What is the best way to diagnose a suspected rotator cuff tear?

* Evidence summary

Rotator slap tears can cause shoulder pain, decreased force and decreased range of motion. Clinical findings associated with a rotator stroke injury can vary. Full-thickness and partial-thickness tears may at hand differently, and it is important to proof clinically for both of these conditions.

A meta-analysis of 10 cohort studies lay the foundation of the overall sensitivity and specificity of a clinical exam to empire out a full-thickness rotator blow tear to be 0.9 (95% confidence interval [CI], 087-093) and 054 (95% CI, 047-061) (1) However, no single physical exam finding provided comparable accuracy. Another prospective inquiry of 400 patients comparing 23 different clinical exams rest that 3 simple clinical tests-supraspinatus weakness, weakness in external rotation, and the vicinity of impingement--were highly predictive of rotator slap tear. When all 3 trials were positive, or when 2 ordeals were positive for a patient aged >60 years, there was a 98% chance of the patient having a rotator stroke tear. (2)

Ultrasound can be used to evaluate the two suspected full- and partial-thickness rotator blow tears. In a systematic review of 38 cohort studies, the overall sensitivity and specificity of ultrasound for full-thickness rotator slap tears was 0.87 (95% CI, 084-089) and 096 (95% CI, 094-097) (1) For partial-thickness tears, ultrasound sensitivity was 067 (95% CI, 061-073) (1) The incidence of rotator stroke tears increases with age and with athletic activity. (5)

Positive and negative predictive values of a experiment depend on the prevalence of the condition in the application of mind population. In the case of rotator box tears, such differences in prevalence of rotator box tears in the 38 cohort studies left it unclear whether a negative ultrasound could reliably government out a tear.

A meta-analysis of 29 cohort studies of MRI for the diagnosis of full-thickness tears base a pooled sensitivity of 089 (95% CI, 086-092) and a pond ed specificity of 0.93 (95% CI, 091-095) respectively. (1) For partial-thickness tears, the pond ed MRI sensitivity was lower at 044 (95% CI, 036-051) on the contrary with a high specificity of 090 (95% CI, 087-092) (1) This implies that MRI is the greatest in quantity valuable test to rule without a partial-thickness tear. However, we place no studies that directly compared the experiment characteristics of ultrasound and MRI.

Conventional arthrography can be used as an invasive alternative to MRI imaging for full-thickness tears, particularly when an implanted device obviates the use of MRI. individual prospective trial (in which patients were randomized to the order in which MRI or arthrography were performed) of 38 patients showed arthrography to have a sensitivity of 050 and a specificity of 096 when used to diagnose full-thickness tears. (36)

Magnetic resonance arthrography (MRA), based upon 6 cohort studies, may be accurate in the diagnosis of a full-thickness tear, with a sensitivity of 095 (95% CI, 082-098) and specificity of 093 (95% CI, 084-097) (1) In these studies, diagnosis of partial-thickness tears with MRA was inconsistent. (1) The invasiveness of MRA limits its utility as compared with MRI and ultrasound. The TABLE summarizes these findings.

Recommendations from others

The American Academy of Orthopaedic Surgeon has a clinical guideline upon shoulder pain, (4) and the Brigham and Women's Hospital has a guide to the prevention, diagnosis and treatment of upper extremity musculoskeletal disorders. (5) These guidelines emphasize the importance and utility of physical examination of the shoulder. A patient with a full-thickness tear will likely demonstrate compromised vigor in shoulder active mid-arc abduction and resisted external rotation with flexure flexed at patient's side. However, a partial tear might not compromise vigor Atrophy of the infraspinatus or supra-spinatus muscles is sometimes seen with a full-thickness tear that is several weeks elderly (5)

Following a clinical assessment, the guidelines give no estimation to any of the diagnostic ordeals mentioned above, with the exception of arthrography in the nearness of implantable devices. Plain X-rays are typically unrevealing, on the other hand could be used to sway out other reasons for pain, of that kind as calcific tendonitis.

EVIDENCE-BASED ANSWER

The evaluation of a suspected rotator blow tear should start with a history and a clinical exam of the shoulder (strength of recommendation [SOR]: B based upon a systematic review of cohort studies). (1) Three clinical trial results in particular--supraspinatus weakness, weakness of external rotation, and impingement--or 2 positive proofs for a patient older than 60 years were highly predictive of rotator slap tear (SOR: B, based upon individual prospective study). (2)

Either magnetic resonance imaging (MRI) or ultrasound can confirm a possible full-thickness tear (SOR: B based upon a systematic review of cohort studies). (1) If a patient has an implantable device prohibiting MRI imaging, conventional arthrography is an alternative (SOR: A, individual randomized controll trial). (3) Suspected partial-thickness tears are best verified with an ultrasound (SOR: B based upon a systematic review of cohort studies). (1)