Shoulder Pain and Disability: Comparison with MR Findings

M u s c ul o s kel et a l I m ag i n g • O r i g i na l R e s e a rc h
Krief and
Huguet
MRI of the
Shoulder
A
C E N T U
R Y
MEDICAL
O F
IMAGING
Olivier P. Krief1
Dominique Huguet2
Krief OP, Huguet D
Shoulder Pain and Disability:
Comparison with MR Findings
OBJECTIVE. The objective of our study was to compare the level of disability induced by
shoulder pain as reported by patients on the L’Insalata Self-Administered Questionnaire (SAQ)
with shoulder MRI results.
MATERIALS AND METHODS. One thousand seventy-nine consecutive patients referred for shoulder MRI were asked to complete the L’Insalata SAQ. Results from the L’Insalata SAQ and MRI were cross-tabulated and analyzed with multivariable linear regression.
RESULTS. No statistical relationship could be found between the level of pain, impairment, and disability as reported on the L’Insalata SAQ and the location and size of full-thickness tears of the rotator cuff as observed on MRI. Pain and disability are significantly linked to
the presence of supraspinatus tendon lesions and the presence of bursitis, but these factors contribute little to the symptoms. Patients with biceps tendinopathy did not experience increased
pain when compared with patients without biceps tendinopathy or with biceps tendon rupture.
CONCLUSION. No statistical relationship was found between the level of pain and disability and the size and location of full-thickness tears of the rotator cuff.
houlder pain is one of the most common complaints in medical practice
and often leads to significant disabilities. Currently, imaging studies
are being performed for patients with longstanding shoulder pain. The clinical examination
alone has a low accuracy for the identification of
the source of pain as compared with arthroscopic
findings [1, 2] and for the assessment of the size
of rotator cuff tears [3], which is the most limiting factor for repair of full-thickness tears [4, 5].
Finding a correlation between symptoms
and images is a challenging task and is essential
to ensure that the imaging findings explain the
symptoms and can be used to adjust the therapy,
especially if the option of surgery is retained.
Previous imaging or surgical studies have
shown the high prevalence of rotator cuff tears
in an asymptomatic population [6–11]. Therefore, misuse or misinterpretation of clinical
data without imaging or of imaging without
clinical data may not lead to accurate management of patients with rotator cuff disease [6].
The purpose of our study was to compare
the level of shoulder pain and disability at rest
and in everyday activities indicated by the
L’Insalata Self-Administered Questionnaire
(SAQ) with the location and extent of rotator
cuff lesions observed on MRI.
S
Keywords: abnormalities, bursitis, MR arthrography, MRI,
musculoskeletal imaging, rotator cuff, shoulder, sports
medicine, surgery
DOI:10.2214/AJR.04.1766
Received November 14, 2004; accepted after revision
March 23, 2005.
1Service Radiologie, Polyclinique Atlantique, Rue Claude
Bernard, BP419, Saint Herblain, Cedex 44819, France.
Address correspondence to O. P. Krief ([email protected]).
2Service Orthopedie, Polyclinique Atlantique, Saint
Herblain, Cedex 44819, France.
AJR 2006; 186:1234–1239
0361–803X/06/1865–1234
© American Roentgen Ray Society
1234
Materials and Methods
Patients
One thousand seventy-nine consecutive patients
were referred for shoulder MRI between January
2003 and March 2004. Most patients had a history
of pain in the deltoid region and were referred for
MRI by sports medicine clinicians or orthopedic
surgeons after the failure of noninflammatory therapy and a rehabilitation program.
