Diagnostic Test Accuracy Review

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

  1. Mário Lenza1,*,
  2. Rachelle Buchbinder2,
  3. Yemisi Takwoingi3,
  4. Renea V Johnston2,
  5. Nigel CA Hanchard4,
  6. Flávio Faloppa5

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 24 SEP 2013

Assessed as up-to-date: 22 AUG 2011

DOI: 10.1002/14651858.CD009020.pub2


How to Cite

Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009020. DOI: 10.1002/14651858.CD009020.pub2.

Author Information

  1. 1

    Hospital Israelita Albert Einstein, Orthopaedic and Trauma Department, São Paulo, Sao Paulo, Brazil

  2. 2

    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia

  3. 3

    University of Birmingham, Public Health, Epidemiology and Biostatistics, Birmingham, UK

  4. 4

    Teesside University, Health and Social Care Institute, Middlesbrough, Tees Valley, UK

  5. 5

    Universidade Federal de São Paulo, Department of Orthopaedics and Traumatology, São Paulo, São Paulo, Brazil

*Mário Lenza, Orthopaedic and Trauma Department, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, São Paulo, Sao Paulo, CEP 05651-901, Brazil. mariolenza@yahoo.com.br. mario.lenza@einstein.br.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 24 SEP 2013

SEARCH

 
Characteristics of included studies [ordered by study ID]
De Candia 2002

Clinical features and settingsInclusion criteria: Participants with clinical suspicion of rotator cuff tear who underwent surgery

Exclusion criteria: Not reported

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Not reported


ParticipantsPlace of study: Udine, Italy

Period of study: January 2000 to December 2000

Number of participants eligible: 157 participants

Number of participants enrolled IT and RS:

- US and surgery: 71 participants

Data available for analyses:

- US and surgery: 71 participants

Age (range): 34 to 80 years

Male/Female: 31/40

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To determine the values of the US real time compound imaging in the evaluation of supraspinatus tendon in subacromial impingement disease

Study design: Prospective, accuracy cohort study
Unclear whether consecutive recruitment

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery, unclear whether arthroscopy or open surgery

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): US

- Description of technique:

Scanner: 7 to 12 MHz linear-array probe applying the soon CT digital algorithm

Technique: Images were obtained in static and dynamic evaluations as described in (Martino 1998; Teefey 2000)

Patient position: Static evaluation was performed on the patient’s arm in standard position; dynamic evaluation was performed first with the patient’s arm positioned from the internal rotation and extended position to abduction and internal rotation (forearm flexed and the back face of fingertips pointing to the scapula); the second part of the evaluation was performed by moving the patient's arm in adduction and keeping the internal rotation

- Criteria for a positive result: Not reported

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Index test was performed on the day before reference standard


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesPart of population of this study was also reported in De Candia 2003 Although De Candia 2003 is more updated than this study, there were no extra data available to be included in the analyses

The rotator cuff tears were focused on only supraspinatus tendon tears

A two-by-two table of the ITs and RS was given, which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearUnclear whether consecutive recruitment

Acceptable reference standard?
All tests
UnclearThe reference standard was surgery (unclear whether arthroscopy or open surgery) and the target conditions were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
YesIndex test was performed on the day before reference standard

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Of the 157 eligible participants, only 71 (45.2%) underwent to reference standard

Differential verification avoided?
All tests
NoThe result of the index test probably influenced the choice of the reference standard

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Reference standard results blinded?
All tests
NoThe results of the index tests were probably known to the person interpreting the reference tests

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
NoThe results of 86 (54.8%) patients were not reported

Withdrawals explained?
All tests
NoSome of the eligible patients who entered the study did not complete it and these patients were not accounted for

Learning curve / training reported of index test?
All tests
UnclearThe interpreters of index tests were two radiologists; however, the training/expertise was not described

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
NoNot reported

Della Sala 1996

Clinical features and settingsInclusion criteria: Patients with recent trauma without documented articular bone defect radiologically, shoulder pain and disability persisting after appropriate conservative treatment, clinical examination suggestive of rotator cuff tears and/or impingement

Exclusion criteria: Patients with suspected shoulder instability

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Tertiary or secondary


ParticipantsPlace of study: Trento, Italy

Period of study: January 1993 to December 1994

Number of participants eligible: 80 participants

Number of participants enrolled IT and RS:

- MRI and open surgery: 30 participants

Data available for analyses:

- MRI and open surgery: 30 participants

Age: mean 50.1 years (range 21 to 71 years)

Male/Female: 23/7

Dominant arm: Not reported

Nature of onset: Traumatic and chronic injury


Study designPrimary objective: Not reported

Study design: Unclear whether prospective design. Non-consecutive recruitment

Language: Italian


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Open surgery

- Description of technique:

Open surgery: as described by Neer 1983

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): MRI

- Description of technique:

MRI unit: 1.0 T scanner

Sequences and Planes: Spin-echo T1-weighted (TR/TE: 786/17) in coronal and sagittal oblique planes; and TR/TE 450/12 in axial plane

Patient position: Not reported

- Criteria for a positive result:

Full-thickness tears: an increase signal on the T1-weighted in the entire extension of the rotator cuff

Partial thickness tears: an increased signal in not whole extension of the cuff

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesRaw data were given and it was possible to back-calculate this from the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearInsufficient information was given to permit judgement

Acceptable reference standard?
All tests
UnclearThe reference standard was open surgery and the target conditions were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Of the 80 eligible participants, only 30 received the reference standard

Differential verification avoided?
All tests
NoThe result of the index test probably influenced the choice of the reference standard

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
NoThe results of 50 (62.5%) patients were not reported

Withdrawals explained?
All tests
NoSome of the eligible patients who entered the study did not complete it and these patients were not accounted for

Learning curve / training reported of index test?
All tests
UnclearInsufficient information was given to permit judgement

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
NoNot reported

Gagey 1993

Clinical features and settingsInclusion criteria: Patients with a rotator cuff syndrome resistant to any medical treatment and indication for surgery

Exclusion criteria: Not reported

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Tertiary


ParticipantsPlace of study: Paris, France

Period of study: 15 months period

Number of participants eligible: 38 participants

Number of participants enrolled IT and RS:

- MRI and open surgery: 38 participants

Data available for analyses:

- MRI and open surgery: 38 participants

Age (mean): 47 years

Male/Female: 14/24

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To compare the results of the MRI with the open surgery

Study design: Prospective accuracy cohort study. Unclear whether consecutive recruitment

Language: French


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Open surgery

- Description of technique: Not reported

- Criteria for a positive result:

Visual identification of the tears by the surgeon


Index and comparator testsIndex test(s): MRI

- Description of technique:

MRI unit: 1.5 T surface circular coil

Sequences: Spin-echo T2-weighted (TR/TE: 2000/25 to 75; TR/TE 1500/25 to 75) and TR/TE 300 to 500/20.

Planes: Sagittal and coronal

Patient position: Not reported

- Criteria for a positive result:

Increased signal on T2-weighted images

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesMr Jean-Philippe Regnaux and Mr Ludovic Trinquart kindly translated into English and extracted the data of this study

The same population of this study was also reported in Gagey 1991

No two-by-two table of the ITs and RS was given, but it was possible to back-calculate this from the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearInsufficient information was given to permit judgement

Acceptable reference standard?
All tests
UnclearThe reference standard was open surgery and the target conditions were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesAll patients received the same reference standard, regardless of the result of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe number of results reported agrees with the number of patients recruited

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
UnclearInsufficient information was given to permit judgement

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Iannotti 2005

Clinical features and settingsInclusion criteria: Participants with a clinical diagnosis of rotator cuff symptoms, consisting of pain, decreased function, and/or weakness

Exclusion criteria: Not reported

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Tertiary and secondary


ParticipantsPlace of study: Cleveland, Ohio, USA

Period of study: Not reported

Number of participants eligible: 98 participants (99 shoulders)

Number of participants enrolled IT and RS:

- MRI and arthroscopy or open surgery: 98 participants (99 shoulders)

- US and arthroscopy or open surgery: 98 participants (99 shoulders)

Data available for analyses:

- MRI and arthroscopy or open surgery: 98 participants (99 shoulders)

- US and arthroscopy or open surgery: 98 participants (99 shoulders)

Age: Not reported

Gender: Not reported

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To define the accuracy of US, when performed in an orthopaedic surgeon's office, for the diagnosis of rotator cuff tears

Study design: Prospective, consecutive, accuracy cohort study with fully paired direct comparison between MRI and US

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy or open surgery

- Description of technique(s): Not reported

- Criteria for a positive result:

Full thickness tears: a gap in the tendon; the involved tendons were measured with a calibrated probe or ruler, and the total tendon gap was measured in centimetres prior to débridement of the tendon edges

Partial thickness tears: on either the bursal or the articular surface was identified as tendon-fraying and loss of tendon substance

The size of the partial thickness tears was measured after débridement of the frayed portions of the tendon


Index and comparator testsIndex test(s): MRI and US

- Description of technique:

MRI

MRI unit: 1.5-T magnet

Sequences and Planes: T1 and T2-weighted image sequences in the sagittal and coronal oblique and axial planes

Patient position: Not reported

US

Scanner: 7.5 MHz transducer

Technique: Static and dynamic examinations

Images were obtained in transverse plane scans of the biceps tendon; longitudinal and parallel scans of the subscapularis tendon; perpendicular and parallel scans of the supraspinatus and infraspinatus tendons

Patient position: Both the patient and the examiner seated on backless stools facing each other

The patient positioned the arm at the side with the elbow bent to 90o

- Criteria for a positive result:

MRI: Full thickness tears: a fluid filled the gap in the tendon on the T2-weighted sagittal or coronal oblique images

Partial thickness tears: an increase signal on the T1-weighted images, with brighter signal on the T2-weighted paired image

The location of the tear was defined by the tendon(s) involved

US: Full thickness tears: a gap in the tendon substance with retraction with increased echogenic signal from the exposed articular cartilage of the humeral head

Partial thickness tears: an increase echogenic signal intensity or a focal decrease in the thickness of the tendon or both

The location of the tear was defined by the tendon(s) involved

- Time from symptoms to index test: Not reported

- Time from US to MRI: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesA two-by-two table of the ITs and RS was given, which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
YesTertiary or secondary care, participants with suspected of having any rotator cuff tears

The study was prospective and recruitment was consecutive

Acceptable reference standard?
All tests
UnclearThe reference standard was arthroscopy or open surgery and the target conditions were presence of full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
UnclearThe study did not report how many patients had US and did not proceed to surgery

Differential verification avoided?
All tests
UnclearInsufficient information was given to permit judgement

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe study was prospective and the results of the index tests were interpreted before the reference standard

Reference standard results blinded?
All tests
NoThe results of the index tests were known to the person interpreting the reference tests

Relevant clinical information?
All tests
YesThe authors had knowledge of history, physical findings and radiographs

Uninterpretable results reported?
All tests
UnclearInsufficient information was given to permit judgement

Withdrawals explained?
All tests
UnclearInsufficient information was given to permit judgement

Learning curve / training reported of index test?
All tests
NoPerformace of index tests was not by radiologist or surgeon and they had only two training sections

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Kang 2009

Clinical features and settingsInclusion criteria: Participants with clinical findings of impingement and suspected rotator cuff tear referred for MRA

Exclusion criteria: Participants with previous rotator cuff repair, dislocation, previous humeral fracture, and infectious or inflammatory arthritis were excluded from the study

