Surgical Science, 2013, 4, 6-14
http://dx.doi.org/10.4236/ss.2013.49A002 Published Online September 2013 (http://www.scirp.org/journal/ss)
Surgeon-Operated In-Office Ultrasonography for the
Diagnosis of Rotator Cuff Tears: A Comparison with
Magnetic Resonance Imaging
Tsutomu Kobayashi1*#, Atsushi Yamamoto1*, Hitoshi Shitara1, Tsuyoshi Ichinose1, Eiji Takasawa1,
Daisuke Shimoyama1, Toshihisa Osawa2, Kenji Takagishi1
1Department of Orthopaedi c Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
2Department of Orthopae d ic Surgery, Takasaki General Medical Center, Takasaki, Japa n
Received May 26, 2013; revised June 27, 2013; accepted July 6, 2013
Copyright © 2013 Tsutomu Kobayashi et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Obje ctive: Few investigators have evaluated whether ultrasonography operated by a surgeon during a patient’s clinic
visit is capable of obtaining a similar degree of accuracy as magnetic resonance imaging in regard to the diagnosis of
rotator cuff tears and lesions of the biceps tendon. Th e purpose of this study was to clarify the accur acy of in-office ul-
trasonography for the diagnosis of rotator cuff tears in comp arison to magnetic resonance imaging. Methods: One hun -
dred and three patients (105 shoulders) with a clinical diagnosis of impingement and suspected rotator cuff tear, who
subsequently underwent arthroscopic surgery were retrospectively enrolled in this study, including 7 males with 89
shoulders, and 33 females with 33 shoulders, and their mean age was 60.9 years (range, 30 to 83 years). The subjects
were examined using ultrasonography and magnetic resonance imaging within three months pre-operatively per normal
practice of the outpatient clinic. The two modalities were then compared to the reference standard, arthrosco pic finding s.
Results: Intra-operatively, 79 full-thickness and 15 partial-thickness rotator cuff tears were found. The agreement be-
tween ultrasonography and magnetic resonance imaging for diagnosis of rotator cuff tears was statistically good; ob-
served degree of agreement was 87 % with Kappa coefficient of 0.73. Ultrasonograph y showed a sensitiv ity of 94% an d
a specificity of 100% for full-thickness tears, and a sensitivity of 80% and a specificity of 91% for partial-thickness
tears. The agreement of the two modalities for diagno sis of lesions of the biceps ten don was also good; observed degree
of agreement was 93% with Kappa coefficient of 0.76. In addition, ultrasonography showed comparable accuracy for
classifying the size of rotator cuff tears to that of magnetic resonance imaging. Conclusion: Surgeon-operated in-office
ultrasonography is an appropriate technique for the assessment of rotator cuff tears with a comparable sensitivity and
specificity to that of magnetic resonance imaging.
Keywords: Diagnostic Accuracy; Magnetic Resonance Imaging; Rotator Cuff Tear; Ultrasonography; Arthroscopic
Surgery
1. Introduction
A rotator cuff tear is one of the most common disorders
affecting the shoulder and a recent population-based
study showed that approximately one-fourth of residents
of a rural area over 50 years of age had full-thickness
rotator cuff tears [1]. A proper diagnosis based on accu-
rate imaging is indispensable for deciding on the appro-
priate management.
The first study using ultrasonography to detect rotator
cuff tears was reported in 1979 by Seltzer et al. [2]. Al-
though several studies tried to develop accurate diagnos-
tic methods, the early reports of ultrasonography for ro-
tator cuff tears were not able to show favorable results,
probably due to the immaturity of the technique related
to the procedure and the instrument itself [3,4]. Thus,
magnetic resonance imaging had been considered the
first-choice imaging modality for the detection of rotator
cuff tears because of its high accuracy, despite its rela-
tively high cost and occasional limited availability [5,6].
However, following the development of new devices,
such as high-frequency transducers and improvements in
*Both authors contributed equally to this work.