L’Insalata SAQ
On arrival at the MR unit, all patients referred
for shoulder MRI were asked to complete the L’Insalata SAQ and a consent form for the examination
and study. The L’Insalata SAQ can be used to assess
symptoms in different domains of pain, daily activities, work, satisfaction, and areas for improvement; 18 questions are scored from 1 to 5, two
questions discuss the general level of satisfaction
and areas in which the patient wishes to improve,
and the global assessment of impairment is assessed on a visual analog scale [12]. Four of the
questions refer directly to pain (pain at rest, during
activities, and at night; and the frequency of severe
pain during the previous months). The next six
questions concern the patient’s ability to perform
personal or household activities (global disability;
limitations in putting on and removing a sweater,
combing hair, reaching overhead shelves, washing
AJR:186, May 2006
MRI of the Shoulder
lower back, and lifting a bag of groceries). The next
three questions relate to recreational and athletic
activities (overall limitation, limitation in throwing
a ball, and limitations in the most regularly practiced sport). The next five questions refer to work
(work status and disability induced by the shoulder
pain or weakness, frequency of inability to work
because of shoulder pain, impairment at work
linked to shoulder pain, frequency of reduced
workday due to shoulder pain). For each patient the
total score of the 18 questions was recorded, the
mean value for each domain of pain and disability
was entered on a scale from zero to 10, and the
overall disability was evaluated on the visual analog scale from zero to 10.
The mean time for a patient to complete the SAQ
was less than 5 min and never exceeded 10 min.
When necessary, a secretary assisted a patient in
completing the SAQ and checked for omitted
fields. The results of the SAQ, age, sex, dominant
arm, occupation, worker’s compensation status,
and MRI findings were cross-tabulated for statistical analysis.
MR Protocol
Nine hundred thirty-nine examinations were
performed using an indirect arthrographic method
with an IV injection of 15 mL of gadopentetate dimeglumine (Omniscan, Amersham) 15 min before
the examination with gentle active mobilization of
the upper limb.
Direct MR arthrography was performed in 140
patients: 26 patients for suspicion of labral tear; 18
patients for postsurgical examination, five of whom
had undergone rotator cuff repair; 57 patients with a
discrepancy between the previous MR findings and
the clinical findings, 42 of whom had undergone a
previous MR examination at another institution; and
17 patients for suspicion of posterosuperior glenoid
impingement. The remainder of the MR arthrography examinations was performed due to a specific
professional or sports-related request. MR arthrography was performed with injection under fluoroscopic control of 12 mL of a gadopentetate dimeglumine preparation for intraarticular use (25 µmol/mL,
Artirem, Guerbet) mixed with 1 mL of 1% lidocaine
and iodinated contrast material.
All shoulder MR scans were obtained on a 1.5T unit (Intera, Philips Medical Systems) using a 3inch (8-cm) surface receive-only coil. Patients
were placed in a slight lateral decubitus position
with the examined shoulder and scapula horizontal on the MRI table to minimize motion artifacts
and the arm by their side in a neutral position or in
mild external rotation.
The MRI scanning protocol was identical for direct and indirect arthrography and included the following: oblique coronal, sagittal, and axial fat-sup-
AJR:186, May 2006
pressed proton density–weighted sequences (TR/TE,
1,500/25; field of view, 120 mm; 4-mm-thick slices
with 0.4-mm gap and 320 × 512 matrix; 4 excitations); and coronal and sagittal T2-weighted fast
spin-echo sequences (1,800/100; field of view, 100
mm; 4-mm-thick slices with 0.4-mm intersection gap
and 354 × 512 matrix; 4 excitations). The total scanning time was less than 15 min.
MR Analysis
All the MR examinations were prospectively analyzed by the same musculoskeletal radiologist.
The radiologist was not blinded to the L’Insalata
SAQ results. Each rotator cuff tendon was evaluated according to a grading system adapted for imaging from Ellman’s arthroscopic classification
system [13]. This classification system indicates
which surface of the tendon is involved and grades
the severity of the tear according to its depth: grade
0, homogeneous signal and regular margins of tendon; grade 1, articular or bursal surface side lesion
involving less than a quarter of the tendon thickness; grade 2, partial-thickness tear involving less
than half the thickness of the tendon; and grade 3,
partial-thickness tear involving more than one half
of the thickness of the tendon with tenuous continuity but without full-thickness tear. In the presence of a full-thickness tear with fluid signal intensity extending from the bursal to the articular side
lesion of the rotator cuff, the size of the tear was assessed in the coronal and sagittal planes except isolated full-thickness tears of the subscapularis tendon, which were measured in the coronal and axial
planes. When full-thickness tears were associated
with trophic alterations of the proximal tendon or
with having high and irregular intensity of the tendon stump, both the size of the full-thickness tear
and the size of the whole tendon with the abnormalities were measured.