Participants who showed clinical improvement while scheduled for surgery and refused it

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Not reported


ParticipantsPlace of study: Seoul, Korea

Period of study: February 2007 to August 2008

Number of participants eligible: 128 participants

Number of participants enrolled IT and RS:

- MRA and arthroscopy: 50 participants

- 3D-US and arthroscopy: 50 participants

Data available for analyses:

- MRA and arthroscopy: 50 participants

- 3D-US and arthroscopy: 50 participants

Age: mean 55.6 years (range 22 to 78 years)

Male/Female: 32/18

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To compare the diagnostic performance of three-dimensional (3D) US and MRA for both the detection of supraspinatus tendon tears and the quantification of their size, with arthroscopic findings used as the standard

Study design: Prospective, consecutive, accuracy cohort study with fully paired direct comparison between MRA and 3D-US

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

- Description of technique:

In a partial thickness tear or in which the initial arthroscopic findings differed from those reported on the imaging, the rotator cuff was examined from both the articular side and the bursal side

Cuff tear size was measured with a calibrated probe using the posterior portal to measure the anterior–posterior dimension and the lateral portal to measure the medial–lateral dimension

- Criteria for a positive result:

The presence or absence of a full or partial thickness tear was noted at the arthroscopy

An estimate of tear size was performed by the location of the medial edge of the tear


Index and comparator testsIndex test(s): MRA and 3D-US

- Description of technique:

MRA

MRI unit: 3.0 T magnet with a dedicated shoulder coil

Sequences and Planes: Fat-suppressed T1-weighted spin-echo images (TR/TE, 650 to 750/12) in the transverse plane, sagittal oblique plane and coronal oblique plane. T2-weighted turbo spin-echo (TSE) images (4000 to 4500/70) in the sagittal oblique and coronal oblique plane

Contrast and procedure: 12 to 15 mL of diluted gadopentetate dimeglumine with a concentration of 2.0 mmol/L
The procedure involved direct intra-articular injection with fluoroscopic guidance

Patient position: Supine with the arm in neutral position

3D US

Scanner: 8 to 15 MHz with a dedicated 3D-volume transducer

Technique: Images were obtained in longitudinal scans of supraspinatus tendon 3D-US data were transferred to a separate workstation which was equipped with various post-processing software that allowed display and interactive analysis of the 3D data

In the section mode the volume data were visualised in three orthogonal scan planes, i.e., longitudinal, transverse, and the C-plane (parallel to the surface of the transducer)

Patient position: Patients with the arm in internal rotation, as the patient placed his or her arm on the buttock

- Criteria for a positive result:

MRA: Full-thickness tears: the extension of the contrast medium through the entire thickness of the rotator cuff or presence of the contrast medium in the subacromial–subdeltoid bursa or both

Partial thickness tears: no communication between the glenohumeral joint and the subacromial–subdeltoid bursa

3D-US: Full thickness tear: a hypoechoic zone extending through the entire substance of the cuff or segmental or complete loss of rotator cuff substance with visualised tear margins or non-visualisation of the cuff

Partial thickness tear: a focal hypoechoic or anechoic defect in the tendon involving either the bursal or the articular surface and manifesting in both longitudinal transverse planes

- Time from symptoms to index test: Not reported

- Time from 3D-US to MRA: The index tests were performed sequentially on the same day beginning with 3D-US and ending with the MRA

- Time from index test to reference standard: mean 24.9 days (range 4 to 99 days


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesThe rotator cuff tears were focused on only supraspinatus tendon tears

A two-by-two table of the ITs and RS was given, which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearPopulation was patients with suspected of having any rotator cuff tears The study was prospective and recruitment was consecutive

The care setting was not specified

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target conditions were presence of full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
YesThe average interval between reference standard and index test was less than one month

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Of the 128 eligible participants only 50 (39%) underwent to reference standard

16 patients (12.5%) refused surgery as they had improved and it was unclear why the other patients did not receive the reference standard

Differential verification avoided?
All tests
NoProbably the result of the index test influenced the choice of the reference standard

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe index tests were interpreted before and without knowledge of the reference standard results

Reference standard results blinded?
All tests
NoThe results of the index tests were probably known to the person interpreting the reference tests

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
NoThe results of 78 (41%) patients were not reported

Withdrawals explained?
All tests
NoSome of the eligible patients who entered the study did not complete it and these patients were not accounted for

Learning curve / training reported of index test?
All tests
YesThe interpreter of MRA was a musculoskeletal radiologist with 15 years experience

The interpreters of US were two radiologists with respectively 5 and 10 years experience performing musculoskeletal US

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Lambert 2009

Clinical features and settingsInclusion criteria: Not reported

Exclusion criteria: Not reported

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Tertiary or secondary


ParticipantsPlace of study: Dijon, France

Period of study: November 2005 to June 2007

Number of participants eligible: 192 participants

Number of participants enrolled IT and RS:

- MRI and arthroscopy or open surgery: 48 participants

Data available for analyses:

- MRI and arthroscopy or open surgery: 48 participants

Age (mean): 56 years

Gender: Not reported

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To demonstrate the value of 3.0 T MRI for the detection of rotator cuff tendon tears

Study design: Prospective, accuracy cohort study
Unclear whether consecutive recruitment

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy or open surgery

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): MRI

- Description of technique:

MRI unit: 3.0 T scanner with a shoulder coil

Sequences and Planes: Fat suppressed TSE T2-weighted in three planes (TR/TE 3000/39)

A sagittal T1-weighted sequence to detect fatty muscle atrophy

Patient position: Not reported

- Criteria for a positive result:

Full thickness tears: presence of hyperintense fluid signal with a communication between the glenohumeral joint and subacromial space

Partial thickness tears: hyperintense fluid signal or irregularity at the articular or bursal surface of the tendon

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: mean 77.6 days (range 22 to 169 days)


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesA two-by-two table of the ITs and RS was given, which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
NoUnknown why patients had MRI shoulder as included all people who had one at their institution of a period of time November 2005 to June 2007

Acceptable reference standard?
All tests
UnclearThe reference standard was shoulder arthroscopy or open surgery and the target condition were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
NoThe average interval between reference standard and index test was 77.6 days

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status. Of the 192 eligible participants, only 48 underwent to reference standard

Differential verification avoided?
All tests
UnclearInsufficient information was given to permit judgement

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Reference standard results blinded?
All tests
NoThe results of the index tests were known to the person interpreting the reference tests

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
UnclearInsufficient information was given to permit judgement

Withdrawals explained?
All tests
NoSome of the eligible patients who entered the study did not complete it and these patients were not accounted for

Learning curve / training reported of index test?
All tests
UnclearInsufficient information was given to permit judgement

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Martin-Hervas 2001

Clinical features and settingsInclusion criteria: Patients with shoulder pain and limited movement

Exclusion criteria: Patients with claustrophobia, metallic implants, and pacemaker

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Not reported


ParticipantsPlace of study: Madrid, Spain

Period of study: During 1998

Number of participants eligible: 140 shoulders

Number of participants enrolled IT and RS:

- MRI and arthroscopy or open surgery: 61 shoulders

- US and arthroscopy or open surgery: 72 shoulders

Data available for analyses:

- MRI and arthroscopy or open surgery: 61 shoulders

- US and arthroscopy or open surgery: 61 shoulders

Age: Not reported

Male/Female: 25/36

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To compare the accuracy of US and MRI in the diagnosis of rotator cuff injuries (focusing on supraspinatus tears) using arthroscopy or open surgery findings as the gold standard

Study design: Prospective accuracy cohort study with fully paired direct comparison between US and MRI

Unclear whether consecutive recruitment

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy or open surgery

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): MRI and US

- Description of technique:

MRI

MRI unit: 0.5 T superconducting magnet

Sequences: Spin echo T1-weighted sequences for coronal and oblique plane images and gradient echo T2*-weighted sequences for axial and oblique coronal images; when the supraspinatus tendon showed a suggestive increased signal intensity, spin echo T2-weighted sequences were performed

Planes: Axial, oblique coronal and oblique sagittal images

Patient position: Patient in a supine position and the arm in a neutral position

US

Scanner: 7.5 MHz high-resolution linear electronic transducer

Technique and Patient position: Images were obtained in transverse and longitudinal plane scans on the anterior plane of a shoulder with a neutrally rotated humerus to visualise bicipital and subscapularis bursae and axilla

Next, sections of the shoulder were performed with internal humeral rotation, and the transducer was moved laterally to visualise the supraspinatus tendon and subacromial bursa

The last images were obtained in the posterior plane with the humerus in a neutral position to visualise the infraspinatus and teres minor tendons

- Criteria for a positive result:

MRI: Full thickness tears: hypersignal on the T1- and T2-weighted images or any irregularity in the borders of the entire thickness of the tendon

Partial thickness tears: any irregularity within the tendon or at the bursal or joint surfaces

US: Full thickness tears: complete absence of the tendon, focal atrophy, a concave border, liquid-filled hypoechoic bands, and/or lineal hyperechoic bands

Partial thickness tears: heterogeneous tendon with hypoechoic areas (> 3 mm) that do not reach both sides of the tear and an irregular or indented border

- Time from symptoms to index test: Not reported

- Time from MRI and US: Not reported

- Time from index test to reference standard: Less than 6 months


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesThe rotator cuff tears were focused on only supraspinatus tendon tears

No two-by-two table of the ITs and RS was given, but it was possible to back-calculate this from the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearTertiary or secondary care, participants with suspected of having any rotator cuff tears

The study was prospective

It was unclear whether consecutive recruitment

Acceptable reference standard?
All tests
UnclearThe reference standard was arthroscopy or open surgery and the target conditions were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
UnclearThe interval between tests was not clearly reported

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Differential verification avoided?
All tests
UnclearInsufficient information was given to permit judgement

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe study was prospective and the results of the index tests were interpreted before the reference standard

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
UnclearInsufficient information was given to permit judgement

Withdrawals explained?
All tests
NoSome of the eligible patients who entered the study did not complete it and these patients were not accounted for

Learning curve / training reported of index test?
All tests
UnclearThe interpreter of index test was a musculoskeletal radiologist Experience was not reported

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Milosavljevic 2005

Clinical features and settingsInclusion criteria: Participants with shoulder symptoms longer than 3 months duration and clinical findings of impingement and suspected rotator cuff tears were referred for US of the shoulder

The patients had pain at rest and during motion, the pain-provoking test was positive, and some patients had weakness of the rotator cuff muscles

Exclusion criteria: Not reported

Duration of symptoms: Participants with shoulder symptoms longer than 3 months duration

Previous treatments: Not reported

Care setting: Not reported


ParticipantsPlace of study: Uppsala, Sweden

Period of study: February 1999 to October 2002

Number of participants eligible: 185 participants (190 shoulders)

Number of participants enrolled IT and RS:

- US and arthroscopy: 185 participants (190 shoulders)

Data available for analyses:

- US and arthroscopy: 185 participants (190 shoulders)

Age: mean 57 years (range 22 to 78 years)

Male/Female: 114/71

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To evaluate the accuracy of high-resolution shoulder US compared with arthroscopy in a large group of consecutive patients with clinically suspected rotator cuff disease

Study design: Prospective consecutive accuracy cohort study

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

- Description of technique:

Patient in the beach-chair position under general anaesthesia

Posterior and anterior portal were used

The cartilage of the humeral head and the glenoid fossa, the labrum ligament complex, the biceps tendon, the intraarticular portion of the subscapular tendon, and the underside of the rotator cuff were inspected