#Corresponding author.
C
opyright © 2013 SciRes. SS

T. KOBAYASHI ET AL. 7
real-time imaging, a number of studies have reported the
high accuracy of ultrasonography for detecting rotator
cuff tears [7-9]. Ultrasonography of the shoulder has be-
come an accepted method for evaluating rotator cuff
tears.
Although both ultrasonography and magnetic reso-
nance imaging are highly accurate, widely-used and non-
invasive imaging modalities for the diagnosis of rotator
cuff tears [10] ultrasonography is relatively less expen-
sive, less time-consuming, and permits a dynamic eval-
uation of the shoulder. Furthermore, the portability of
ultrasonography means that the integrity of the rotator
cuff can be assessed in geographically isolated locations
or by a surgeon during a clinic session to allow more ef-
ficient planning of treatment [8]. There have been several
studies that compared the accuracy of ultrasonography
and magnetic resonance imaging [9,11,12], however, few
investigators have evaluated whether ultrasonography
performed by a surgeon during the patient’s clinic visit is
capable of obtaining a similar degree of accuracy as
magnetic resonance imaging with regard to the diagnosis
of rotator cuff tears and lesions of the biceps tendon. The
purpose of this study was to compare the accuracy of
surgeon-operated in-office ultrasonography and magnetic
resonance imaging for the detection and measurement of
the size of rotator cuff tears, with the results of arthro-
scopic surgery as the reference standard.
2. Materials and Methods
2.1. Subjects
After institutional review board approval was obtained,
122 patients (122 shoulders) with a clinical diagnosis of
impingement and a suspected rotator cuff tear, experi-
encing pain, decreased function, and/or weakness, who
subsequently underwent arthroscopic surgery in our in-
stitute from January 2010 to August 2012, were retro-
spectively enrolled in th is study.
All patients gave informed consent to particip ate in the
study. The patients were allocated to one of three ortho-
paedic surgeo ns, with a specialist interest in the shoulder
for more than 7 years. And these surgeons have more
than 5-years experiences of orthopaedic ultrasonography.
Each of these surgeons performed a preoperative evalua-
tion including ultrasonography and magnetic resonance
imaging, and subsequently performed arthroscopic sur-
gery, independently. This process occurred as part of the
standard outpatient allo cation, but did not involve patient
pre-selection by the clinicians. Of these pa tients, the sub-
jects who were involved in the study included patients
who 1) had undergone a preoperative examination by
both ultrasonography and magnetic resonance imaging
within three months before surgery, 2) had complete data
of all target evaluation items.
The exclusion criteria were patients 1) with claustro-
phobia, 2) who had metal devices in the field of view, 3)
has undergone a previous surgery, 4) had a previous
fracture, or 5) had a known inflammatory arthropathy.
Based on these criteria, one patient was excluded because
of claustrophobia and 16 patients were excluded because
they had incomplete data.
Thus, this study comprised 103 patients (105 shoul-
ders); there were 87 males with 89 shoulders, and 33
females with 33 shoulders, and their mean age was 60.9
years (range, 30 to 83 years).
2.2. Ultrasonography
All ultrasonographic examinations were performed be-
fore MRI within the normal flow of the outpatient clinic
by one of the three aforementioned orthopaedic surgeons,
using a LOGIQ e instrument (GE Healthcare, Bucking-
hamshire, England) with linear-array probes at 12 MHz.
The standard technique was a modification of the
technique described by Middleton et al. [13] and Teefey
et al. [14]. Parameters such as the scanning frequency,
focal zone number and placement, field of view, and gain
were not standardized, but left to the discretion of the
observer.