The biceps tendon lesions were classified as
grade zero when the tendon had a normal shape and
signal in all planes, grade 1 when shape abnormalities or signal abnormalities without discontinuity
were present, and grade 2 when a discontinuity of
the tendon was observed.
Statistical Analysis
The statistical analysis was performed with software (version 2.03 SigmaStat, Systat Software Inc.)
using a multivariable linear regression and backward
stepwise method. The SigmaStat software allows the
use of a specific missing value code to handle the
presence of eventual missing data on an SAQ. The
dependent variable for the regression model was the
L’Insalata SAQ results, with the overall and mean
scores for each domain of pain and disability (pain,
disability in everyday life, disability in work and
sports activities) and the mean score for disability as
assessed on the visual analog scale. The independent
variables included in the model were patient age,
sex, occupation, affected shoulder side, and dominant arm side; existence of a work compensation
claim; and MR results. The MR variables included in
the model were the Ellman stage of the tendon, from
zero to 3, for each tendon of the rotator cuff; the sizes
of the full-thickness tears in the sagittal and coronal
planes; the stage, from zero to 2, of the biceps tendon; and the presence of subacromial bursitis. In
each step, the normality test was assessed and the
variable with the smallest contribution to the model
was removed as long as the p value was greater than
0.05. For each regression analysis and for each domain, the p values, the R2 and adjusted R2, the standard error of the estimate (SEE), and the residual
were reported. The power for each test was assessed
with an alpha value of 0.05.
In the first step, the statistical analysis was performed for all patients. Then, the regression analysis
was performed after having excluded patients with
previous surgery or patients with an abnormality or
disease other than rotator cuff tendinopathy that
could interfere with rotator cuff symptoms, even
when concomitant rotator cuff tendinopathy was
present (Table 1). To avoid a selection bias that could
arise from excluding patients with abnormalities or
diseases other than rotator cuff disease, the statistical
analysis was performed for both populations. Two
hundred nineteen patients were excluded from this
second statistical analysis: 13 patients with previous
subacromial decompression, five with associated
surgical repair of the rotator cuff, 31 with calcifications greater than 5 mm, 87 with clinical or MRI
findings suggestive of capsulitis (painful and re-
TABLE 1: Patients with Abnormalities
Other Than Cuff
Tendinopathy Who Were
Excluded from the Second
Regression Analysis
Exclusion Criteria
No. of
Patients
Subacromial decompression
13
Surgery
Subacromial repair
Glenohumeral chondrolysis
Glenohumeral joint instability
5
19
9
Capsulitis
87
Posttraumatic bone bruise
20
Acromioclavicular osteoarthritis
29
Calcification > 5 mm
31
Neoplastic disease
3
Humeral osteonecrosis
2
Long thoracic nerve palsy
1
1235
Krief and Huguet
stricted passive and active range of motion or capsular thickening > 5 mm with enhancement on MRI),
nine with glenohumeral instability, 29 with important signs of acromioclavicular osteoarthritis (painful joint at palpation and positive cross-arm test), 20
with posttraumatic bone bruises, 19 with chondral
glenohumeral lesions observed on MRI, three with
signs of neoplastic diseases (one case of multiple
myeloma, one metastasis, and one aneurysmal bone
cyst), two with avascular necrosis of the humeral
head, and one patient with scapular winging linked
to long thoracic nerve palsy. Patients with mild acromioclavicular osteoarthritis associated with rotator
cuff lesions were not excluded.
Results
SAQ
The mean age of the patients was 52 years
(range, 13–85 years) with a male–female ratio
of 53:47. The dominant arm for 916 (85%) of
the 1,079 patients was the right arm, 618 patients (60%) displayed pain in their dominant
arm, and 669 patients (62%) presented with
pain of the right shoulder. Two hundred ninetyeight patients (28%) were retired, and 319 patients (30%) had physical professions involving the shoulder. The average score for pain (at
rest, at night, during effort, and maximal pain
throughout the previous months) was 6.03, and
the mean level of disability observed in everyday life was 6.3. The mean level of disability in
the professional domain was 6.4. The mean
disability as reported on the visual analog scale
was 6.2 with an SD of 1.92.