- Criteria for a positive result:

In the same manner as for the US findings, i.e. intact cuff, full thickness tears, or partial thickness tears (see below)


Index and comparator testsIndex test(s): US

- Description of technique:

Scanner: 10 MHz linear-array transducer

Technique: All tendons were examined in longitudinal and transversal plane

Patient position: Both patient and examiner seated on rotatable chairs without armrests

The examiner faced the patient and was seated at the patient’s right side

- Criteria for a positive result:

Full thickness tears: defect (hypoechoic zone) extending through the entire substance of the cuff; focal, mixed hyper- and hypoechoic lesion extending through the entire substance of the cuff; focal thinning with visible margins of the tear; and non-visualisation of the cuff

Partial thickness tears: mixed hyper- and hypoechoic focus or a hypoechoic lesion visualised in two orthogonal imaging planes located within the tendon substance but not extending to the surface or with either articular or bursal extension

- Time from symptoms to index test: More than 3 months

- Time from index test to reference standard: mean 6 months (range 1 day to 18 months)


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesA two-by-two table of the ITs and RS was given, which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearPopulation was patients with suspected of having any rotator cuff tears The study was prospective and recruitment was consecutive

The care setting was not specified

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target conditions were presence of any rotator cuff tear, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
NoThe average interval between reference standard and index test was 6 months

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesAll patients received the same reference standard regardless of the result of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
NoWhen there was disagreement between index test and reference standard findings the results of index test (US) were re-evaluated to explain discrepancy

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe study was prospective, recruitment was consecutive and results were reported for all initially included participants

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
UnclearThe interpreter of index tests was a radiologist

Training and expertise were not described

Learning curve / training reported of reference standard?
All tests
UnclearThe reference standards were performed by three shoulder surgeons Training and expertise were not described

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Misamore 1991

Clinical features and settingsInclusion criteria: Participants with symptoms and physical findings consistent with chronic tendinitis or with degeneration or a tear of the rotator cuff

Patients who had signs indicating stage II or stage III impingement were included

Exclusion criteria: Patients who had an acute injury or who had symptoms for less than one year were excluded

Patients were excluded if they had a previous operation on the affected shoulder, if they had any associated disorders of the shoulder (such as arthritis or instability), or if they had cervical radiculopathy or peripheral neuropathy

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Not reported


ParticipantsPlace of study: Indianapolis, Indiana, USA

Period of study: January 1988 to June 1989

Number of participants eligible: 82 participants

Number of participants enrolled IT and RS:

- US and arthroscopy or open surgery: 32 participants

Data available for analyses:

- US and arthroscopy or open surgery: 32 participants

Age: mean 47 years (range 35 to 65 years)

Male/Female: 26/6

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To compare the accuracy of arthrography compared with US in the evaluation of thirty-two patients who had a degenerative lesion of the rotator cuff.

Study design: Prospective consecutive accuracy cohort study

Language: English


Target condition and reference standard(s)Target conditions: Presence of full thickness tears and partial thickness rotator cuff tears

Reference standard(s): Shoulder arthroscopy or open surgery

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): US

- Description of technique: Not reported

- Criteria for a positive result:

Full thickness tear: an obvious defect localised to the tendon of the rotator cuff was seen or alternatively when there was no echo of the rotator cuff

An abnormality of echogenicity alone was not considered to be a tear

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesNo two-by-two table of the ITs and RS was given, but it was possible to back-calculate this from the reported summary data for detecting any rotator cuff tears


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearPopulation was patients with suspected of having any rotator cuff tears

The study was prospective and recruitment was consecutive

The care setting was not specified

Acceptable reference standard?
All tests
UnclearThe reference standard was arthroscopy or open surgery and the target conditions were presence of full and partial thickness tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Of the 82 eligible participants, 32 patients received the reference standard

For 50 patients the symptoms were not severe enough to justify surgery or satisfactory improvement was achieved with conservative treatment

Differential verification avoided?
All tests
NoProbably the result of the index test influenced the choice of the reference standard

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe index tests were interpreted before and without knowledge of the reference standard results

Reference standard results blinded?
All tests
NoThe results of index tests were probably known to the person interpreting the reference standard

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesResults were reported for all initially included participants

Withdrawals explained?
All tests
YesThe number and reasons of all withdrawals from the study were explained

Learning curve / training reported of index test?
All tests
YesThe interpreters of index tests were radiologists who were skilled in the technique

Learning curve / training reported of reference standard?
All tests
UnclearThe reference standards were performed by one of the authors (orthopaedic surgeon)

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Mohtadi 2004

Clinical features and settingsInclusion criteria: Patients with shoulder pain at night or with overhead activity greater than 3 months duration or both

A minimum of 3 of the following 6 clinical findings: a painful arc of motion in the scapular plane (60° to 120°) of elevation; pain-related weakness on resisted elevation in the scapular plane; Neer’s impingement sign; Hawkin’s impingement sign; point of maximal tenderness over the supraspinatus tendon; and positive impingement xylocaine test

Failure of conservative management

The patients consented to undergo shoulder arthroscopy and subacromial decompression

Exclusion criteria: Patients with symptoms of instability

Signs of instability

Point of maximum tenderness over the acromioclavicular joint

Any signs or symptoms consistent with associated cervical spine pathology Previous surgery, arthrography, ultrasound, or MRI

Duration of symptoms: More than 3 months of symptoms

Previous treatments: Conservative management (nonsteroidal anti-inflammatory drugs, physiotherapy, home-based rehabilitation, cortisone injections, and modification of activity)

Care setting: Tertiary or secondary


ParticipantsPlace of study: Calgary, Alberta, Canada

Period of study: 1998 to 2000

Number of participants eligible: 73 participants

Number of participants enrolled IT and RS:

- Indirect MRA and arthroscopy: 58 participants

Data available for analyses:

- Indirect MRA and arthroscopy: 58 participants

Age: mean 46.2 years (range 21 to 73 years)

Male/Female: 43/15

Dominant arm: Not reported

Nature of onset: Of these 58 patients, 91.4% reported pain at night and 96.6% reported pain with activity above shoulder level


Study designPrimary objective: To determine the diagnostic ability of MRI compared with a reference standard, arthroscopy, in patients presenting with shoulder pain consistent with the signs and symptoms of shoulder impingement

Study design: Prospective, consecutive accuracy cohort study

Language: English


Target condition and reference standard(s)Target conditions: Presence full thickness tears and partial thickness supraspinatus tendon tears

Presence of any infraspinatus tendon tears

Presence of any subscapularis tendon tears

Reference standard(s): Shoulder arthroscopy

- Description of technique:

In accordance with the standardised 15-point protocol of Snyder classification This included standard posterior and anterior portal examination with subsequent visualisation in the subacromial bursa

The subacromial (bursal) examination was not performed

All surgeries were videotaped

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): Indirect MRA

- Description of technique:

MRI unit: 1.5 T with conventional shoulder coil

Sequences and Planes: Axial water density (TR/TR 1000/20) and multi-planar gradient recalled (TR/TE 400/20, flip angle20o)

Oblique coronal fast multi-planar inversion recovery (TR/TE 4600/28, inversion time 150)

Oblique coronal post-gadolinium fat-saturated T1-weighted (TR/TE 400/8) and sagittal T1-weighted (TR/TE 400/8)

Contrast and procedure: Intravenous gadolinium administration

Patient position: Supine with the arm in a neutral position

- Criteria for a positive result: Not reported

- Time from symptoms to index test: More than 3 months of symptoms

- Time from index test to reference standard: Upon entry into the study patients were scheduled to undergo MRI within 1 week before arthroscopy


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesThe analyses of rotator cuff tears were focused on only supraspinatus and subscapularis tendons tears

No two-by-two table of the ITs and RS was given, but it was possible to back-calculate this from the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
YesTertiary or secondary care, participants with suspected of having any rotator cuff tears

The study was prospective and recruitment was consecutive

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target conditions were presence full thickness tears and partial thickness supraspinatus tendon tears; presence of any infraspinatus tendon tears; presence of any subscapularis tendon tears

Acceptable delay between tests?
All tests
YesPatients were scheduled to undergo MRI within 1 week before arthroscopy

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Of the 73 eligible participants, eight cancelled the surgery and seven did not undergo MRI within a week and were excluded but their results were not reported

Differential verification avoided?
All tests
YesAll patients received the same reference standard regardless of the result of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe index tests were interpreted before and without knowledge of the reference standard results

Reference standard results blinded?
All tests
YesBefore and during diagnostic arthroscopy, the surgeon was blinded to the MRI results

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe study was prospective recruitment was consecutive and results were reported for all initially included participants

Withdrawals explained?
All tests
YesThe number and reasons of all withdrawals from the study were explained

Learning curve / training reported of index test?
All tests
UnclearThe interpreter of index tests was a musculoskeletal radiologist Training and expertise were not described

Learning curve / training reported of reference standard?
All tests
UnclearThe reference standards were performed by two experienced orthopaedic surgeons

Training and expertise were not described

Index test criteria for a positive test result reported?
All tests
NoNot reported

Nicoletti 1994

Clinical features and settingsInclusion criteria: Patients who had shoulder pain and signs and symptoms of rotator cuff tears with failure of conservative treatment

Exclusion criteria: Patients with suspected of instability and neurologic symptoms

Duration of symptoms: More than 3 months

Previous treatments: Physiotherapy

Care setting: Tertiary


ParticipantsPlace of study: Sao Paulo, Brazil

Period of study: Not reported

Number of participants eligible: 48 participants

Number of participants enrolled IT and RS:

- US and arthroscopy: 48 participants

Data available for analyses:

- US and arthroscopy: 48 participants

Age: mean 48 years (range 19 to 79 years)

Male/Female: 16/32

Dominant arm: 65%

Nature of onset: Not reported


Study designPrimary objective: To evaluate the sensitivity, specificity and accuracy of arthrography and US to detect rotator cuff tears

Study design: Unclear whether prospective design

Unclear whether consecutive recruitment

Language: Portuguese


Target condition and reference standard(s)Target conditions: Presence any rotator cuff tears

Reference standard(s): Shoulder arthroscopy

- Description of technique:

Patient in lateral position with traction in the operative limb

The posterior and anterior portals were used to visualise the glenohumeral and subacromial spaces

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): US

- Description of technique:

Scanner: 5 or 7 MHz linear transducer in real time

Technique and Patient position: As described by Crass 1985

- Criteria for a positive result:

US signs were: focal or diffuse thinning or non-visualisation of tendon(s)

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesA two-by-two table of the ITs and RS was given which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearUnclear whether prospective design and consecutive recruitment

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target condition was presence of any rotator cuff tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
UnclearInsufficient information was given to permit judgement

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe number of results reported agrees with the number of patients recruited

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
YesThe interpreter of index tests was a musculoskeletal radiologist

Learning curve / training reported of reference standard?
All tests
YesThe reference standards were performed by an experienced shoulder surgeon

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Sipola 2010

Clinical features and settingsInclusion criteria: Participants with acute or chronic shoulder pain and suspicion of rotator cuff tears

Patients who had undergone conservative treatment without sufficient symptom relief

Exclusion criteria: Time elapsed between index test and reference standard was more than 12 months

Duration of symptoms (pain): mean 21 months (range 2 to 144 months

Previous treatments: Conservative treatment including physiotherapy for at least 3 months

