










































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW 

 

12 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020 

 
 

Diagnostic Accuracy of Imaging Techniques for Rotator Cuff 
Pathology: An Evidence-to-Practice Review 
Hayley O’Connell, SCAT, ATC; Brittany deCamp, SCAT, ATC; and Zachary Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 
  

 
ABSTRACT 

When comparing imaging techniques for rotator cuff 
pathologies, clinicians tend to consider musculoskeletal 
ultrasonography (MSK US), magnetic renaissance imaging 
(MRI), and magnetic renaissance imaging with arthrogram 
(MRA) as diagnostic imaging techniques. Since the most recent 
systematic review on imaging conducted in 2003, imaging 
technology has improved, indicating the need for a meta-
analysis to evaluate the accuracy of new diagnostic 
techniques (MSK US) for evaluating rotator cuff pathologies. 
The accuracy of MSK US readings between radiologists and 
non-radiologists was also analyzed. Data were extracted 
from three different databases and included articles 
exploring diagnostic imaging and the accuracy of technique 
at the shoulder joint. All research findings were then rated for 
any risk of bias using the revised version of the quality 
assessment of diagnostic accuracy studies (QUADAS-2). 
Statistically, the authors used hierarchical summary receiver-
operating characteristics to compare accuracy of diagnostic 
imaging techniques across the literature. The results from the 
guiding manuscript indicated that MSK US, MRI, and MRA 
were considered highly sensitive diagnostic imaging 
techniques for full-thickness rotator cuff tears (Sn: US: 0.86-
0.94, MRI: 0.85-0.95, MRA: 0.83-0.95). For partial-thickness 
rotator cuff tears, likelihood ratios indicated an increased 
accuracy in MRA diagnostic ability (Sn: MRA: 0.83), though 
MSK US and MRI were still considered highly sensitive for 
diagnosing partial-thickness rotator cuff tears (Sn: MSK US: 
0.68, MRI: 0.67). When comparing radiologists and non-
radiologists use of MSK US, there was no significant 
difference in diagnostic accuracy based on the reading 
provider. As the diagnosis based on imaging determines the 
need for surgical intervention, the guiding review indicated 
that all three diagnostic tools  (MSK US, MRI and MRA) were 
considered highly sensitive for rotator cuff pathologies 
(average SN of all diagnostic tools: 0.90-0.91). Determining 
which imaging technique to use should be based on patient-
centered factors, such as possibility of the presence of other 
shoulder pathology, invasiveness of the procedure, and 
financial implications. Diagnostic MSK US optimizes these 
factors, in addition to being highly sensitive.   
 
Key Phrases 
Diagnostic testing and physical examination: upper 
extremity; college and university patient population, clinic 
and hospital patient population  
 
 

Correspondence 
Dr. Zachary Winkelmann, University of South Carolina 
1300 Wheat Street, Columbia, SC 29208.  
E-mail: winkelz@mailbox.sc.edu  
Twitter: @zachwinkelmann 
 
Full Citation 
O’Connell H, deCamp B, Winkelmann ZK. Diagnostic 
accuracy of imaging techniques for rotator cuff pathology: 
an evidence-to-practice review. Clin Pract Athl Train. 
2020;3(3):12-17. 
https://doi.org/10.31622/2020/000.3.3.       
 
Submitted: April 20, 2020 Accepted: August 17, 2020 

 

ORIGINAL REFERENCE  

Roy JS, Braen C, Leblond J, et al. Diagnostic 
accuracy of ultrasonography, MRI, and MR 
arthrography in the characterization of rotator cuff 
disorders: a systematic review and meta-analysis. Br 
J Sports Med. 2015;49(20):1316-1328  

SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 

Shoulder pathologies affect much of the general 

population and most commonly are a result of 
injury to the rotator cuff tendons.1 The rotator cuff 
is the group of muscles (supraspinatus, 
infraspinatus, teres minor and subscapularis) that 
are primarily responsible for external and 
internal rotation of the shoulder along with 
assisting in stabilizing the glenohumeral joint 
during a majority of all other shoulder movements. 
and in stabilizing the glenohumeral joint. 
Conditions of the rotator cuff often constitute 
rotator cuff tendinopathies, partial thickness 
rotator cuff tears, and full thickness rotator cuff 
tears.2 Without treatment, such as therapeutic 
rehabilitation or surgical intervention, patients 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2020/000.3.3