MR Results
The MR results are summarized in Table 2.
In 389 patients, a normal rotator cuff was displayed on MRI, with regular smooth border
tendons and homogeneous low signal intensity on all sequences. Four hundred fifty-one
patients presented with a partial-thickness
tear, including 286 grade 1 tears on the Ellman classification system, 115 grade 2 tears,
and 50 grade 3 tears.
Two hundred thirty-nine patients displayed
full-thickness tears of the rotator cuff on MRI.
All but 17 tears involved the supraspinatus
tendon. Of those 17 remaining tears, 16 involved the subscapularis tendon and one, the
infraspinatus tendon in a patient with a history of previous calcification.
One hundred twenty patients displayed an
isolated tear of the supraspinatus tendon; 60
patients had tears involving both the supraspinatus and infraspinatus tendons; 13 patients had tears involving the supraspinatus
and subscapularis tendons; and 29 patients
had tears involving the supraspinatus, infraspinatus, and subscapularis tendons.
The mean size of the rotator cuff tear was
18 mm, with an SD of 11 mm, and the largest
tear observed measured 66 mm.
Statistical Analysis
The dependent variable could be predicted
from a linear combination of the independent
variables before and after exclusion of patients with a history of surgery or with abnor-
TABLE 2: Results Regarding Rotator Cuff Lesions on MRI
Rotator Cuff
Type of
Injury
Structures Involved in Injury
Normal
No. of
Cases
389
Injured
Partial-thickness tear Isolated
Supraspinatus tendon
8
Subscapularis tendon
23
Associated Supraspinatus and infraspinatus tendons
Supraspinatus and subscapularis tendons
Full-thickness tear
Isolated
Supraspinatus tendon
22
25
120
TABLE 3: Statistical Results for
Global Disability on
Visual Analog Scale
Infraspinatus tendon
1
Subscapularis tendon
16
Variable Statistically Linked to Global
Disability
p
60
Lesion on supraspinatus bursal side
< 0.001
Supraspinatus and subscapularis tendons
13
Lesion on supraspinatus articular side
< 0.001
Supraspinatus, infraspinatus, and subscapularis tendons
29
Bursitis
0.001
Rotator cuff tear and biceps tendinopathy
90
Patient age
0.015
Rotator cuff tear and biceps tendon rupture
41
Dominant arm
0.002
Associated Supraspinatus and infraspinatus tendons
1236
373
Infraspinatus tendon
malities or diseases other than rotator cuff
tendinopathy. The global disability was statistically linked to partial-thickness tears involving the superficial and deep surfaces of the supraspinatus tendon (p < 0.01), to the presence
of bursitis (p = 0.01), and to the age of the patient and the side of the dominant arm
(p = 0.04) (Table 3). Pain and disability in all
domains were positively correlated to age
(p = 0.01), despite lower demand with aging.
Although significant results were obtained for
the presence of supraspinatus tendon lesions
and bursitis, the contribution of these factors
to the symptoms was low, with an R2 of 0.350
and adjusted R2 of 0.337 even with a limited
number of independent variables. This means
that the contribution of the selected variables
to the model was about one third and that
there must be other factors not included in the
study that could explain the symptoms.
The global disability was not statistically
linked to any abnormality of the subscapularis
(p = 0.25) or infraspinatus (p = 0.44) tendon,
biceps tendinopathy or rupture (p = 0.5), or
patient sex or work status (p = 0.1). The presence, size, and location of full-thickness tears
of the rotator cuff did not influence the level
of disability (p = 0.1) or the level of pain
(p = 0.09). Patients with biceps tendinopathy
in the presence of a rotator cuff tear were not
associated with increased pain or disability.
Patients with a discontinuous biceps tendon
in the presence of a rotator cuff tear did not
present with a lower level of pain than patients with biceps tendinopathy without rupture. Figure 1 displays a scatterplot graph for
overall disability versus maximal size of the
rotator cuff tears, and Figure 2 shows a scatterplot graph for the results of the L’Insalata
SAQ in the pain domain (average level of pain
at rest, during effort, and at night; and maximal pain) versus maximal size of the rotator
cuff tears.
There was no statistical difference relating
to patient sex in the incidence of rotator cuff
lesions.