Both the patient and the observer were seated on
backless stools facing each other. First, the biceps tendon
was examined in front of the shoulder by transverse and
longitudinal scans. Then the patient was asked to hold
the arm in external rotation, and the lon gitudinal scans of
the subscapularis tendon were examined. Next, the lon-
gitudinal scans of the supraspinatus tendon was exam-
ined with the shoulder extended, the elbow flexed, and
the hand placed on the iliac wing to expose as much of
the supraspinatus tendon as possible from under the ac-
romion. The transducer was moved anteriorly to posteri-
orly in order to provide the best longitudinal scans of the
infraspinatus tendon. The transducer was then rotated 90
degrees in order to examine the transverse areas of the
supraspinatus and infrasupinatus tendons.
A full-thickness rotator cuff tear was diagnosed when
there was a focal discontinuity or thinning of the rotator
cuff or when the cuff could not be visualized because of
complete avulsion and retraction under the acromion [14,
15]. A partial-thickness tear was diagnosed when there
was minimal flattening of the bursal side of the rotator
cuff or a distinct hypoechoic or mixed hyperechoic and
hypoechoic defect was visualized in both the longitudinal
and the transverse planes at the deep articular side of the
rotator cuff [14].
The size of the tear in centimeters was also measured
directly on freeze-frame images with use of the cursor
software function. When the torn cuff was retracted un-
der the acromion, the size was recorded as a “not lower
than” measured length. Additionally, a finding of a rup-

T. KOBAYASHI ET AL. 8
ture of the biceps tendon was recorded when the tendon
was not identified within or medial to the intertubercular
sulcus. Dislocation of the biceps tendon was recorded
when the tendon was anterior or medial to the lesser tu-
berosity [14].
2.3. Magnetic Resonance Imaging
After examining clinical findings and ultrasonography,
magnetic resonance imaging was performed with the
same equipment at various facilities, but all examinations
were performed under the same standardized conditions.
Patients were positioned in the supine positio n with their
arms in a neutral position. A 1.5-T system with standard
coil was used. The slice thickness was 3 - 4 mm, the field
of view was small (12 - 16 cm) and the imaging matrix
was 256 mm × 192 mm or higher. The sequences per-
formed in all patients were T1- and T2-weighted images
in the oblique coronal, oblique sagittal and axial planes.
All magnetic resonance imaging was also referred blind-
ly within the normal flow of the outpatient clinic by an-
other orthopaedic surgeon who ultrasonographically ex-
amined the patient.
A full-thickness rotator cuff tear was diagnosed if
there was a fluid-filled gap on the T2-weighted oblique
coronal or oblique sagittal plane that extended through
the entire thickness of the tendon, or a complete disrupt-
tion of all tendon fibers with retraction. A partial-thick-
ness tear was defined as an increase in the signal noted
on the T1-weighted images with a brighter signal on the
T2-weighted images, as well as an identification of a
focal defect on either the bursal or the articular surface of
the involved tendon [16]. The size of the tear was meas-
ured in centimeters with use of the magnetic resonance
imaging scale noted on the images. Additionally, a find-
ing of a rupture and dislocation of the biceps tendon was
recorded.
2.4. Arthroscopic Surgery
One of the three aforementioned orthopaedic surgeons
who examined the ultrasonography scans and magnetic
resonance images of the patient performed the same pa-
tient’s surgery independently. There were 92 cases of
arthroscopic rotator cuff repair and 13 cases of arthro-
scopic subacromial decompression. A capsular release
was added in five cases, biceps tenotomy was added in
three cases and resection of the distal clavicle was added
in one case.
All surgeries were performed with completely arthro-
scopic techniques, placing the patient in the beach-chair
position under general anesthesia. Intraoperatively, the
following findings were recorded: the presence or ab-
sence of a rotator cuff tear, the type (full- or partial-
thickness) of the tear and the size of the tear in centime-
ters. A calibrated arthroscopic probe was used to define
both the anteroposterior and the medilolateral size of the
tear. In addition, the presence or absence of a complete
rupture and complete dislocation of the biceps tendon
were recorded. Any suspected cases of partial-thickness
tears and subluxation of the biceps tendon were consid-
ered to be negative findings in this study.