Care setting: Tertiary or secondary


ParticipantsPlace of study: Kuopio, Finland

Period of study: Not reported

Number of participants eligible: 79 participants

Number of participants enrolled IT and RS:

- MRA and arthroscopy or open surgery: 75 participants

- US and arthroscopy or open surgery: 77 participants

Data available for analyses:

- MRA and arthroscopy or open surgery: 75 participants

- US and arthroscopy or open surgery: 77 participants

Age: mean 57 years (range 42 to 76 years)

Male/Female: 40/37

Dominant arm: Not reported

Nature of onset: The etiology of suspected tear was traumatic in 22% and degenerative in 78% of the participants


Study designPrimary objective: To compare the accuracy of US and MRA for the detection and measurement of rotator cuff tears using surgical findings as the standard in a prospective study setting

Study design: Prospective, consecutive, accuracy cohort study with fully paired direct comparison between MRA and US

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy or mini-open

- Description of technique: Not reported

- Criteria for a positive result:

The size and type (partial/full thickness) of tendon tear was determined and measured from anterior to posterior and from lateral to medial dimensions A sterile ruler or a calibrated arthroscopic probe was used to define both the anteroposterior and the mediolateral size of the tear


Index and comparator testsIndex test(s): MRA and US

- Description of technique:

MRA

MRI unit: 1.5 T scanner equipped with a flexible surface coil

Sequences and Planes: Oblique coronal T1-weighted spin-echo (TR/TE 650/20); a T2-weighted fat-saturated dual-echo fast spin-echo (FSE), 3500/16; oblique sagittal T2-weighted dual-echo FSE, 3500/16, 98; axial T2*-weighted gradient echo two-dimensional FLASH, 580/15, flip angle 15o; a T1-weighted fat-saturated SE, 800/20; T1-weighted fat-saturated spin-echo 800/20 images in the sagittal oblique, coronal oblique and axial planes, and T2-weighted FSE 4500/96 images in the coronal oblique plane

Contrast and procedure: 10 to 20 mL of gadopentetate dimeglumine in a concentration of 469.01 mg/mL was diluted in 250 mL of saline

The procedure involved direct intra-articular injection

Patient position: Not reported

Seven participants underwent to MRI only (without an intra-articular contrast)

US

Scanner: 7.5 MHz linear-array transducers in real-time

Technique: Images were obtained on the long and short axes of the tendon

Patient position: The subscapularis tendon was evaluated with the forearm rotated externally

The supraspinatus tendon was assessed with the arm on the ipsilateral side The supraspinatus was assessed with the hand behind the patient’s back (Crass position) or on the waist (modified Crass position) (Crass 1987; Ferri 2005)

The infraspinatus tendon was assessed with the patient placed the ipsilateral hand across the chest on top of the contralateral shoulder

- Criteria for a positive result:

MRA: Full thickness tears: the contrast agent was detected on the MR image throughout the full thickness of the rotator cuff and/or when the contrast agent was detected in the subacromial bursa

Partial thickness tears: the contrast agent entered the cuff substance without reaching the subacromial bursa

US: Full thickness tears: hypoechoic area or volume loss extended from the bursal surface to the articular surface of the tendon

Otherwise the tear was diagnosed as a partial thickness tear

- Time from symptoms to index test: mean 21 months (range 2 to 144 months

- Time from MRA and US: in the same day

- Time from index test to reference standard: mean 2.3 months (range 0 to 9.5 months)


Follow-upAdverse events due to index test(s): Of the 77 patients, two (3%) could not undergo MRA due to claustrophobia

Adverse events due to reference standard test(s): Not reported


NotesA two-by-two table of the ITs and RS was given, which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
YesTertiary or secondary care, participants with suspected of having any rotator cuff tears

The study was prospective and recruitment was consecutive

Acceptable reference standard?
All tests
UnclearThe reference standard was arthroscopy or open surgery and the target conditions were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
NoThe average interval between reference standard and index test was 2.3 months

Partial verification avoided?
All tests
YesOnly two patients (2.5%) were excluded of study because of delay in surgery 12 months due to medical illness

Differential verification avoided?
All tests
NoThe choice of reference standard (arthroscopy or open surgery) varied between individuals

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe study was prospective, recruitment was consecutive and results were reported for all initially included participants

Withdrawals explained?
All tests
YesThe number and reasons of all withdrawals from the study were explained

Learning curve / training reported of index test?
All tests
YesThe interpreter of MRA was a radiologist who had 1 year of experience in musculoskeletal MRI at the beginning of the study

The interpreters of US were three radiologists each with more than 10 years experience in shoulder US

Learning curve / training reported of reference standard?
All tests
UnclearThe reference standards were performed by three experienced orthopaedic surgeons

Training and expertise were not described

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Stetson 2005

Clinical features and settingsInclusion criteria: Patients with chronic shoulder pain who were suspected of having a rotator cuff abnormality underwent MRA with use of an intra-articular injection of gadolinium

Exclusion criteria: Not reported

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Tertiary or secondary


ParticipantsPlace of study: Burbank, California, USA

Period of study: During 2 years

Number of participants eligible: 50 participants

Number of participants enrolled IT and RS:

- MRA and arthroscopy: 50 participants

Data available for analyses:

- MRA and arthroscopy: 50 participants

Age: Not reported

Gender: Not reported

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To detect partial thickness articular-sided rotator cuff tears using an intra-articular injection of gadolinium and MRI

Study design: Prospective accuracy cohort

Unclear whether consecutive recruitment

Language: English


Target condition and reference standard(s)Target conditions: Presence partial articular-side thickness tears

Reference standard(s): Shoulder arthroscopy

- Description of technique:

All participants were taken to surgery and underwent a complete 15-point glenohumeral arthroscopic examination

The presence or absence of articular-sided rotator cuff tears was recorded

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): MRA

- Description of technique:

MRI unit: 1.5 T scanner.

Sequences and Planes: Axial proton-density-weighted image with fat suppression, oblique coronal proton-density-weighted image, oblique coronal T2-weighted with fat suppression, oblique sagittal T1-weighted, and oblique sagittal proton-density-weighted image with fat suppression. In addition, axial T1-weighted with fat suppression, oblique coronal T1-weighted with fat suppression

Contrast and procedure: 1.5 mL of gadolinium with normal saline solution intra-articularly into the glenohumeral joint under fluoroscopic control

Patient position: Supine in neutral position and abduction and external rotation images were also acquired

- Criteria for a positive result: Not reported

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesThe authors described as false positive the four patients who were incorrectly diagnosed with MRA, as having a full thickness tear, but, at the time of shoulder arthroscopy, they had partial thickness articular-sided tears

To make concordance with our analyses we described these participants as false negative

No two-by-two table of the ITs and RS was given, but it was possible to back-calculate this from the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearThe study was prospective and the population was participants with shoulder pain and suspected of having any rotator cuff tears. However, it was unclear whether there was consecutive recruitment

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target condition was presence of partial articular-side rotator cuff tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesAll patients received the same reference standard, regardless of the result of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Reference standard results blinded?
All tests
NoThe results of the index tests were probably known to the person interpreting the reference tests

Relevant clinical information?
All tests
UnclearInsufficient information was given to permit judgement

Uninterpretable results reported?
All tests
YesThe number of results reported agrees with the number of patients recruited

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
YesThe interpreter of index tests was a fellowship-trained musculoskeletal radiologist

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
NoNot reported

Swen 1998

Clinical features and settingsInclusion criteria: Patients awaiting surgery because of clinically suspected of rotator cuff tears

The clinical diagnosis of rotator cuff tears was based on marked difficulty in initiating abduction of the arm with weakness and limitation of movement Lidocaine was injected below the acromion, if after the injection the strength of the rotator cuff was still decreased; this was considered to indicate rotator cuff tears

Exclusion criteria: Patients with neurologic origins of the weakness

Duration of symptoms: mean 2.3 years (range 0.3 to 10 years)

Previous treatments: Not reported

Care setting: Not reported, probably tertiary or secondary


ParticipantsPlace of study: The Netherlands

Period of study: January 1993 to December 1995

Number of participants eligible: 48 participants

Number of participants enrolled IT and RS:

- US and arthroscopy or open surgery: 48 participants

Data available for analyses:

- US and arthroscopy or open surgery: 48 participants

Age: mean 55 years (range 30 to 76 years)

Male/Female: 28/20

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To compare the diagnostic value of US performed by the rheumatologist with that of arthrography by a radiologist for otherwise healthy patients with suspected rotator cuff tears

Study design: Prospective consecutive accuracy cohort study

Language: English


Target condition and reference standard(s)Target conditions: Presence full thickness tears

Reference standard(s): Shoulder arthroscopy and open surgery

- Description of technique: Not reported

- Criteria for a positive result:

A full-thickness was diagnosed if free communication was found between the bursal and humeral sides of the cuff


Index and comparator testsIndex test(s): US

- Description of technique:

Scanner: 7.5 MHz linear array and the 5.0 MHz curved array transducers

Technique: The shoulder was examined in the anterior, lateral, and posterior directions, in both the transverse and the longitudinal planes as described by Van Holsbeeck 1991

Patient position: The patients were seated

For the anterior approach, the patient’s upper arm was visualised in internal rotation, which was achieved by placing the patient’s hand behind the back

- Criteria for a positive result:

Full thickness tears: a discontinuity in the rotator cuff extending from the bursal to the humeral side of the rotator cuff

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesA two-by-two table of the ITs and RS was given which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
YesTertiary or secondary care

Participants with suspected of having any rotator cuff tears The study was prospective and recruitment was consecutive

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy or open surgery and the target conditions were presence of full thickness tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesAll patients received the same reference standard, regardless of the result of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe study was prospective and the results of the index tests were interpreted before the reference standard

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe study was prospective, recruitment was consecutive and results were reported for all initially included participants

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
YesThe interpreter of index tests was a rheumatologist with experience in this technique

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Swen 1999

Clinical features and settingsInclusion criteria: Patients awaiting surgery because of a clinically suspected rotator cuff tears

The clinical diagnosis of rotator cuff tears was based on marked difficulty in initiating abduction of the arm with weakness and limitation of movement Lidocaine was injected below the acromion, if after the injection the strength of the rotator cuff was still decreased; this was considered to indicate rotator cuff tears

Exclusion criteria: Patients with neurologic origins of the weakness

Duration of symptoms: mean 2.3 years (range 0.3 to 8 years)

Previous treatments: Not reported

Care setting: Not reported

Probably tertiary or secondary


ParticipantsPlace of study: The Netherlands

Period of study: Not reported

Number of participants eligible: 21 participants

Number of participants enrolled IT and RS:

- MRI and arthroscopy: 21 participants

- US and arthroscopy: 21 participants

Data available for analyses:

- MRI and arthroscopy: 21 participants

- US and arthroscopy: 21 participants

Age (mean/SD): 54/12 years

Male/Female: 12/9

Dominant arm: Not reported

Nature of onset: In four patients the shoulder complaints could be attributed to trauma


Study designPrimary objective: To evaluate the ability of US and MRI to detect full thickness rotator cuff tears in patients with a clinically suspected rotator cuff tears as a solitary non-inflammatory condition

Study design: Prospective, consecutive, accuracy cohort study with fully paired direct comparison between MRI and US

Language: English


Target condition and reference standard(s)Target conditions: Presence full thickness tears

Reference standard(s): Shoulder arthroscopy

- Description of technique:

First the arthroscope was introduced in the glenohumeral joint and then into the subacromial space

After introducing the scope into the subacromial space, the bursa was removed to enable examination of the bursal side of the cuff

- Criteria for a positive result:

A full-thickness was diagnosed if free communication was found between the bursal and humeral sides of the cuff


Index and comparator testsIndex test(s): MRI and US

- Description of technique:

MRI

MRI unit: 1.0T system with a dedicated shoulder coil as receiver

Sequences: T1-weighted (TR/TE 680/15) and a standard T2 coronal spin-echo sequence (TR/TE 3000/15,105 ms)

Planes: Oblique coronal

Patient position: Supine position

US

Scanner: 7.5 MHz linear array and the 5.0 MHz curved array transducers

Technique: The shoulder was examined in the anterior, lateral, and posterior directions, in both the transverse and the longitudinal planes as described by Van Holsbeeck 1991

Patient position: The patients were seated

For the anterior approach, the patient’s upper arm was visualised in internal rotation, which was achieved by placing the patient’s hand behind the back

- Criteria for a positive result:

MRI: Full-thickness tears: a focal, well-defined area of increased signal intensity on T1-weighted and T2-weighted images that extended through the entire thickness of the tendon

US: Full-thickness tears: a discontinuity in the rotator cuff, extending from the bursal to the humeral side of the rotator cuff

- Time from symptoms to index test: Not reported

- Time from Conventional MRA and 3D isotropic MRA: Not reported

- Time from index test to reference standard: MRI and US were performed within 3 weeks before surgery


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesThe results of index test were interpreted by two experienced musculoskeletal radiologists

The data of only one reader (reader 1) were arbitrarily chosen to be included in our analyses

Raw data were given and it was possible to back-calculate this from the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
YesTertiary or secondary care, participants with suspected of having any rotator cuff tears

The study was prospective and recruitment was consecutive

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target condition was presence of full thickness tears

Acceptable delay between tests?
All tests
YesThe index tests were performed within 3 weeks of surgery

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesAll patients received the same reference standard, regardless of the result of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe study was prospective and the results of the index tests were interpreted before the reference standard

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
NoThe interpreters were blinded to history and physical examination

Uninterpretable results reported?
All tests
YesThe study was prospective, recruitment was consecutive and results were reported for all initially included participants

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
UnclearA rheumatologist and a radiologist, both experienced with this test

In fact they had different results but this was not examined in this study

Learning curve / training reported of reference standard?
All tests
UnclearThe reference standards were performed by a single experienced surgeon

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Taboury 1992

Clinical features and settingsInclusion criteria: Not reported

Exclusion criteria: Not reported

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Tertiary


ParticipantsPlace of study: Paris, France

Period of study: Not reported

Number of participants eligible: 24 participants

Number of participants enrolled IT and RS:

- US and open surgery: 24 participants

Data available for analyses:

- US and open surgery: 24 participants

Age: Not reported

Gender: Not reported

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To compare the results of US to open surgery in order to evaluate the characteristics of the rotator cuff tears

Study design: Prospective accuracy cohort study

Unclear whether consecutive recruitment

Language: French


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears

Reference standard(s): Open surgery

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): US

- Description of technique:

Scanner: 5 to 10 MHz linear or vectorial short focal probe

Technique: Static and dynamic examination of rotator cuff tendons

Patient position: Patients seated with the arm in adduction and internal rotation by asking the patients to place their arm behind their back

- Criteria for a positive result: Not reported

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesMr Jean-Philippe Regnaux and Mr Ludovic Trinquart kindly translated into English and extracted the data of this study

A two-by-two table of the ITs and RS was given, which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearUnclear whether consecutive recruitment

Acceptable reference standard?
All tests
UnclearThe reference standard was open surgery and the target condition was presence of any rotator cuff tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesAll participants included in the analyses received open surgery, regardless of the results of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe person undertaking the index test was blinded to the results of the standard reference

Reference standard results blinded?
All tests
YesThe reference standard results were performed blind to the results of the index test

Relevant clinical information?
All tests
UnclearInsufficient information was given

Uninterpretable results reported?
All tests
YesThe number of results reported agrees with the number of patients recruited

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
UnclearInsufficient information was given

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given

Index test criteria for a positive test result reported?
All tests
NoNot reported

Teefey 2004

Clinical features and settingsInclusion criteria: Acute or chronic shoulder pain accompanied by a high clinical suspicion of rotator cuff disease

Exclusion criteria: Participants with severe claustrophobia, which is a contraindication for magnetic resonance imaging; a previous operation on the shoulder; a humeral fracture; and inflammatory arthritis

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Not reported, probable tertiary or secondary


ParticipantsPlace of study: St. Louis, Missouri, USA

Period of study: December 1998 and April 2001

Number of participants eligible: 130 participants

Number of participants enrolled IT and RS:

- MRI and arthroscopy: 71 shoulders

- US and arthroscopy: 71 shoulders

Data available for analyses:

- MRI and arthroscopy: 71 shoulders

- US and arthroscopy: 71 shoulders

Age: mean 59 (range 31 to 80 years)

Male/Female: 41/30

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To compare the diagnostic performances of US and MRI for both the detection of a rotator cuff tear and the quantification of its size, with use of arthroscopic findings as the standard

Study design: Prospective, consecutive, accuracy cohort study with fully paired direct comparison between US and MRI

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

- Description of technique:

The rotator cuff was examined from both the articular and the bursal side. A tagged suture (number-1 PDS [polydioxanone]) was placed, during intra-articular viewing, through the suspected region of the cuff tear to guide arthroscopic bursal imaging

- Criteria for a positive result:

The presence or absence of a rotator cuff tear and the size and extent of the tear, when present, were recorded. Specifically, the presence or absence of a full thickness tear or of a bursal or articular-side partial thickness tear and the width (perpendicular to the long axis of the cuff fibres) of any tear that was found were recorded


Index and comparator testsIndex test(s): MRI and US

- Description of technique:

MRI

MRI unit: 1.5 T with high field strength with a two-piece shoulder array coil (54 participants); and with flexible local coils (17 participants)

Sequences: Fat-suppressed, fast-spin-echo, proton-density-weighted, spin-echo, or fast-spin-echo and transverse, T2-weighted, fast-spin-echo images with or without fat suppression

Planes: Oblique coronal and oblique sagittal

Patient position: Not reported

US

Scanner: 7.5 to 9 MHz linear-array transducer in real-time

Technique and Patient position: As previously described (Teefey 2000).

- Criteria for a positive result:

MRI: Full thickness tears: complete disruption of all tendon fibres or when the signal within the cuff tendons was isointense compared with fluid on the T2-weighted images and extended from the articular to the bursal surface on one or more images. Partial thickness tears: fluid-intensity signal within the tendons was in contact with only one of the surfaces

US: Full thickness tears: non-visualisation of rotator cuff or a focal defect in the rotator cuff created by a variable degree of retraction of the torn tendon ends. Partial thickness tears: minimal flattening of the bursal side of the rotator cuff (bursal-side tear) or a distinct hypoechoic or mixed hyperechoic and hypoechoic defect visualized in both the longitudinal and the transverse plane at the deep articular side of the rotator cuff (articular-side tear)

- Time from symptoms to index test: Not reported

- Time from US and MRI: MRI was performed on the same day as the US for all but three patients, two of whom had the studies six days apart and one of whom had them one day apart

- Time from index test to reference standard: mean 56 days (range 2 to 190 days)


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesPart of population (only the participants with full thickness rotator cuff tears) of this study was also reported in Teefey 2005

A two-by-two table of the ITs and RS was given, which tallied with the reported summary data with a few discrepancy


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearInsufficient information was given to permit judgement

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target condition were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
NoThe average interval between reference standard and index test was 56 days

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Of the 130 eligible participants 71 underwent to reference standard

Differential verification avoided?
All tests
NoThe result of the index test probably influenced the choice of the reference standard

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe person undertaking the index test was blinded to the results of the standard reference

Reference standard results blinded?
All tests
NoThe results of the index tests were known to the person interpreting the reference tests

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
UnclearInsufficient information was given to permit judgement

Withdrawals explained?
All tests
NoSome of the eligible patients who entered the study did not complete it and these patients were not accounted for

Learning curve / training reported of index test?
All tests
YesThe interpreter of MRI was one of six radiologists with extensive experience in musculoskeletal magnetic resonance imaging

The interpreter of US was one of two radiologists who were very experienced with the technique and who had conducted more than 2500 examinations during a 10-year period

Learning curve / training reported of reference standard?
All tests
UnclearThe reference standards were performed by an experienced orthopaedic surgeon

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Venu 2002

Clinical features and settingsInclusion criteria: Participants with clinical supraspinatus impingement syndrome and failure of clinical improvements with conservative treatment within one year of onset of symptoms

Exclusion criteria: Not reported

Duration of symptoms: Probably more than one year

Previous treatments: Shoulder physiotherapy and sub-acromial steroid injections

Care setting: Not reported


ParticipantsPlace of study: Eastbourne, UK

Period of study: June 1997 to June 1999

Number of participants eligible: 276 participants

Number of participants enrolled IT and RS:

- US and arthroscopy: 41 participants

Data available for analyses:

- US and arthroscopy: 41 participants

Age: mean 54 years (range 34 to 79 years)

Male/Female: 24/17

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To determine the accuracy of ultrasound compared with arthroscopy in the evaluation of the symptomatic supraspinatus tendon and to identify whether ultrasound diagnosis was helpful in pre-operative planning

Study design: Prospective, consecutive, accuracy cohort study

Language: English


Target condition and reference standard(s)Target conditions: Presence of normal tendon, tendinopathy, partial thickness tear, full thickness tear, and rotator cuff rupture

Reference standard(s): Shoulder arthroscopy

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): US

- Description of technique:

Scanner: 5 to 10 MHz using a linear array transducer

Technique: Longitudinal and transverse views of the supraspinatus

Patient position: Patient probably seated with the shoulder internally rotated to visualise the supraspinatus tendon

- Criteria for a positive result:

Tendinopathy: thickened and often decreased echogenicity

Partial thickness tears: a hypo-or hyperechoic tendon defect not involving the full thickness of the tendon

Full thickness tears: a hypo or hyperechoic tendon defect involving the full thickness of the tendon

Rupture: the tendon was absent with often only the retracted proximal tendon visualised

- Time from symptoms to index test: More than 1 year

- Time from index test to reference standard (mean): 6 months


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesThe study reported five categories to classify the tendon (normal tendon, tendinopathy, partial thickness tear, full thickness tear, and rotator cuff rupture)

In our analyses we classified the categories ‘normal’ and ‘tendinopathy’ as normal tendon; and ‘full’ and ‘rupture’ as full thickness tear

No two-by-two table of the ITs and RS was given but it was possible to back-calculate this from the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearPopulation was patients with suspected of having any rotator cuff tears

The study was prospective and recruitment was reported as consecutive

The care setting was not specified

Acceptable reference standard?
All tests
YesThe reference standard was arthroscopy and the target conditions were presence of normal tendon, tendinopathy, partial thickness tear, full thickness tear, and rotator cuff rupture

Acceptable delay between tests?
All tests
NoThe average interval between reference standard and index test was 6 months

Partial verification avoided?
All tests
NoNot all the patients who received the index test underwent a reference standard to verify their true disease status

Of the 276 eligible participants only 41 (15%) received the reference standard

Differential verification avoided?
All tests
NoThe result of the index test influenced the choice of the reference standard