AJR:186, May 2006
MRI of the Shoulder
Discussion
Pain is the major complaint of patients with
rotator cuff abnormalities and a common indication for shoulder imaging. The prevalence of
shoulder pain has been reported to range from
7% to 14% of the overall population [14]. Assessing the degree of impairment related to
shoulder pain presents a challenge, particularly
among patients with chronic pain, because
shoulder pain typically fluctuates and the level
of pain at the time of the examination may dif-
fer significantly from the level of pain during
the months preceding the examination [15].
Clinical tests, such as the American Shoulder
and Elbow Surgeons score or the ConstantMurley rating scale, rely on subjective evaluation of pain and activity and objective assessment of strength and range of motion, but these
tests have poor interobserver reproducibility for
the evaluation of strength [16] and motion [2]
and, therefore, a substantial error in evaluating
disability [14, 17]. SAQs are more impairment
70
Full-Thickness Tear Size (mm)
Full-Thickness Tear Size (mm)
70
60
50
40
30
20
10
0
oriented [12, 18, 19]. They are well suited for
assessing surgical outcome because they may
be completed by mail, e-mail, or telephone.
SAQs are also well suited to clinical–radiologic
studies because completion of an SAQ is not
time consuming for the medical staff. Like the
Constant score, the L’Insalata SAQ is inappropriate in the assessment of conditions of instability of the glenohumeral joint [12, 20].
MRI is highly accurate in the diagnosis of
full-thickness tears. Recent technical improve-
0
2
4
6
8
10
60
50
40
30
20
10
0
0
2
4
Disability
Fig. 1—Scatterplot for disability as assessed on visual analog scale and maximal
rotator cuff full-thickness tear size observed on MRI confirms absence of
association between disability and size of full-thickness tear of rotator cuff.
A
8
10
Fig. 2—Scatterplot for mean pain scored on 10-point scale and maximal rotator cuff
full-thickness tear size observed on MRI, without any linear trend between size of
full-thickness tear and level of pain experienced by patients.
B
Fig. 3—Coronal fat-suppressed T2-weighted image of 62-year-old woman who experienced pain on right side 6
years earlier who presented with pain on left side. Disability for right side was scored at 2 on 10-point visual analog
scale and at 9 on left side with predominant night pain.
A and B, MR images of both shoulders were obtained on same day and disclose bilateral full-thickness tear
measuring 40 mm on right side (A) and 27 mm on left side (arrow, B) without discontinuity of long portion of biceps
tendon (displayed on other slices, not shown).
AJR:186, May 2006
6
Pain
Fig. 4—Coronal T2-weighted image of 54-year-old man
who had been experiencing shoulder pain for previous
4 months since a bicycle fall. Patient presented with
permanent pain at rest and at night affecting sleep
despite medication and scored disability assessed at 9
on 10-point visual analog scale. MRI discloses 4-mm
full-thickness tear (arrow), which was confirmed at
arthroscopy.
1237
Krief and Huguet
ments have even increased the visibility of
small tears with a level of sensitivity approaching 100% [21]. The performance of MRI for the
diagnosis of partial-thickness tear is lower. MR
arthrography with the affected shoulder in the
abducted and externally rotated (ABER) position highlights the visibility of articular side
partial-thickness tears [22], but MR arthrography is less sensitive to bursal side lesions. It is
a more time-consuming and aggressive procedure, and its cost effectiveness has not yet been
evaluated, to our knowledge. MR arthrography
is therefore not currently performed in our institution for the diagnosis of rotator cuff lesions, except for high-level athletes, patients
with glenohumeral instability, or cases for
which a discrepancy exists between nonarthrographic MR examination and clinical findings.
MR arthrography has a low sensitivity for the
diagnosis of biceps tendinopathy [23]. Results
for the present study regarding partial-thickness tears of the rotator cuff and the long head
of the biceps tendon lesions should therefore be
analyzed more cautiously than those regarding
full-thickness tears of the rotator cuff.
Our study confirms previous results regarding the discrepancy between MRI findings and symptoms related to rotator cuff disease. Our statistical analysis did not reveal
any relationships between the location or the
size of rotator cuff tears and the intensity of
pain and the level of disability perceived by
the patient. In their MRI study, Miniaci et al.