2.5. Data Analysis
First, the accuracy of ultrasonography and magnetic reso-
nance imaging for the diagnosis of rotator cuff tears was
calculated with 95% con fidence intervals (95% CI) using
the arthroscopic diagnosis as the reference standard. The
two modalities were then compared with regard to the
observed degree of agreement, with Cohen’s Kappa co-
efficient and McNemar’s test for paired proportions.
Subsequently, the diagnostic parameters for a diagnosis
of full- and partial-thickness rotator cuff tears, such as
the sensitivit y, specif icity, po sitive pr edictive value (PPV),
negative predictive value (NPV) and accuracy, were cal-
culated with the 95% CI. When counting the full-thick-
ness rotator cuff tears, partial-thickness tears were con-
sid ered to be no tear, and when counting for partial-thick -
ness tears, full-thickness tears were considered to be par-
tial-thickness tears, because a tear was identified [14].
Second, the accuracy of ultrasonography and magnetic
resonance imaging for the diagnosis of the lesions of the
biceps tendon was calculated and data were compared in
the same way. When counting for the rupture of the bi-
ceps tendon, the dislocation of the biceps tendon was
considered to be a negative finding, because the tendon
was assumed to be visualized, and when counting for the
dislocation of the biceps tendon, a rupture of the biceps
tendon was considered to be a positive finding, because
the tendon w as assume d to h ave not be en visualized.
Finally, the size of the tear was examined. According
to the classification of DeOrio and Cofield [17], th e leng-
th of the greatest diameter was used to divide the tear
int o one of four categories: small (one centimeter or less) ,
medium (one to three centimeters), large (three to five
centimeters), massive (greater than five centimeters). Be-
cause ultrasonography could not measure the exact di-
ameter of a huge tear due to the interference of the ac-
romion, the categories of large and massive wer e counted
together.
Thus, each case was classified as following four cate-
gories in this study; no tear, small (one centimeter or
less), medium (one to three centimeters), large/massive
(greater than three centimeters). The accuracy of ultra-
sonography and magnetic resonance imaging for the
classification of the tear size was calculated with the 95%
CI. In addition, the agreement of the two modalities was
examined with the observed degree of agreement, and

T. KOBAYASHI ET AL. 9
Cohen’s Kappa coefficient and McNemer’s test were
used for paired proportions.
All statistical analyses were performed by using the R
software program, version 2.15.0
(http://www.R-project.org) [18], and the critical value for
significance was set at P < 0.05. The Kappa coefficient
was interpreted as follows: 0.00 - 0.20, poor agreement;
0.21 - 0.40, fair agreement; 0.41 - 0.60, moderate agree-
ment; 0.61 - 0.80, good agreement; and 0.81 - 1.00, ex-
cellent agreement.
3. Results
3.1. Diagnosis of Rotator Cuff Tears
At arthroscopic surgery, 79 full-thickness and 15 par-
tial-thickness rotator cuff tears were found. The overall
accuracy of ultrasonography and magnetic resonance
imaging for the diagnosis of rotator cuff tears was 93%
and 84%, respectively (Table 1). The agreeme nt b etwe en
the ultrasonography and magnetic resonance imaging
findings was good: the observed degree of agreement
was 87% and the weighted Cohen’s Kappa coefficient
was 0.73. The McNemar test showed that the differences
between the two modalities were not statistically signifi-
cant (Table 2). The diagnostic parameters of ultrasono-
graphy and magnetic resonance imaging for the diagnosis
of rotator cuff tears are shown in Table 3.
3.2. Diagnosis of Lesions of the Biceps Tendon
At arthroscopic surgery, 11 ruptures and nine disloca-
tions of the biceps tendon were found. The overall accu-
racy of ultrasonography and magnetic resonance imaging
for the diagnosis of lesion s of the bicep s tendon was 93%
and 92%, respectively (Table 4). The agreeme nt b etwe en
the ultrasonography and magnetic resonance imaging
findings was good: the observed degree of agreement
was 93% and Cohen’s Kappa coefficient was 0.76. The
McNemar test showed that the differences between the
two modalities were not statistically significan t (Table 5).