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe study was prospective and the results of the index tests were interpreted before the reference standard

Reference standard results blinded?
All tests
NoThe surgeon knew the US diagnosis prior to surgery

Relevant clinical information?
All tests
YesClinical data and plain radiographs were available at the time of performing the US examination

Uninterpretable results reported?
All tests
NoThe results of 235 (85%) patients were not reported

Withdrawals explained?
All tests
NoSome of the eligible patients who entered the study did not complete it and these patients were not accounted for

Learning curve / training reported of index test?
All tests
YesThe interpreters of index tests were two radiologists specialised in shoulder US

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Wallny 2001

Clinical features and settingsInclusion criteria: Participants suffering from shoulder pain with histories and physical examinations suggestive of rotator cuff lesions

Exclusion criteria: Participants with prior shoulder surgery or previous fracture of the humeral head

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Tertiary or secondary


ParticipantsPlace of study: Bonn, Germany

Period of study: Not reported

Number of participants eligible: 40 participants

Number of participants enrolled IT and RS:

- Two-dimensional (2D) US and arthroscopy or open surgery: 40 participants

- Tree-dimensional (3D) US and arthroscopy or open surgery: 40 participants

Data available for analyses:

- 2D US and arthroscopy or open surgery: 40 participants

- 3D US and arthroscopy or open surgery: 40 participants

Age: mean 54 years (range 38 to 79 years)

Male/Female: 25/15

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To determine the validity of 3D US in the diagnosis of rotator cuff lesions

Study design: Prospective, consecutive, accuracy cohort study with fully paired direct comparison between 3D US and 2D US

Language: English


Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy or open surgery

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): 3-D US and 2-D US

- Description of technique:

Scanner: 10 MHz electronic linear array in broad bandwidth technology, 192 fine pitch elements, frequency ranges: resolution: 4.5 to 13 MHz, penetration: 2.5 to 10 MHz

Technique and Patient position: Not reported

The region of interest was defined by 2D US before 3D US could be undertaken

- Criteria for a positive result:

Full thickness tear was defined as: marked thinning, sudden changes of calibre, hyper- and/or hypoechoic zones and total absence of the cuff

Partial thickness tear was defined as: constituting no more than loss of 1/4 to 1/2 of full thickness of the intact rotator cuff

- Time from symptoms to index test: Not reported

- Time from 2D US and 3D US: in the same examination

- Time from index test to reference standard: Not reported


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesThe study reported that the target conditions were presence of any rotator cuff tears, full thickness tears and partial thickness tears

Only the data for analysing presence of any rotator cuff tears were available

The study reported the data of two different types of US (three-dimensional and two-dimensional)

Inasmuch as the 2D US examinations are more often used in clinical practice we arbitrarily chose 2D US to be included in our analyses

A two-by-two table of the ITs and RS was given which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
YesTertiary or secondary care, participants with suspected of having any rotator cuff tears

The study was prospective and recruitment was consecutive

Acceptable reference standard?
All tests
UnclearThe reference standard was arthroscopy or open surgery and the target conditions were presence of full thickness tears and partial thickness tears

Acceptable delay between tests?
All tests
UnclearThe study did not report the time elapsed between the index tests and reference standard

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesThe indication for surgery was based on the results of clinical assessment and an MRI scan but independent of the result of the index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe study was prospective and the results of the index tests were interpreted before the reference standard

Reference standard results blinded?
All tests
UnclearInsufficient information was given to permit judgement

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe study was prospective

Recruitment was consecutive and results were reported for all initially included participants

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
UnclearInsufficient information was given to permit judgement

Learning curve / training reported of reference standard?
All tests
UnclearThe reference standards were performed by a single orthopaedic surgeon

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

Yen 2004

Clinical features and settingsInclusion criteria: Patients with shoulder pain and suspected of rotator cuff tears

Exclusion criteria: Not reported

Duration of symptoms: Not reported

Previous treatments: Not reported

Care setting: Not reported


ParticipantsPlace of study: Taiwan, China

Period of study: Not reported

Number of participants eligible: 50 participants

Number of participants enrolled IT and RS:

- US and open surgery: 50

Data available for analyses:

- US and open surgery: 50

Age: mean 63 years (range 17 to 81 years)

Male/Female: 26/24

Dominant arm: Not reported

Nature of onset: Not reported


Study designPrimary objective: To prospectively compare the US and operative findings of rotator cuff tears

Study design: Prospective accuracy cohort study

Unclear whether consecutive recruitment

Language: English


Target condition and reference standard(s)Target conditions: Presence any rotator cuff tears

Reference standard(s): Open surgery

- Description of technique: Not reported

- Criteria for a positive result: Not reported


Index and comparator testsIndex test(s): US

- Description of technique:

Scanner: 7 MHz linear transducer

Technique: Longitudinal, transverse and oblique scans of the tendons were used

Patient position: Probably patient seated with the arm in

External rotation for scanning the subscapularis tendon

Neutral position for the long head of the biceps tendon

Internal rotation and with the patient's hand behind the back with extreme internal rotation for the supraspinatus tendon

Flexion and adduction for infraspinatus and teres minor tendons

- Criteria for a positive result:

Six US signs were used: non-visualisation;

Floating bright spots

Focal depression

Focal thinning

Focal hypoechoic cleft

Focal heterogeneous hypoechogenicity

- Time from symptoms to index test: Not reported

- Time from index test to reference standard: within 1 month


Follow-upAdverse events due to index test(s): Not reported

Adverse events due to reference standard test(s): Not reported


NotesA two-by-two table of the ITs and RS was given which tallied with the reported summary data


Table of Methodological Quality

ItemAuthors' judgementDescription

Representative spectrum?
All tests
UnclearPopulation was patients with suspected of having any rotator cuff tears

The study was prospective

It was unclear whether consecutive recruitment

Acceptable reference standard?
All tests
UnclearThe reference standard was open surgery and the target condition was presence of any rotator cuff tears

Acceptable delay between tests?
All tests
YesThe reference standard was performed within 1 month after the index test

Partial verification avoided?
All tests
YesAll patients who received the index test went on to receive verification of their disease status using a reference standard

Differential verification avoided?
All tests
YesAll patients received the same reference standard regardless of the result of their index test

Incorporation avoided?
All tests
YesThe index test did not form part of the reference standard

Index test results blinded?
All tests
YesThe index tests were interpreted before and without knowledge of the reference standard results

Reference standard results blinded?
All tests
NoThe results of the index tests were known to the person interpreting the reference tests

Relevant clinical information?
All tests
UnclearNot reported

Uninterpretable results reported?
All tests
YesThe study was prospective and results were reported for all initially included participants

Withdrawals explained?
All tests
YesNo participants were excluded from the analysis

Learning curve / training reported of index test?
All tests
UnclearAll of the procedures were performed by one sonologist and the findings were interpreted by two or three sonologists in consensus prior to surgery

Learning curve / training reported of reference standard?
All tests
UnclearInsufficient information was given to permit judgement

Index test criteria for a positive test result reported?
All tests
YesThe study reported the definition of a positive index test result

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Adams 2010This was a retrospective study with a possible risk of spectrum and verification bias

Al-Shawi 2008Reference standard not relevant: Arthroscopy or MRI was used as reference standard

Aliabadi 1991Type of study not relevant: Narrative review

Aliprandi 2006Participants not relevant: Participants with suspected of chronic or traumatic rotator cuff tear, congenital atraumatic or traumatic glenohumeral instability, traumatic rotator cuff tear and glenohumeral instability, and “frozen shoulder” were enrolled

Allmann 1999Type of study not relevant: Technique report

Ardic 2006Reference standard not relevant: MRI was used as reference standard

Auethavekiat 2006Type of study not relevant: Case report

Awerbuch 2008Type of study not relevant: Narrative review

Balich 1997Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Bencardino 2010Type of study not relevant: Narrative review

Blanchard 1999aParticipants not relevant: Participants with other shoulder complaints, including instability were enrolled

Blanchard 1999bType of study not relevant: Questionnaire study

Blum 1993Index test not relevant: Arthrographic computed tomography was used as index test

Boisrenoult 1999Type of study not relevant: Index test was not compared with reference standard(s)

Boorstein 1992Type of study not relevant: Narrative review

Brandt 1989Reference standard not relevant: Arthrography or surgery was used as reference standard

Brasseur 1994Type of study not relevant: Anatomic description

Brenneke 1992Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Bryant 2002Type of study not relevant: The purpose of this study was to determine how well the size of rotator cuff tears could be estimated noninvasively by ultrasonography and MRI and how well arthroscopy could detect the size of rotator cuff tears

Burk 1989Reference standard not relevant: Arthrography or surgery was used as reference standard

Chang 2002Participants not relevant: Participants with shoulder pain; however, it was unclear if all participants were suspected of having rotator cuff tears

Chaubal 2007Type of study not relevant: Narrative review

Chen 1996Target condition not relevant: The aim of the study was to determine the MRI findings that are associated with full thickness rotator cuff tears

Chiodi 1994Participants not relevant: Selective population that all participants had full thickness tears (100% of prevalence) and the study was retrospective and reported non-consecutive recruitment

Chiodi 1995Participants not relevant: Selective population that all participants had rotator cuff tears (100% of prevalence)

The study also included patients that were reported in Chiodi 1994

Chiou 1999This was a retrospective study with a possible risk of spectrum and verification bias

Chucair 2008Type of study not relevant: Narrative review

Chun 2010Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Crass 1987Type of study not relevant: Case report

Crass 1988This was a retrospective study with a possible risk of spectrum and verification bias

Cullen 2007This was a retrospective study with a possible risk of spectrum and verification bias

Cusmano 2000Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

D'Erme 1993Reference standard not relevant: Surgery or arthrography was used as reference standard

Davidson 2005Target condition not relevant: To determine the MRI criteria for predicting rotator cuff tear pattern and method of repair

Davis 1991Type of study not relevant: Technique report

De Muynck 1994Reference standard not relevant: Arthrography or arthroscopy or open surgery was used as reference

standard

Demouy 1993Type of study not relevant: Narrative review

Deutsch 1997Participants not relevant: Selective population, restricted to subscapularis tendon tear (retrospective, so selected out patients with the diagnosis)

Dhagat 2002Type of study not relevant: Index test (US) was not compared with reference standard(s)

Dinter 2008Participants not relevant: Participants with shoulder pain; however, it was unclear if all participants were suspected of having rotator cuff tears

Drakeford 1990Participants not relevant: Asymptomatic participants were included

El-Dalati 2005Insufficient data to be included in the meta-analyses

El-Kouba 2010This was a retrospective study with a possible risk of spectrum and verification bias

Evancho 1988Reference standard not relevant: Arthroscopy or arthrography as reference standard

Fabis 1999aParticipants not relevant: Participants with other shoulder complaints, including instability were enrolled

Fabis 1999bParticipants not relevant: The aim was to evaluate US images of rotator cuff integrity after surgical repair

Farin 1995Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Farin 1996aParticipants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Farin 1996bParticipants not relevant: Selective population that all participants had full thickness tears (100% of prevalence) and the study was retrospective and reported non-consecutive recruitment

Farley 1992Target condition not relevant: The aim of the study was to determine the MRI findings that are associated with full thickness rotator cuff tears

Ferrari 2002Participants not relevant: Selective population that all participants had full thickness tears (100% of prevalence) and the study reported non-consecutive recruitment