[10] found rotator cuff lesions to be present in
asymptomatic professional throwing athletes
without any decrease in the level of their performances. In their sonography studies, Milgrom et al. [8] found a prevalence of rotator
cuff tears of more than 50% in patients older
than 70 years, and Tempelhof et al. [11] found
that more than 20% of asymptomatic volunteers above the age of 80 years presented with
rotator cuff tears larger than 5 cm. Both
groups of researchers concluded that rotator
cuff lesions may be regarded as a natural correlate of aging. It is more likely to find a rotator cuff abnormality on an MR examination in
an asymptomatic elderly population than in
young patients with a painful shoulder.
It is not known what makes some tears
symptomatic and others asymptomatic [24].
Many tears do not interfere with normal function [7, 24, 25] (Fig. 3). Yamaguchi et al. [26]
did not find any relationship between the evolution of rotator cuff size and the occurrence of
symptoms in a longitudinal sonography follow-up of initially asymptomatic rotator cuff
tears. Some of the tears may even become si-
1238
lent with increasing size [26], whereas initially
silent tears may become symptomatic, which
makes the surgical decision complex [27].
Goodman et al. [6] and Sher et al. [7] concluded that the surgical decision should not
rely only on imaging. The age of the patient is
thus an essential element in the therapeutic decision: Orthopedic surgeons suggest repairing
the rotator cuff in young patients even when
the level of disability remains moderate because of their unpredictable evolution.
From a fluoroscopic study, Burkhart [25]
states that normal function is possible as long
as the posterior aspect of the rotator cuff is preserved to such a degree that the force couple in
the transverse plane is maintained. A rindlike
margin resistant to tearing limits the extension
of the tear and acts as a suspension bridge,
thereby limiting its biomechanical consequences. Burkhart’s theory thus assumes that
there is a threshold effect, with small painless
lesions, and that pain and disability appear
only once the rotator cable has been ruptured.
Burkhart’s theory could explain why some
full-thickness tears may present with a negative Jobe test, but we did not find any threshold
effect for symptoms relating to the tear size.
Some small rim-rent tears may be painful,
whereas some large tears, completely painless
and even compatible with normal and painless
functional activity (Fig. 4). In a review of 80
patient files, Patte and Goutallier [28] found
that anterior rotator cuff lesions were more frequently revealed by pain and posterior rotator
cuff lesions, by weakness. We did not find any
relationship between the type of symptom and
the location of rotator cuff lesions as observed
on MRI. Patients with full-thickness tears involving the infraspinatus tendon did not display any increased disability compared with
patients with full-thickness tears sparing the
infraspinatus tendon.
Several factors other than rotator cuff lesions may be involved in shoulder pain and
disability. Bursitis is frequently associated
with rotator cuff lesions, and we found a significant increase in shoulder pain and perception of disability with patients who presented
with bursitis. Pain may also be related to the
presence of labral capsular ligamentous complex or cartilaginous lesions. Labral lesions
are often secondary to glenohumeral joint instability [29], but may be also age-dependant
degenerative lesions in conjunction with glenohumeral chondropathy [30]. Cartilage lesions have been reported to be present on arthroscopy in up to 29% of patients referred for
subacromial impingement, and these lesions
are underestimated on MRI [31]. Occult labral or cartilage lesions could partially explain the discrepancy between pain and disability and the importance of rotator cuff
lesions observed in our study. Lastly, there
may simply be no relationship between rotator cuff tear size and the inflammatory reaction responsible for the pain and the disability,
like lower back pain intensity is unrelated to
the size of disk herniations. This could explain the fluctuant character of shoulder disability due to incremental progression of cuff
tears, with possible increasing tear size while
the pain may regress.
These results raise the problem of the place
for imaging in the management of rotator cuff
lesions. Because there is no clear relationship
between symptoms and lesions, some surgical
teams suggest that presurgical imaging may
not in any way affect the management of rotator cuff lesions [32]. However, preoperative
knowledge of the size and shape of the fullthickness rotator cuff tear is important for patient counseling because tear size affects the
choice of surgery and its functional outcome
[4, 5, 33] and it is not possible to assess the size
and the precise position of the ends of the remaining tendons on the basis of the clinical examination [3]. Moreover, fatty degeneration of
the muscles of the rotator cuff assessed on MRI
may not be depicted on clinical examination
and may not be reversed by surgery regardless
of the tear size. Imaging should therefore be included in the preoperative assessment.