The diagnostic parameters of ultrasonography and mag-
netic resonance imaging for the diagnosis of lesions of
the biceps tendon are shown in Table 6.
3.3. Accuracy for the Classification of the Tear
Size
Table 7 shows the comparison between the arthroscopic
classification of the size of the rotator cuff tears and the
classification made with ultrasonography and magnetic
resonance imaging. The overall accuracy of ultrasono-
graphy and magnetic resonance imaging for the classifi-
cation of the size of rotator cuff tears was 74% and 75%,
respectively. The agreement between the ultrasonogra-
phy and magnetic resonance imaging findings was good:
the observed degree of agreement was 79%, and the wei-
ghted Cohen’s Kappa coefficient was 0.77. The McNe-
mar test showed that the differences between the two
modalities were not statistically significant (Table 8).
4. Discussion
There have been a number of studies presenting the ac-
sess its diagnostic ability, and showed a sensitivity of
92% - 96% and a specificity of 93% - 96% for full-
thickness tears, and a sensitivity of 67% - 84% and a
specificity of 89% - 94% for partial-thickness tears [7,8,
10]. They all agreed that ultrasonography is an appropri-
ate technique for assessing rotator cuff tears with an ac-
ceptable sensitivity and specificity, despite the fact that
the diagnostic accuracy for partial-thickness tears is
somewhat inferior to that for full-thickness tears. The
current study showed almost the same results as these
meta-analyses, with a sensitivity of 94 % and a specificity
of 100% for full-thickness ro tator cuff tears, and a sensi-
tivity of 80% and a specificity of 91% for partial-thick-
ness rotator cuff tears.
Regarding the comparison between ultrasonography
and magnetic resonance imaging for the diagnosis of
rotator cuff tears, only two studies have directly com-
pared the two modalities with the use of surgery as the
reference standard. Martín-Hervás et al. [11] prospec-
tively assessed 61 painful shoulders and found that the
diagnosis of full-thickness tears was highly specific by
both imaging techniques (100% for ultrasonography and
97% for magnetic resonance imaging) but was not as
sensitive, (58% for ultrasonography and 81% for magnetic
Table 1. Comparison of the arthroscopic diagnosis of rotator cuff tears with the ultrasonography and magnetic resonance
imaging findings.
Ultrasonography Magnetic reso nance imaging
FTT PTT No tear Total FTT PTT No tear Total
Arthroscopic diagnosis
FTT 74 3 2 79 74 5 0 79
PTT 8 4 3 15 7 5 3 15
No tear 0 1 10 11 0 2 9 11
Total 82 8 15 105 81 12 12 105
Accuracy* 98/105 (93% [87% - 97%]) 88/105 (84% [75% - 90%])
*The 95% confidence interval is given in brackets. FTT: full-thickness rotator cuff tears, PTT: partial-thickness rotator cuff tears.

T. KOBAYASHI ET AL. 10
Table 2. Agreement between the ultrasonography and magnetic resonance imaging findings for the diagnosis of rotator cuff
tears.
Magnetic resona n ce imaging
FTT PTT No tear
Ultrasonography
FTT 78 3 1
PTT 2 4 2
No tear 1 5 9
Observed degree of agreement* 91/105 (87% [79% - 93%])
Weighted Cohen’s Kappa coefficient* 0.73 [0.60 - 0.87]
McNemar test P = 0.79
*The 95% confidence interval is given in brackets. FTT: full-thickness rotator cuff tears, PTT: partial-thickness rotator cuff tears.
Table 3. The diagnostic parameters of ultrasonography and magnetic resonance imaging for the diagnosis of rotator cuff
tears.
