The purpose of this study was to compare the incidence of presumed
rotator cuff pathology based on radiologist and surgeon interpretation of
preoperative magnetic resonance images (MRIs) with actual rotator cuff
pathology found intraoperatively in patients undergoing arthroscopic capsular
release for adhesive capsulitis.
The medical records of 38 consecutive patients who underwent
arthroscopic glenohumeral capsular release for adhesive capsulitis between
September 2001 and May 2007 were retrospectively reviewed. Radiologist and
surgeon predicted status of the rotator cuff by prospective MRI interpretation
was compared to the actual status of the rotator cuff intraoperatively.
Radiologists preoperative MRI interpretations predicted a 57.9% incidence
of rotator cuff pathology, while operative findings revealed a true incidence
of only 13.2% (P<.0001). Radiologists accurately predicted the
absence or presence of a rotator cuff tear in 19 of 38 cases (50%), compared to
the surgeon, who correctly interpreted 29 of 38 MRIs (76.3%).
Interpretations of shoulder MRIs in patients with adhesive capsulitis
may provide misleading information regarding rotator cuff pathology. The actual
findings of shoulder MRI scans may lead to the appearance of false rotator cuff
pathology in this population, and a high percentage of false positive MRI
reports of rotator cuff tears was observed in these patients. If MRI is chosen
as a diagnostic adjunct in this patient population, careful consideration
should be given to its interpretation to avoid unnecessary or possibly
aggravating surgical intervention.
Idiopathic adhesive capsulitis is a condition of unknown etiology
characterized by painful restriction of both active and passive glenohumeral
and periscapular range of motion (ROM) that occurs in the absence of a known
intrinsic shoulder disorder or preceding traumatic or surgical
event.1 Classically, the clinical presentation of idiopathic
adhesive capsulitis is characterized by the spontaneous onset of diffuse and
often severe shoulder pain, followed by a period of progressively increasing
limitations in active and passive shoulder motion. Ultimately, some patients
experience a thawing phase of clinical improvement.2 However, some
patients experience prolonged or permanent symptoms of shoulder pain or
stiffness.3 In these cases of recalcitrant or severe adhesive
capsulitis, arthroscopic capsular release may be performed to restore shoulder
motion and minimize the morbidity associated with this
It has been suggested that rotator cuff disease and adhesive
capsulitis can typically be distinguished based on a careful history and
physical examination.1 Adhesive capsulitis is most commonly found in
women aged 40 to 60 years and may occur in association with diabetes mellitus,
thyroid disorders, or other endocrine conditions.5-7 In contrast,
rotator cuff pathology is seen in both men and women with increasing frequency
after the age of 40, and often results in limited active shoulder motion, while
passive ROM is characteristically maintained. Although these 2 clinical
entities may be present concomitantly, it is unusual for patients with
idiopathic adhesive capsulitis to have rotator cuff tears and vice versa.
Although magnetic resonance imaging (MRI) is not routinely recommended
in the evaluation of patients with adhesive capsulitis,1 Carrillon
et al8 and Connell et al9 have suggested that MRI with
intravenous gadolinium may be used to specifically evaluate the rotator
interval and axillary pouch in the diagnosis of unclear cases of adhesive
capsulitis. The study of Connell et al9 included patients with
surgically confirmed changes of fibrovascular scar tissue formation in the
rotator interval and around the biceps anchor. Three of their 24 patients with
clinical evidence of adhesive capsulitis had preoperative MRI interpretations
of partial-thickness rotator cuff tears; however, they did not report findings
of rotator cuff pathology at the time of surgery. Carrillon et al8
found evidence of partial- or full-thickness supraspinatus tears in 8 of 25
patients with a clinical diagnosis of adhesive capsulitis, but there was no
mention of preoperative MRI findings in these patients. To our knowledge, no
study of patients with idiopathic adhesive capsulitis has compared the accuracy
of preoperative MRI interpretations of rotator cuff pathology with the actual
status of the rotator cuff as noted intraoperatively.
We hypothesized that the intraoperative status of the rotator cuff
would not consistently correlate with radiologists preoperative MRI
interpretations of patients with idiopathic adhesive capsulitis. The purpose of
this study was to compare the incidence of presumed rotator cuff pathology
based upon radiologist and surgeon interpretations of preoperative MRIs with
actual rotator cuff pathology found intraoperatively in patients undergoing
arthroscopic capsular release for adhesive capsulitis.