Our study has several limitations. There is
a selection bias for patients referred for shoulder MRI. Neither patients who respond favorably to nonoperative therapy nor those with
straightforward clinical diagnosis of very
large tears obviating MRI or with decreased
acromiohumeral distance in the case of large
tears are usually referred for MRI and, therefore, are not candidates for surgical repair of
the rotator cuff. Moreover, the time lapse between the onset of symptoms and the MRI examination depended on the appointment delay for MRI, which is approximately 4–6
weeks in our unit. Any change in the length of
this delay would certainly affect the results of
the SAQ at the time of the examination.
Therefore, the results of the L’Insalata SAQ
and the comparison between symptoms and
images could not fit the overall population.
Another limitation is the absence of a gold
standard for the results of the MRI examinations; however, to avoid selection bias, we did
not include the surgical results even for the
patients who did benefit from a surgical pro-
AJR:186, May 2006
MRI of the Shoulder
gram. Finally, we did not include the glenoid
labral lesions as a variable in our statistical
analysis because the different clinical tests
and L’Insalata SAQ are inappropriate for the
assessment of disability linked to glenohumeral joint instability, and only a few of our
patients underwent MR arthrography.
In conclusion, the level of disability is significantly linked to the presence of supraspinatus tendon lesions or bursitis, but the
contribution of these factors to the presence of
symptoms remains low. There is no clear statistical relationship between the level of pain
and disability and the location and extent of
full-thickness tears of the rotator cuff as observed on MRI. This discrepancy could be related to the secondary inflammatory reaction,
which may not be proportional to the size of
the rotator cuff lesions, thus explaining the
fluctuant character of pain and disability. Despite the absence of correlation between the
size of the rotator cuff tears and the level of
disability, MRI provides important data that
may affect the management of rotator cuff lesions and should be performed before rehabilitation or surgery.
References
1. Naredo E, Aguado P, De Miguel E, et al. Painful
shoulder: comparison of physical examination and
ultrasonographic findings. Ann Rheum Dis 2002;
61:132–136
2. Nørregaard J, Krosgsgaard M, Lorenzen T, Jensen
E. Diagnosing patients with longstanding shoulder
joint pain. Ann Rheum Dis 2002; 61:646–649
3. Hawkins RJ, Misamore GW, Hobeika PE. Surgery
for full-thickness rotator-cuff tears. J Bone Joint
Surg Am 1985; 67A:1349–1355
4. Ellman H, Hanker G, Bayer M. Repair of the cuff:
end-result study of factors influencing reconstruction. J Bone Joint Surg Am 1986; 68A:1136–1144
5. Bartolozzi A, Andreychik D, Ahmad S. Determinant of outcome in the treatment of rotator cuff disease. Clin Orthop 1994; 308:90–97
6. Goodman R, Sher J, Uribe J, Posada A, Murphy B,
Zlatkin M. Correspondence. J Bone Joint Surg Am
1996; 78A:633
AJR:186, May 2006
7. Sher J, Uribe J, Posada A, Murphy B, Zlatkin M.
Abnormal findings on MRI of asymptomatic shoulders. J Bone Joint Surg Am 1995; 77A:10–15
8. Milgrom C, Schaffler M, Gilbert S, Hoslberg M.
Rotator changes in asymptomatic adults. J Bone
Joint Surg Br 1995; 77B:296–298
9. Needell SD, Zlatkin MB, Sher JS, Murphy BJ,
Uribe JW. MRI of the rotator cuff: peritendinous
and bone abnormalities in an asymptomatic population. AJR 1996; 166:863–867
10. Miniaci A, Mascia A, Salonen D, Becker E. MRI of
the shoulder in asymptomatic professional baseball
pitchers. Am J Sports Med 2002; 30:66–73
11. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999; 8:296–299
12. L’Insalata J, Warren R, Cohen S, Altchek D, Peterson M. A self-administered questionnaire for assessment of symptoms and function of the shoulder.