Ultrasonography Magnetic reso nance imaging
FTT PTT FTT PTT
Sensitivity 74/79 (94% [86% - 98%]) 12/15 (80% [52% - 96%]) 74/79 (94% [86% - 98%]) 12/15 (80% [52% - 96%])
Specificity 11/11 (100% [76% - 100%]) 10/11 (91% [59% - 100%])11/11 (100% [76% - 100%]) 9/11 (82% [48% - 98%])
PPV 74/74 (100% [96% - 100%]) 12/13 (92% [64% - 100%])74/74 (100% [96% - 1 00 %]) 12/14 (86% [57% - 98 %])
NPV 11/16 (69% [41% - 89%]) 10/13 (77% [46% - 95%]) 11/16 (69% [41% - 89%]) 9/12 (75% [43% - 95 %])
Accuracy 85/90 (94% [88% - 98 %]) 22/26 (85% [65% - 96%]) 85/90 (94% [88% - 98%]) 21/26 (81% [61% - 93%])
The 95% confidence interval is given in brackets. PPV: positive predictive value, NPV: negative predictive value, FTT: full-thickness rotator cuff tears, PTT:
partial-thickness rotator cuff tears.
Table 4. Comparison of the arthroscopic diagnosis of lesions of the biceps tendon with the ultrasonography and magnetic
resonance imaging findings.
Ultrasonography Magnetic resonance imaging
Rupture Dislocation Normal Total Rupture Dislocation Normal Total
Arthroscopic diagnosis
Rupture 10 1 0 11 8 1 2 11
Dislocation 2 4 3 9 3 4 2 9
Normal 0 1 84 85 0 0 85 85
Total 12 6 87 105 11 5 89 105
Accuracy* 98/105 (93% [87% - 97%]) 97/105 (92% [86% - 97%])
*The 95% conf i d ence interval is given in brackets.
Table 5. Agreement betw een the ultrasonography and magnetic re sonance imaging findings for the diagnosis of lesions of the
biceps tendon.
Magnetic r esonance imaging
Rupture Dislocation Normal
Ultrasonography
Rupture 9 1 2
Dislocation 0 4 2
Normal 2 0 85
Observed degree of agreement* 98/105 (93% [87% - 97%])
Cohen’s Kappa coefficient* 0.76 [0.60 - 0.93]
McNemar test P = 0.45
*The 95% conf i d ence interval is given in brackets.

T. KOBAYASHI ET AL. 11
Table 6. The diagnostic parameters of ultrasonography and magnetic resonance imaging for the diagnosis of lesions of the
biceps tendon.
Ultrasonography Magnetic reso nance imaging
Rupture Dislocation Rupture Dislocation
Sensitivity 10/11 (91% [59% - 100%]) 6/9 (67% [30% - 93%]) 8/11 (73% [39% - 94%]) 7/9 (78% [40% - 97%])
Specificity 85/85 (100% [97% - 100%]) 84/85 (99% [94% - 100%])85/85 (100% [97% - 100%]) 85/85 (100% [97% - 100%])
PPV 10/10 (100% [74% - 100%]) 6/7 (86% [42% - 100%]) 8/8 (100% [69% - 100%]) 7/7 (100% [65% - 100%])
NPV 85/86 (99% [94% - 100%]) 84/87 (97% [90% - 99% ])85/88 (97% [90% - 99%]) 85/87 (98% [92% - 10 0%])
Accuracy 95/96 (99% [94% - 10 0% ]) 90/94 (96% [90% - 99%])93/96 (97% [91% - 99% ]) 92/94 (98% [93% - 100%])
*The 95% conf i d ence interval is given in brackets. PPV: positive predictive value, NPV: negative predictive value.
Table 7. Comparison between the arthroscopic classification of the size of rotator cuff tears and the classification made based
on ultrasonography and magnetic resonance imaging.
