgery is being considered.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, MEDLINE, EMBASE, and LILACS from inception to February 2011. We also searched trial registers, conference proceedings and reference lists of articles to identify additional studies. No language or publication restrictions were applied.

SELECTION CRITERIA

We included all prospective diagnostic accuracy studies that assessed MRI, MRA or US against arthroscopy or open surgery as the reference standard, in people suspected of having a partial or full thickness rotator cuff tear. We excluded studies that selected a healthy control group, or participants who had been previously diagnosed with other specific causes of shoulder pain such as osteoarthritis or rheumatoid arthritis. Studies with an excessively long period (a year or longer) between the index and reference tests were also excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on study characteristics and results of included studies, and performed quality assessment according to QUADAS criteria. Our unit of analysis was the shoulder. For each test, estimates of sensitivity and specificity from each study were plotted in ROC space and forest plots were constructed for visual examination of variation in test accuracy. Meta-analyses were performed using the bivariate model to produce summary estimates of sensitivity and specificity. We were unable to formally investigate potential sources of heterogeneity because of the small number of studies.

MAIN RESULTS

We included 20 studies of people with suspected rotator cuff tears (1147 shoulders), of which six evaluated MRI and US (252 shoulders), or MRA and US (127 shoulders) in the same people. Many studies had design flaws, with the potential for bias, thus limiting the reliability of their findings. Overall, the methodological quality of the studies was judged to be low or unclear. For each test, we observed considerable heterogeneity in study results, especially between studies that evaluated US for the detection of full thickness tears and studies that evaluated MRA for the detection of partial thickness tears. The criteria for a positive diagnostic test (index tests and reference standard) varied between studies.Meta-analyses were not possible for studies that assessed MRA for detection of any rotator cuff tears or partial thickness tears. We found no statistically significant differences in sensitivity or specificity between MRI and US for detecting any rotator cuff tears (P = 0.13), or for detecting partial thickness tears (P = 1.0). Similarly, for the comparison between MRI, MRA and US for detecting full thickness tears, there was no statistically significant difference in diagnostic performance (P = 0.7). For any rotator cuff tears, the summary sensitivity and specificity were 98% (95% CI 92% to 99%) and 79% (95% CI 68% to 87%) respectively for MRI (6 studies, 347 shoulders), and 91% (95% CI 83% to 95%) and 85% (95% CI 74% to 92%) respectively for US (13 studies, 854 shoulders). For full thickness tears, the summary sensitivity and specificity were 94% (95% CI 85% to 98%) and 93% (95% CI 83% to 97%) respectively for MRI (7 studies, 368 shoulders); 94% (95% CI 80% to 98%) and 92% (95% CI 83% to 97%) respectively for MRA (3 studies, 183 shoulders); and 92% (95% CI 82% to 96%) and 93% (95% CI 81% to 97%) respectively for US (10 studies, 729 shoulders).Because few studies were direct head-to-head comparisons, we could not perform meta-analyses restricted to these studies. The test comparisons for each of the three classifications of the target condition were therefore based on indirect comparisons which may be prone to bias due to confounding.

AUTHORS' CONCLUSIONS

MRI, MRA and US have good diagnostic accuracy and any of these tests could equally be used for detection of full thickness tears in people with shoulder pain for whom surgery is being considered. The diagnostic performance of MRI and US may be similar for detection of any rotator cuff tears. However, both MRI and US may have poor sensitivity for detecting partial thickness tears, and the sensitivity of US may be much lower than that of MRI. The strength of evidence for all test comparisons is limited because most studies were small, heterogeneous and methodologically flawed, and there were few comparative studies. Well designed studies that directly compare MRI, MRA and US for detection of rotator cuff tears are needed.