Diagnostic Accuracy of Imaging Techniques for Rotator Cuff Pathology: An Evidence-to-Practice Review 
 

 

13 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020 
 

suffering from a rotator cuff pathology may 
experience lifelong pain and significant functional 
limitations.2 Surgical intervention is often indicated 
and time-sensitive for individuals with full thickness 
rotator cuff tears, so an accurate diagnosis is 
critical.3 The three diagnostic imaging techniques 
tools to determine the degree of injury and guide 
treatment are musculoskeletal ultrasonography 
(MSK US), magnetic resonance imaging (MRI) and 
magnetic resonance arthrography (MRA). 
Musculoskeletal ultrasound (often referred to as 
diagnostic ultrasound) is the use of a sound wave 
through a transducer to visualize the structures 
below. The MRI and MRA are both operated by 
using a high-powered magnet within the machine 
to formulate an image to be interpreted by a 
radiologist. The sole difference between MRI and 
MRA is the joint being evaluated is injected with 
medical dye  before an MRA scan to help define 
the structures of concern.1 Since each diagnostic 
imaging technique’s last systematic review (2010-
2015) of diagnostic accuracy, new research and 
advanced technology have emerged including a 
more widespread use (+347% between 2003-
2015) of musculoskeletal ultrasonography non-
radiologists (radiology us decreased by 28% 
from 2003-2015).4,5  In sports medicine cases, a 
re-evaluation of the diagnostic imaging 
techniques is warranted. A new statistical 
measure, the hierarchical summary receiver-
operating characteristic (HSROC), has been 
validated for diagnostic accuracy and guides the 
study recommendations for utilization of MSK US, 
MRI and MRAl.  HSROC allows researchers to take 
into account within and between study variability 
and better differentiates different thresholds of 
study results.6-8 The purpose of the guiding 
systematic review study was to evaluate the 
diagnostic accuracy of MSK US, MRI, and MRA for 
rotator cuff pathologies. The secondary aim was 
to determine the accuracy of improved technology 
in diagnosing rotator cuff tears and to assess the 
use of MSK US when utilized by radiologists as 
compared to non-radiologists. Understanding the 
diagnostic accuracy of MSK US, MRI and MRA is 

important to better guide intervention strategies, 
especially in regard to making surgical 
recommendations, in addition to the benefits 
regarding patient-centered care (i.e. less cost, 
time, and a less invasive of the procedure). 

SUMMARY OF LITERATURE  

The guiding systematic review and meta-analysis 
authors used Medline, EMBASE and CINAHL in 
their search for articles published before 2014. 
Articles were included if they 1) included adults 
participants with shoulder pain, 2) utilized MSK 
US, MRI, and/or MRA as a diagnostic tool and 
surgery as a reference standard, and 3) reported 
on the diagnostic accuracy of the imaging 
techniques in diagnosing a rotator cuff 
pathology.4 The search of the databases revealed 
264 studies that met criteria for a full review. 
Studies were excluded due to incomplete data, 
small population size, and the use of a different 
index/diagnostic test.  After study exclusion 
based on two evaluator analyses, 82 studies were 
included in the meta-analysis. Of these, 47 articles 
included MSK US studies, 29 articles were 
included for MRI, and 21 articles were included 
for MRA. These articles were then analyzed for 
bias using the Quality Assessment Tool for 
Diagnostic Accuracy Studies (QUADAS-2) 
assessing  four main components of bias including 
patient selection bias, the diagnostic test utilized, 
the reference standard (surgery), and flow and 
timing in regard to patient retention and speed of 
intervention.9 Of the studies included, most had a 
high risk of bias in 3 of the 4 QUADAS-2 
categories.9 As the reference standard is an 
invasive procedure (surgery), researchers noted 
that some bias could not be avoided, particularly 
in participant selection.  