Ultrasonography Magnetic reso nance imaging
No tear Small Medium Large/MassiveTotal No tearSmallMedium Large/Massive Total
Arthroscopic diagnosis
No tear 13 2 0 0 15 11 3 1 0 15
Small 4 3 0 0 7 2 4 1 0 7
Medium 2 3 37 1 43 2 4 34 3 43
Large/Massive 0 0 15 25 40 0 0 10 30 40
Total 19 8 52 26 105 15 11 46 33 105
Accuracy* 78/105 (74% [65% - 82%]) 79/105 (75% [66% - 83%])
*The 95% conf i d ence interval is given in brackets.
Table 8. Agreement between the ultrasonography and magnetic resonance imaging findings for the classification of the size of
rotator cuff tears.
Magnetic resonance imaging
No tear Small Medium Large/Massive
Ultrasonography
No tear 12 4 3 0
Small 2 5 1 0
Medium 1 2 41 8
Large/Massive 0 0 1 25
Observed degree of agreement* 83/105 (79% [70% - 86%])
Weighted Cohen’s Kappa coefficient* 0.77 [0.67 - 0.86]
McNemar test P = 0.05
*The 95% confi dence interval is given in bracket.
resonance imaging). This low specificity of ultrasono-
graphy may be due to the use of older equipment with a
lower-frequency transducer. Teefey et al. [9] prospec-
tively studied 71 patients with shoulder pain by ultra-
son ogr aphy using a high-frequency transducer, and sho w-
ed that ultrasonography and magnetic resonance imaging
have comparable degrees of accuracy for diagnosing ro-
tator cuff tears; a sensitivity of 98% for ultrasonography
and 100% for magnetic resonance imaging, and a speci-
ficity of 80% for ultrasonography and 68% for magnetic
resonance imaging. The current study showed that there
was a good agreement between the ultrasonography and
magnetic resonance imaging findings for detecting both
full-thickness and partial-thickness rotator cuff tears, and
the differences between the two modalities were not sta-
tistically significant.
Ultrasonography of the shoulder is considered to be
operator-dependent, with its accuracy being related to the
operator’s level of experience. In their systemic review,
Smith et al. described that the diagnostic test accuracy
was greatest under the direction of a musculoskeletal
radiologist, followed by orthopaedic surgeons.

T. KOBAYASHI ET AL. 12
There were lower levels of diagnostic test accuracy for
ultrasonographers and general radiologists who did not
express a particular specialist interest in musculoskeletal
radiology [8]. There have been two studies regarding the
accuracy of surgeon-operated in-office shoulder ultra-
sonography. Al-Sh awi et al. [19] examined 143 consecu-
tive ultrasonographic scans of patients who subsequently
underwent shoulder arthroscopy. All the scans were per-
formed by an orthopaedic surgeon using portable ultra-
sonography in a one-stop clinic, and sho wed a sensitivity
of 96%, a specificity of 95%, a positive predictive value
of 96% and a negative predictive value of 95% for the
dia gno sis of f ull- thic kness rotator cuff tears. Ziegler et al.
[20] examined 282 in-office ultrasonographic scans per-
formed by an attending orthopaedic surgeon.
Using the findings at surgery as the standard reference,
the sensitivity, specificity, positive predictive value and
negativ e p r ed ictiv e v alu e w ere 96 %, 94 %, 93 % a nd 97 %,
re sp ect iv el y, for full-thick ness tears; and wer e 9 4% , 96 %,
97% and 93%, respectively, for partial-thickn ess tears. In
addition, Iannotti et al. [21] assessed the accuracy of a
surgeon interpreting office-based ultrasonography scans
for the diagn osis of rotator cuff tears. Although the scans
were performed not by a surgeon, but by a physician-
assistant or nurse clinician who had undergone six hours
of formal training and 30 supervised scans, the sensitivity
was 88% for full-thickness tears and 70% for partial-
thickness tears in 98 patients who subsequently under-
went rotator cuff surgery. The current study showed that
the sensitivity and the specificity were as high as these
results for both full-thickness and partial-thickness rota-
tor cuff tears.