Ferri 2005Target condition not relevant: The aim of the study is to assess the accuracy of the Crass and modified Crass positions

Flannigan 1990Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Fotiadou 2008This was a retrospective study with a possible risk of spectrum and verification bias

Frei 2008This was a retrospective study with a possible risk of spectrum and verification bias

Fritz 1992Type of study not relevant: Letter

Furtschegger 1988This was a retrospective study with a possible risk of spectrum and verification bias

Girard 1995Type of study not relevant: Narrative review

Goergen 1996Type of study not relevant: Technique report

Goldberg 2003Reference standard not relevant: Arthrography findings and clinical examination were used as reference standard

Hedtmann 2002Type of study not relevant: Narrative review

Heijne 2004Type of study not relevant: Editorial letter

Herold 2006Participants not relevant: A history of trauma was reported in 17 (33%) of 51 patients

Fourteen (27%) of 51 patients had previous shoulder dislocation, and 36 (71%) presented with clinical signs of impingement

Herzog 1997Type of study not relevant: Narrative review

Herzog 1998Type of study not relevant: Narrative review

Hodler 1987Reference standard not relevant: Arthrography was used as reference standard

Hodler 1988This was a retrospective study with a possible risk of spectrum and verification bias

Hodler 1992Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Hollister 1995Target condition not relevant: The aim of the study was to determine the association between bursal and joint effusion (index tests findings) that are associated with rotator cuff tears

Homsi 1989This was a retrospective study with a possible risk of spectrum and verification bias

Horii 1998Participants not relevant: Selective population that all participants had full thickness tears (100% of prevalence) and the study was retrospective and reported non-consecutive recruitment

Iannotti 1991Participants not relevant: Asymptomatic participants were enrolled

Imhoff 1992Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Imhoff 1993Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Imhoff 1996Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Iovane 2001Participants not relevant: Selective population that all participants had full thickness tears (100% of prevalence) and the study was retrospective and reported non-consecutive recruitment

Iyengar 2010Type of study not relevant: Technique report

Jacobson 2003Type of study not relevant: Narrative review

Jacobson 2004Target condition not relevant: The aim of the study was to determine which US signs are important for the diagnosis of a surgically identifiable supraspinatus tendon tear

Jaovisidha 1999Type of study not relevant: The time elapsed between the index and reference tests was during a 26-month follow-up

Jeyam 2008This was a retrospective study with a possible risk of spectrum and verification bias

Jung 2009Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Jung 2010Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Kaneko 1994Participants not relevant: A control group without suspected of rotator cuff tears was included

Kautzner 2008Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Kelly 2009Type of study not relevant: Diagnostic Test Accuracy review

Kerkovsky 2008Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Kluger 2003Target condition not relevant: The aim of this study was to evaluate the accuracy of MRA and US in millimetres for both width and retraction of full-thickness rotator cuff tears, and not to detect the tears

Kneeland 1987Reference standard not relevant: Arthroscopy or arthrography was used as reference standard

Kujat 1986Type of study not relevant: Technique report

Kurol 1991This was a retrospective study with a possible risk of spectrum and verification bias

Lawson 1991Type of study not relevant: Narrative review

Lee 2002Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Lipman 1992Type of study not relevant: Letter

Loew 2000Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Lopez 2007This was a retrospective study with a possible risk of spectrum and verification bias

Low 1998Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Lucas 1991Type of study not relevant: Narrative review

Mack 1988This was a retrospective study with a possible risk of spectrum and verification bias

Magee 2003aParticipants not relevant: Participants with shoulder pain; however, it was unclear if all participants were suspected of having rotator cuff tears

Magee 2003bParticipants not relevant: Participants with shoulder pain; however, it was unclear if all participants were suspected of having rotator cuff tears

Magee 2006Participants not relevant: Participants with shoulder pain; however, it was unclear if all participants were suspected of having rotator cuff tears

Magee 2007Participants not relevant: Participants with clinical diagnosis of pain or instability or both were enrolled

Magee 2009Participants not relevant: Participants with shoulder pain; however, it was unclear if all participants were suspected of having rotator cuff tears

Malvestiti 1997Reference standard not relevant: Arthroscopy or MRI or arthrography was used as reference standard

Martin 2008Type of study not relevant: Technique report

Masaoka 1999Participants not relevant: Participants who underwent index test after surgery were enrolled

Masciocchi 1989Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Meister 2004This was a retrospective study with a possible risk of spectrum and verification bias

Mendieta-Sevilla 2009Reference standard not relevant: Surgery or MRI or arthrography or rehabilitation was used as reference

standard

Merl 1996Type of study not relevant: Narrative review

Middleton 1993Type of study not relevant: Letter

Miller 2008This was a retrospective study with a possible risk of spectrum and verification bias

Montrucchio 1997This was a retrospective study with a possible risk of spectrum and verification bias

Monu 1994Participants not relevant: The study included selective participants without rotator cuff tears

Moosmayer 2005Participants not relevant: Participants with other shoulder complaints, including symptoms from the long head of the biceps muscle were enrolled

Moosmayer 2007Participants not relevant: Participants with shoulder pain; however, it was unclear if all participants were suspected of having rotator cuff tears

Morrison 1990Reference standard not relevant: Arthrography or arthroscopy or open surgery was used as reference standard

Naqvi 2009This was a retrospective study with a possible risk of spectrum and verification bias

Narbona 2007Target condition not relevant: The aim of this study was to detect SLAP lesion in patients with rotator cuff tears

Needell 1997Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Nelson 1991Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Nogueira-Barbosa 2002This was a retrospective study with a possible risk of spectrum and verification bias

Norregaard 2002Participants not relevant: Participants with clinical suspicion of labral or rotator cuff lesion were enrolled

Oh 2009Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Oh 2010Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Ostlere 1997Type of study not relevant: Narrative review

Ozcakar 2005Type of study not relevant: Letter

Paavolainen 1994This was a retrospective study with a possible risk of spectrum and verification bias

Palmer 1993Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Palmer 1994Type of study not relevant: Narrative review

Parsa 1997Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Pattee 1988This was a retrospective study with a possible risk of spectrum and verification bias

Patten 1994Reference standard not relevant: Arthroscopy, arthrography and non-surgical therapy were used as reference standard

Peetrons 1986Type of study not relevant: Index test was not compared with reference standard(s).

Pfirrmann 1999Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Pfirrmann 2004Participants not relevant: Asymptomatic participants were included

Pigeau 1992Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Poey 1990Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Porcellini 1994Reference standard not relevant: Surgery or arthrography was used as reference standard

Prendergast 1992Type of study not relevant: Narrative review

Quinn 1995This was a retrospective study with a possible risk of spectrum and verification bias

Rafii 1990Participants not relevant: Asymptomatic participants were included

Read 1998Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all

participants were suspected of having rotator cuff tears

Recht 1993Type of study not relevant: Narrative review.

Recht 1994Type of study not relevant: Narrative review.

Reinus 1995Participants not relevant: Participants with shoulder pain; however, it was unclear if all participants had suspected of having rotator cuff tears.

Roberts 1998Reference standard not relevant: MRI or arthrography was used as reference standard.

Roberts 2001Participants not relevant: Participants with other shoulder complaints, including adhesive capsulitis and osteoarthritis were enrolled.

Robertson 1995Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Rouaud 1989Type of study not relevant: Index test (US) was not compared with reference standard(s)

Rubin 1997Type of study not relevant: Letter

Rutten 2010aParticipants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Rutten 2010bParticipants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears.

Sahin-Akyar 1998Participants not relevant: Participants with rotator cuff tear and other disorders were enrolled

Sartoris 1992Type of study not relevant: Narrative review

Sasaki 1990Participants not relevant: Asymptomatic participants were included

Schneider 2003Insufficient data to be included in the meta-analyses

Schreinemachers 2009Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Schultz 1994Type of study not relevant: Letter

Seeger 1988Type of study not relevant: The study did not describe the comparison between the index test and the reference standard

Sheah 2009Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Shellock 1996Type of study not relevant: Narrative review

Shellock 2001Participants not relevant: The authors reported that participants with suspected of ‘shoulder pathology’ were included, probable included participants with suspected of rotator cuff tears and shoulder instability

Shiv 1990Type of study not relevant: Index test (US) was not compared with reference standard(s)

Singer 1995Type of study not relevant: Index test was not compared with reference standard(s)

Singson 1996Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Skib 1998Type of study not relevant: Letter

Soble 1989This was a retrospective study with a possible risk of spectrum and verification bias

Sonin 1996This was a retrospective study with a possible risk of spectrum and verification bias

Sonnabend 1997This was a retrospective study with a possible risk of spectrum and verification bias

Soto Araiza 1998Reference standard not relevant: Surgery or MRI was used as reference standard

Steinbach 2000Type of study not relevant: Narrative review

Strauss 1998This was a retrospective study with a possible risk of spectrum and verification bias

Suder 1994Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Sunde 2001Type of study not relevant: Letter

Sunde 2008Type of study not relevant: Letter

Taboury 1995Participants not relevant: Selective population that all participants had full thickness tears (100% of prevalence) and the study was retrospective and reported non-consecutive recruitment

Takagishi 1993Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Takagishi 1996This was a retrospective study with a possible risk of spectrum and verification bias

Teefey 2000Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Teefey 2009Type of study not relevant: Case report

Theodoropoulos 2010Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Tirman 1994Participants not relevant: Selective population of five professional throwing athletes were evaluated; and, these participants had other shoulder complaints, including instability

Torstensen 1999Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Touzard 1991Reference standard not relevant: Surgery or arthrography was used as reference standard

Toyoda 2005Participants not relevant: Selective population that all participants had full thickness tears (100% of prevalence) and the study was retrospective and reported non-consecutive recruitment

Traughber 1992This was a retrospective study with a possible risk of spectrum and verification bias

Traughber 1996Type of study not relevant: Letter

Traughber 2006Type of study not relevant: Letter

Tuite 1994Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Tuite 1995Participants not relevant: It was unclear if all participants were suspected of having rotator cuff tears;

furthermore, the study reported that part of participants of Tuite 1994 were included

Thus, participants with other shoulder complaints, including instability were enrolled

Tuite 1998Participants not relevant: It was unclear if all participants were suspected of having rotator cuff tears; furthermore, the study reported that part of participants of Tuite 1994 were included

Thus, participants with other shoulder complaints, including instability were enrolled

Tuite 2001Participants not relevant: It was unclear if all participants were suspected of having rotator cuff tears; probable the study included participants with shoulder instability

Turrin 1997This was a retrospective study with a possible risk of spectrum and verification bias

Vahlensieck 2001Type of study not relevant: Letter

Van Dyck 2009Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Van Holsbeeck 1995This was a retrospective study with a possible risk of spectrum and verification bias

Van Moppes 1995Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Vander Maren 1995Participants not relevant: Participants with shoulder pain were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

Vanecek 2000Type of study not relevant: Narrative review

Waldt 2007Participants not relevant: Participants with symptomatic shoulder; however, it was unclear if all participants were suspected of having rotator cuff tears

Wallny 1999Type of study not relevant: Technique report

The study described an index to improve the accuracy of diagnosis of chronic rotator cuff tears

Walz 2007Target condition not relevant: The aim of this study was a description of delamination tears of the supraspinatus, subscapularis, infraspinatus or teres minor tendons, as well as for mention of partial or full thickness tears

Wang 1994Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Weinstabl 1988Type of study not relevant: Technique report

Wiener 1993This was a retrospective study with a possible risk of spectrum and verification bias