SUMMARY OF OUTCOMES  

Data was extracted based on participant 
characteristics, index test, diagnostic accuracy 
(sensitivity and specificity) and based on the 
reference standard. The researchers of the 



Diagnostic Accuracy of Imaging Techniques for Rotator Cuff Pathology: An Evidence-to-Practice Review 
 

 

14 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020 
 

guiding systematic review utilized the HSROC to 
evaluate the diagnostic accuracy of the three 
different diagnostic imaging techniques with a 
specific focus on test settings and technology. The 
HSROC is a statistical measure used to determine 
the overall sensitivity and specificity of diagnostic 
testing.6 This statistical measure was utilized as it 
considers between-study and within-study 
variability and ultimately provides a receiver 
operating curve, graphing specificity over 
sensitivity to indicate the tool’s accuracy.9 In 
addition to analyzing diagnostic accuracy, this 
measure was also used to compare MRI magnet 
strength and MSK US transducer frequency levels 
to guide the best practice use of these tools.  
Accuracy of radiologist and non-radiologist use of 
the MSK US was also calculated. Results were 
deemed clinically important only if variation was 
beyond the error associated with the accuracy 
scores. This, along with the analysis of bias through 
the QUADAS-2 were combined and used to 
formulate diagnostic tool recommendations.  

FINDINGS AND CLINICAL IMPLICATIONS 

The guiding systematic review and meta-analysis 
suggests that there are no significant differences 
between the accuracy of the three diagnostic 
imaging techniques based on their specificity and 
sensitivity found using the HSROC statistics.8 
Diagnostic imaging techniques were assessed for 
accuracy diagnosing rotator cuff tendinopathy 
(Figure 1), rotator cuff partial-thickness tears 
(Figure 2), and full-thickness rotator cuff tears 
(Figure 3). The HSROC indicated that MSK US had 
an overall sensitivity of 0.79 (95% confidence 
interval [CI] = 0.63 - 0.91) and specificity of 0.94 
(95% CI = 0.86 - 0.99). For partial-thickness 
tears, the literature indicated a sensitivity of 0.68 
(95% CI = 0.54 - 0.83) and specificity of 0.94 
(95% CI = 0.90 - 0.97) while full-thickness rotator 
cuff tears, sensitivity was 0.91 (95% CI = 0.86 -  
0.94) and specificity was 0.93 (95% CI 0.91 -
0.96). For most of these findings, the sensitivity 
and specificity for MSK US were considered high 

enough to rule in and/or out suspected rotator cuff 
pathologies. In addition to assessing the accuracy 
of the diagnostic test, information was extracted 
that indicated the qualifications of radiologists or 
non-radiologist healthcare personnel in reading 
the MSK US, and their ability to accurately 
diagnose a rotator cuff pathology using this 
diagnostic tool. With the reference standard 
being surgical diagnosis of pathology for all 
conditions, they found no significant difference 
(Radiologist - Sn: 0.89, Sp: 0.85; Sonographers & 
Orthopaedists – Sn: 0.88, Sp: 0.89)  in accuracy 
of the reading provider. While this finding 
supports the use of MSK US without preference of 
the individual reading the images, the authors 
noted that all non-radiologists were specifically 
trained in the use of diagnostic ultrasound, which 
could explain the consistencies in imaging 
interpretations, even when considering alterations 
in MSK US transducer frequency. Transducer 
frequency in diagnostic MSK US on average 
ranges from 5MHz to 20MHz, with the most 
widely accepted use being set for 7.5MHz. The  
guiding manuscript indicated that there are no 
improvements in image quality at transducer 
frequencies above or below the generally 
accepted 7.5 MHz.8 

The findings also indicated that MRI is a highly 
specific tool. For partial-thickness rotator cuff 
tears, MRI has a sensitivity of 0.67 (95% CI = 
0.50 - 0.82) and a specificity of 0.94 (95% CI 
0.88 - 0.99). For full-thickness tears in the rotator 
cuff, MRI was found to have an overall sensitivity 
of 0.90 (95% CI = 0.85 - 0.95) and specificity of 
0.93 (95% CI = 0.89 - 0.97). There was minimal 
variation in the sensitivity and specificity numbers 
between MRI and MSK US. For MRI,  



Diagnostic Accuracy of Imaging Techniques for Rotator Cuff Pathology: An Evidence-to-Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020 
 

  RC – Rotator Cuff 



Diagnostic Accuracy of Imaging Techniques for Rotator Cuff Pathology: An Evidence-to-Practice Review 
 

 