There have been several studies regarding the diagnos-
tic accuracy of ultrasonography for lesions of the biceps
tendon [14,22-24]. According to these studies, ultrasono-
graphy showed a sensitivity of 64% - 100% and a speci-
ficity of 98% - 100% for ruptures, and a sensitivity of
83% - 100% and a specificity of 100% for dislocations.
However, few studies have directly compared ultrasono-
graphy and magnetic resonance imaging. The current stu-
dy showed that ultrasonography and magnetic resonance
imaging have comparable degrees of accuracy for diag-
nosing ruptures and dislocations of the biceps tendon.
The diagnostic accuracy was characterized by a sensitiv-
ity of 91% and a specificity of 100% for ruptures, and a
sensitivity of 67% and a specificity of 99% for disloca-
tions. The sensitivity for dislocation in the current study
was inferior to the previously reported accuracy. This
may have been due to the differences in the diagnostic
criteria used for the dislocation of the biceps tendon. We
performed ultrasonography only in th e static position. At
surgery, any suspected cases of subluxation of the biceps
tendon, which were found during the dynamic evaluation
with an arthroscopic probe, were counted as negative
findings in this study.
The size of rotator cuff tears is essential for planning
proper treatment and advising patients regarding their
prognosis and outcome. Moosmayer et al. [25] ultra-
sonographically assessed 58 shoulders to quantify the
tears. Using the surgical findings as the standard refer-
ence, they achieved a 95% range of agreement for tear
size measurement, with less than ±1 cm. Teefey et al. [9]
prospectively examined 71 patients by ultrasonography
and magnetic resonance imaging and compared the ac-
curacy of the two tests for measuring the size of tears.
They found that ultrasonography correctly predicted the
degree of retraction in 73% of the full-th ickness tears and
the length of 85% of the partial-thickness tears, and the
width of 87% of the full-thickness tears and 54% of the
partial-thickness tears. They concluded that these results
were not significantly different in comparison with mag-
netic resonance imaging. In the current study, we as-
sessed the size of tears using four categories, because
ultrasonograp hy could not measure the exact diameter of
huge tears due to the interference of the acromion. The
overall accuracy of ultrasonography and magnetic reso-
nance imaging for the classification of tears was 74% and
75%, respectively. Although a simple comparison is not
accurate, this result seems to be comparable to the pre-
vious studies.
The current study showed that ultrasonography per-
formed by a surgeon during the patient’s clinic visit had
comparable accuracy to magnetic resonance imaging for
identifying rotator cuff tears and lesions of the biceps
tendon, and for classifying the size of rotator cuff tears.
Seagger et al. [26] showed that the use of a portable ul-
trasonography machine by an orthopaedic surgeon in a
shoulder clinic can significantly reduce the time to treat-
ment and the financial cost for patients with rotator cuff
tears. Moreover, Middleton et al. [27] showed that most
patients with shoulder pain prefer ultrasonography to
magnetic resonance imaging. As Teefey et al. [9] de-
scribed, when an investigator has comparable experience
with both imaging tests, the decision regarding which test
to perform for rotator cuff assessment does not need to
be based on accuracy concerns. The choice can be based
on other factors, such as the importance of ancillary
clinical information , the presence of an implanted device,
patient tolerance and co st.
Our study has a limitation that should be kept in mind
when interpreting the results. The intra-rater and in-
ter-rater reliability were not assessed. This was due to the
limitation of the study design, and a prospective study
would be necessary to address such a limitation.
5. Conclusion
In conclusion, the accuracy of surgeon-operated in-office
shoulder ultrasonography was investigated. In-office shoul-

T. KOBAYASHI ET AL. 13
der ultrasonography had comparable accuracy to mag-
netic resonance imaging for detecting rotator cuff tears
and lesions of the biceps tendon, as well as for classify-
ing the size of rotator cuff tears.
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