J Bone Joint Surg Br 1997; 79B:738–748
13. Ellman H. Diagnosis and treatment of incomplete
rotator cuff tears. Clin Orthop 1990; 254:64–74
14. Bergenudd H, Lindgärde F, Nilsson B, Petersson
CJ. Shoulder pain in middle age: a study of prevalence and relation to occupational work load and
psychosocial factors. Clin Orthop Relat Res 1988;
231:234–238
15. Norwood L, Barrack R, Jacobson K. Clinical presentation of complete tears of the rotator cuff. J
Bone Joint Surg Am 1989; 71A:499–505
16. Sapega A. Muscle performance evaluation in orthopedic practice. J Bone Joint Surg Am 1990;
72A:1562–1574
17. Sagihara T, Nakagawa T, Tsuchiya M, Ishizuki M.
Prediction of primary reparability of massive tears
on preoperative MRI. J Shoulder Elbow Surg 2003;
12:222–225
18. Beaton D, Richards R. Measuring function of the
shoulder: a cross-sectional comparison of five questionnaires. J Bone Joint Surg Am 1996; 78A:882–890
19. Dawson J, Fitzpatrick R, Carr A. Questionnaires on
the perceptions of patients about shoulder surgery.
J Bone Joint Surg Br 1996; 78B:593–600
20. Constant C, Murley A. A clinical method of functional assessment of the shoulder. Clin Orthop
1987; 214:160–164
21. Mahtadi N, Vellet D, Clark M, et al. A prospective
double-blind comparison of MRI and arthroscopy
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
in the evaluation of patients presenting with shoulder pain. J Shoulder Elbow Surg 2004; 13:258–265
Lee S, Lee J. Horizontal component of partial-thickness tears of rotator cuff: imaging characteristics
and comparison of ABER view with oblique coronal view at MR arthrography—initial results. Radiology 2002; 224:470–476
Zanetti M, Weishaupt D, Gerber C, Hodler J. Tendinopathy and rupture of the long head of the biceps
brachii muscle: evaluation with MR arthrography.
AJR 1998; 170:1557–1561
Yamaguchi K, Sher J, Andersen W, et al. Glenohumeral motion in patients with rotator cuff tears:
a comparison of asymptomatic and symptomatic
shoulders. J Shoulder Elbow Surg 2000; 9:6–11
Burkhart D. Fluoroscopic comparison of kinematics patterns in massive rotator cuff tears. Clin Orthop 1992; 284:144–152
Yamaguchi K, Tetro M, Blam O, Evanoff B,
Teefey S, Middleton W. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of
asymptomatic tears detected sonographically. J
Shoulder Elbow Surg 2001; 10:199–203
Williams G, Rockwood C, Bigliani L, Ianotti J,
Stanwood W. Rotator cuff tears: why do we repair
them? J Bone Joint Surg Am 2004; 86A:2764–2776
Patte D, Goutallier D. Reflexions sur le traitement
chirurgical de la coiffe des rotateurs. Cahiers de la
Sofcot 1988; 33:113–122
Palmer WE, Brown JH, Rosenthal DI. Labral ligamentous complex of the shoulder: evaluation with
MR arthrography. Radiology 1994; 190:645–651
De Palma AF, Gallery G, Bennett GA. Variational
anatomy and degenerative lesions of the shoulder
joint. In: Edwards JW, ed. Instructional course lectures: The American Academy of Orthopedic Surgery, vol. 6. St. Louis, MO: Mosby, 1949:225–281
Guntern D, Pfirrmann C, Schmid M, et al. Articular
cartilage lesions of the gleno-humeral joint: diagnostic effectiveness of MR arthrography and prevalence in patients with subacromial impingement
syndrome. Radiology 2003; 226:165–170
Budoff JE, Nirschl RP, Guidi EJ. Débridement of partial-thickness tears of the rotator cuff without acromioplasty: long-term follow-up and review of the literature. J Bone Joint Surg Am 1998; 80A:733–748
Watson E, Sonnabend D. Outcome of rotator cuff
repair. J Shoulder Elbow Surg 2002; 11:201–211
1239