16 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020 
 

though not statistically significant, data did reveal 
an advantage in image quality when using a 3.0T 
MRI when compared to a 1.5T machine. Finally, 
the sensitivity and specificity did not significantly 
vary between the results for full-thickness tears 
and partial-thickness rotator cuff tears for MRA. 
The literature did indicate that likelihood ratios 
supported the use of MRA in diagnosing partial-
thickness tears when compared to MSK US and 
MRI.8  

The limitation in this analysis was that the accuracy 
of MSK US as a diagnostic tool may be inflated. 
When the QUADAS-2 assessment was used, 
researchers believed there was bias that led to an 
increased likelihood of rotator cuff pathologies. 
This further resulted in an increased likelihood of 
findings through imaging. This review is also 
limited by the incomplete patient profiles 
reported resulting in incomplete data reporting. 
When exploring HSROC curves assessing 
diagnostic imaging techniques tools for their 
accuracy, it is evident that there is no significant 
difference between MSK US, MRI, and MRA. Each 
graph’s curve was similar and had statistically 
significant numbers to help substantiate the 
accuracy of each tool. The only reason that MRI or 
MRA would be indicated over MSK US would be 
if there is an additional structure injured that may 
be contributing to the signs and symptoms the 
patient is presenting with. Additionally, insurance 
and instrument availability of diagnostic imagery 
may play a role in diagnostic image used though 
not considered by this review.   

CLINICAL BOTTOM LINE 

Patients who participate in sport and physical 
activity experience various pathologies including 
rotator cuff injuries. The sports medicine team is 
tasked with accurately advising their patients in 
the proper management of these shoulder injuries. 
For rotator cuff pathologies, it is imperative that 
full-thickness rotator cuff tears are diagnosed 
quickly and accurately as research indicates 

surgical intervention yields the best outcome for 
patients and athlete to return to play.3 MSK US, 
MRI and MRA are the most commonly used 
diagnostic imaging tools for diagnosing rotator 
cuff pathology. The guiding manuscript indicates 
that there is no statistical difference between the 
ability of MSK US, MRI and MRA to diagnose 
rotator cuff pathology in individuals presenting 
with a possible rotator cuff pathology when 
performed and read by trained individuals.8 
There is some evidence indicating that MRA has a 
slightly increased ability to detect partial-
thickness rotator cuff tears, though this finding is 
not considered to be statistically significant.8 MRI 
and MRA are not cost or time effective due to their 
need for additional insurance authorization and 
appointments since imaging machines need to be 
reserved ahead of time. MSK US is recommended 
as an immediate screening tool, prior to ordering 
further imaging. 

In the athletic population, there is an abundance 
of overuse shoulder pathology, especially in 
overhead sports such as baseball, softball, tennis 
and throwing events in track and field.10 Rotator 
cuff pathology can be managed through intensive 
therapeutic rehabilitation and modification of 
activities, though concern for worse injury is often 
present. Musculoskeletal ultrasound provides a 
cost effective, timely and reliable means of 
preliminarily evaluating a patient to assess the 
degree of injury and determine if surgery is 
warranted. Currently, MSK US can be performed 
by physician’s trained in its uses and in the 
identification of musculoskeletal pathology or by 
an athletic trainer who has been trained and has 
the approval from their supervising physician. 
Further research is warranted to examine the cost 
benefit of an MSK US machine when portability 
and integration with various technological 
interfaces are considered. As the athletic training 
profession advances, all athletic trainers should be 
encouraged to take advantage of MSK training 
options. The use of MSK US in the athletic training 
facility can decrease the need for referral to an 



Diagnostic Accuracy of Imaging Techniques for Rotator Cuff Pathology: An Evidence-to-Practice Review 
 

 

17 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020 
 

orthopedic physician as identification of a 
tendinopathy vs. a tear in the shoulder and other 
joint pathologies would be possible, ultimately 
decreasing cost and time for the patient. For the 
athletic trainer, MSK US machines are on average 
MSK US is recommended when rotator cuff 
pathology is suspected, but considerations should 
be made specific to the individual. Orthopedic 
evaluation should precede the use of MSK US as 
other pathologies may be present and not found 
upon evaluation with this diagnostic imaging 
technique. 

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https://doi.org/10.1249/JSR.0000000000000361