Wilson 1994Type of study not relevant: Letter

Wnorowski 1997Participants not relevant: Participants with shoulder problems were enrolled; however, it was unclear if all participants were suspected of having rotator cuff tears

The study reported that in the majority of the participants the primary diagnosis was unclear after the clinical evaluation

Wu 2003This was a retrospective study with a possible risk of spectrum and verification bias

Yagci 2001Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Yamakawa 2001Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Yeh 2003Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

Yeu 1994This was a retrospective study with a possible risk of spectrum and verification bias

Zehetgruber 2002This was a retrospective study with a possible risk of spectrum and verification bias

Ziegler 2004This was a retrospective study with a possible risk of spectrum and verification bias

Zlatkin 1989This was a retrospective study with a possible risk of spectrum and verification bias

Zlatkin 2004Participants not relevant: Participants with other shoulder complaints, including instability were enrolled

 
Characteristics of studies awaiting classification [ordered by study ID]
Engebretsen 1994

Clinical features and settings

ParticipantsNumber of participants eligible: 41 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 25 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - Norwegian article

The information was collected from titles and abstracts that were reported in English

Farin 1990

Clinical features and settings

ParticipantsNumber of participants eligible: 301 participants

Number of participants enrolled IT and RS:

- US and surgery: 66 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Guo 2000

Clinical features and settings

ParticipantsNumber of participants eligible: 53 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 53 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Open surgery or arthroscopy

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - Chinese article

The information was collected from titles and abstracts that were reported in English

Habermeyer 1984

Clinical features and settings

ParticipantsNumber of participants eligible: 49 participants

Number of participants enrolled IT and RS:

- US and surgery: 17 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears

Reference standard(s): Open surgery

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Hedtmann 1995

Clinical features and settings

ParticipantsNumber of participants eligible: 4172 participants

Number of participants enrolled IT and RS:

- US and surgery: 1227 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears

Reference standard(s): Open surgery

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Heininger-Biner 2000

Clinical features and settings

ParticipantsNumber of participants eligible: 88 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 88 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Kayser 2005

Clinical features and settings

ParticipantsNumber of participants eligible: 239 participants

Number of participants enrolled IT and RS:

- US and surgery: 239 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Kenn 2000

Clinical features and settings

ParticipantsNumber of participants eligible: 40 participants

Number of participants enrolled IT and RS:

- US and surgery: 40 participants

- MRI and surgery: 40 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI and US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Kumagai 1991

Clinical features and settings

ParticipantsNumber of participants eligible: 30 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 30 participants

- MRA and surgery: 30 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI and MRA

Follow-up

NotesAwaiting translation - Japanese article

The information was collected from titles and abstracts that were reported in English

Kumagai 1992

Clinical features and settings

ParticipantsNumber of participants eligible: 115 participants

Number of participants enrolled IT and RS:

- MRI and surgery: unclear

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - Japanese article

The information was collected from titles and abstracts that were reported in English

Kumagai 1995

Clinical features and settings

ParticipantsNumber of participants eligible: 94 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 21 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of full thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - Japanese article

Labanauskaite 2002

Clinical features and settings

ParticipantsNumber of participants eligible: 31 participants

Number of participants enrolled IT and RS:

- US and surgery: 31 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - Lithuanian article

The information was collected from titles and abstracts that were reported in English

Manych 2007

Clinical features and settings

ParticipantsNumber of participants eligible: 275 participants

Number of participants enrolled IT and RS:

- MRA and surgery: 197 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

Index and comparator testsIndex test(s): MRA

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Nagamori 1995

Clinical features and settings

ParticipantsNumber of participants eligible: 45 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 45 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - Japanese article

The information was collected from titles and abstracts that were reported in English

Qu 2008

Clinical features and settings

ParticipantsNumber of participants eligible: 57 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 57 participants

- MRA and surgery: 57 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

Index and comparator testsIndex test(s): MRI and MRA

Follow-up

NotesAwaiting translation - Chinese article

The information was collected from titles and abstracts that were reported in English

Rudolph 2000

Clinical features and settings

ParticipantsNumber of participants eligible: 63 participants

Number of participants enrolled IT and RS:

- MRA and surgery: 32 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Sakuragi 1989

Clinical features and settings

ParticipantsNumber of participants eligible: unclear number of participants

Number of participants enrolled IT and RS:

- US and surgery: unclear number of participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - Japanese article

The information was collected from titles and abstracts that were reported in English

Sasaki 1991

Clinical features and settings

ParticipantsNumber of participants eligible: 30 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 15 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - Japanese article

The information was collected from titles and abstracts that were reported in English

Schedel 1990

Clinical features and settings

ParticipantsNumber of participants eligible: 30 participants

Number of participants enrolled IT and RS:

- US and surgery: unclear number of participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Schroder 2003

Clinical features and settings

ParticipantsNumber of participants eligible: 80 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 80 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Open surgery or shoulder arthroscopy

Index and comparator testsIndex test(s): MRI

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Sell 1992

Clinical features and settings

ParticipantsNumber of participants eligible: 37 participants

Number of participants enrolled IT and RS:

- MRI and surgery: unclear number of participants

- US and surgery: unclear number of participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Open surgery or shoulder arthroscopy

Index and comparator testsIndex test(s): MRI and US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Sperner 1993

Clinical features and settings

ParticipantsNumber of participants eligible: 375 participants

Number of participants enrolled IT and RS:

- US and surgery: 375 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Open surgery

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Vahlensieck 1996

Clinical features and settings

ParticipantsNumber of participants eligible: 25 participants

Number of participants enrolled IT and RS:

- MRI and surgery: 25 participants

- US and surgery: 25 participants

- MRA and surgery: 25 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

Index and comparator testsIndex test(s): MRI, US and MRA

Follow-up

NotesAwaiting translation - German article

The information was collected by titles and abstracts that were reported in English

Wallny 2000

Clinical features and settings

ParticipantsNumber of participants eligible: 25 participants

Number of participants enrolled IT and RS:

- US and surgery: 25 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Surgery

Unclear whether arthroscopy or open surgery

Index and comparator testsIndex test(s): US

Follow-up

NotesAwaiting translation - German article

The information was collected from titles and abstracts that were reported in English

Wang 2009

Clinical features and settings

ParticipantsNumber of participants eligible: 40 participants

Number of participants enrolled IT and RS:

- MRA and surgery: 40 participants

Study design

Target condition and reference standard(s)Target conditions: Presence of any rotator cuff tears, full thickness tears and partial thickness tears

Reference standard(s): Shoulder arthroscopy

Index and comparator testsIndex test(s): MRA

Follow-up

NotesAwaiting translation - Chinese article

The information was collected from titles and abstracts that were reported in English

 
Table 1. Comparison of MRI, US and MRA for detection of any rotator cuff tears (partial or full thickness) using all studies (indirect comparison)

Index testStudiesShouldersCasesSummary sensitivity (95% CI)Summary specificity (95% CI)LR+LR–Test1

Any rotator cuff tears 

MRI634726398 (92, 99)79 (68, 87)5 (2, 10)0.03 (0.01, 0.11)P = 0.13

US1385462691 (83, 95)85 (74, 92)6 (3, 12)0.11 (0.05, 0.22)

Full thickness tears 

MRI736819394 (85, 98)93 (83, 97)13 (6, 29)0.06 (0.02, 0.16)P = 0.7

MRA318310794 (80, 98)92 (83, 97)12 (5, 30)0.06 (0.02, 0.23)

US1072938692 (82, 96)93 (81, 97)12 (5, 34)0.09 (0.04, 0.20)

Partial tears 

MRI63478374 (59, 85)93 (84, 97)10 (4, 26)0.28 (0.17, 0.48)P = 1.00

US866012152 (33, 70)93 (85, 97)8 (3, 19)0.52 (0.33, 0.80)

 1 Likelihood ratio test for evidence of a difference in sensitivity and/or specificity between the tests.
LR+ = positive likelihood ratio; LR– = negative likelihood ratio
 
Table 2. Comparison of MRI and US for detection of rotator cuff tears (any, partial or full thickness) limited to studies in which all participants received both MRI and US (direct comparison)

StudyCasesNon-casesMRIUSDifference in sensitivity (95% CI)Difference in specificity (95% CI)


Sensitivity (95% CI)Specificity (95% CI)Sensitivity (95% CI)Specificity (95% CI)

Any rotator cuff tears

Iannotti 2005792095 (88, 99)75 (51, 91)96 (89, 99)80 (56, 94)-1 (-8, 5)-5 (-31, 21)

Martin-Hervas 2001342791 (76, 98)74 (54, 89)71 (53, 85)67 (46, 83)21 (3, 39)7 (-17, 32)

Teefey 2004656100 (94, 100)67 (22, 96)97 (89, 100)67 (22, 96)3 (-1, 7)0 (-53, 53)

Full thickness tears

Iannotti 2005425795 (84, 99)88 (76, 95)88 (74, 96)82 (70, 91)7 (-5, 19)5 (-8, 18)

Martin-Hervas 2001263581 (61, 93)97 (85, 100)58 (37, 77)100 (90, 100)23 (-1, 47)-3 (-8, 3)

Swen 199913877 (46, 95)88 (47, 100)92 (64, 100)88 (47, 100)-15 (-42, 12)0 (-32, 32)

Teefey 20044625100 (92, 100)68 (46, 85)98 (88, 100)80 (59, 93)2 (-2, 6)-12 (-36, 12)

Partial thickness tears

Iannotti 2005376273 (56, 86)90 (80, 96)70 (53, 84)89 (78, 95)3 (-18, 23)2 (-9, 12)

Martin-Hervas 200185350 (16, 84)75 (62, 86)13 (0, 53)68 (54, 80)38 (-4, 79)8 (-10, 25)

Teefey 2004195263 (38, 84)98 (90, 100)68 (43, 87)96 (87, 100)-5 (-35, 25)2 (-4, 8)

 
Table 3. Comparison of MRA and US for detection of rotator cuff tears (any, partial or full thickness) limited to studies in which all patients received both MRI and US (direct comparison)

StudyCasesNon-casesMRAUS1 Difference in sensitivity (95% CI)Difference in specificity (95% CI)


Sensitivity (95% CI)Specificity (95% CI)Sensitivity (95% CI)Specificity (95% CI)

Any rotator cuff tears

Kang 2009455100 (92, 100)80 (28, 99)96 (85, 99)100 (48, 100)4 (-2, 10)-20 (-55, 15)

Sipola 20102641197 (89, 100)82 (48, 98)92 (83, 97)45 (17, 77)4 (-3, 12)36 (-0.9, 74)

Full thickness tears

Kang 2009401097 (87, 100)90 (55, 100)88 (73, 96)90 (55, 100)10 (-1, 21)0 (-26, 26)

Sipola 20103571888 (76, 95)94 (73, 100)83 (71, 91)53 (29, 76)5 (-8, 18)42 (17, 67)

Partial thickness tears

Kang 200954580 (28, 99)96 (85, 99)40 (5, 85)89 (76, 96)40 (-15, 95)7 (-4, 18)

Sipola 2010476871 (29, 96)88 (78, 95)13 (0, 53)87 (77, 94)59 (18, 99)1 (-10, 12)

 1 For the three target conditions, there were 2 additional shoulders for US
2 66 cases for detection of any rotator cuff tears using US
3 8 cases and 69 non-cases for detection of full thickness tears using US
4 58 cases and 19 non-cases for detection of partial thickness tears using US