Materials and Methods
Using an Institutional Review Board-approved protocol, the medical
records of 78 consecutive patients who underwent arthroscopic glenohumeral
capsular release between September 2001 and May 2007 were retrospectively
reviewed. Patients were included in this study if (1) there was a preoperative
diagnosis of primary adhesive capsulitis, (2) an MRI was obtained prior to
referral for surgical intervention and an official radiologists
interpretation of the MRI was available, and (3) arthroscopic glenohumeral
capsular release was performed after failure of conservative treatment.
Patients were excluded from the study if there was (1) a history of significant
traumatic injury to the shoulder, (2) a pre- or postoperative diagnosis other
than the idiopathic adhesive capsulitis causing shoulder stiffness (eg,
osteoarthritis or avascular necrosis), or (3) a history of prior open or
arthroscopic surgery on the affected shoulder. Thirty-eight of the 78 patients
met criteria for inclusion. The records of these patients were then reviewed to
determine demographics, history, radiologists MRI interpretations, the
surgeons preoperative MRI interpretations, operative findings, and
surgical procedures performed. All surgeries were performed by a single surgeon
who prospectively documented specific intraoperative findings, including
routine inspection of the bursal and articular surfaces of the rotator cuff,
with both the operative report and intraoperative photographs.
The study cohort consisted of 19 men and 19 women with a mean age of
53.4 years (range, 36-70 years). Average duration of symptoms was 12.6 months
(range, 3-30 months). The dominant arm was involved in 23 patients. Fourteen
patients recalled a specific episode of minor trauma that was felt to
subjectively initiate the painful process, while 24 patients reported an
insidious onset of symptoms. Eight patients were diabetic (4 type I and 4 type
II), and 2 patients were being treated for hypothyroidism. Combined
glenohumeral and scapulothoracic preoperative elevation in the scapular plane
averaged 114°, external rotation 35°, and internal rotation to the
ipsilateral greater trochanter.
The MRIs were often obtained prior to our evaluation and at outside
facilities, and therefore the MRIs were not standardized. There was 1
gadolinium-enhanced magnetic resonance arthrogram and no MRIs with intravenous
gadolinium. There were no open MRI studies in this series. Seventeen of the
MRIs were performed using a 1.5-T magnet, and none of the studies used a
>3.0-T magnet. We were unable to determine the field strength of the
remaining MRIs, which were obtained at outside institutions.
Twenty-three of the MRIs were interpreted by fellowship-trained
musculo-skeletal radiologists, while the remainder of the studies were
interpreted by radiologists with unknown levels of additional musculoskeletal
training. Radiology reports described rotator cuff integrity as being intact or
having a partial- or full-thickness tear. Two MRI reports provided equivocal
descriptions of the rotator cuff integrity. In the first case, the report read,
high-grade tendinosis versus partial-thickness tear. In the second
case, the radiologists interpretation was a partial versus
full-thickness tear. In these 2 cases, the more severe of the diagnoses
was recorded for study purposes.
The surgeons preoperative MRI interpretations of all patients
were divided into 2 groups. The first group was felt to have a partial- or
full-thickness rotator cuff tear likely needing repair, while the second group
was interpreted as having either insignificant partial-thickness involvement,
tendinosis, or no tear.
The diagnostic accuracy of the radiologists MRI interpretations
in detecting rotator cuff tears was evaluated by calculating the sensitivity,
specificity, and positive and negative predictive values compared to the gold
standard of direct examination at the time of arthroscopy. To determine the
reliability of these diagnostic accuracy measures, 95% confidence intervals
(CIs) were also calculated. Disagreements between the radiologists
interpretations of the rotator cuff and the actual status of the rotator cuff
intraoperatively were evaluated using McNemars test.
Of the 38 patients included in the study, radiologists interpreted the
preoperative MRIs as having either a partial- or full-thickness rotator cuff
tear in 22 patients (57.9%), while the surgeon predicted this in only 8
patients (21.1%). Radiologists interpreted 15 MRIs as having partial-thickness
tears (39.5%), 7 as having full-thickness tears (18.4%), and 16 as having an
intact rotator cuff (42.1%). The surgeon interpreted 1 MRI as having a
partial-thickness tear (2.6%), 7 as having full-thickness tears (18.4%), and 30
as having an intact rotator cuff (78.9%). The accuracy of these interpretations
is summarized in Table 1.
Intraoperatively, only 5 of the 38 patients (13.2%) were found to have
objective rotator cuff pathology. Three patients (7.9%) with minimal
articular-sided tears of the supraspinatus involving <3 mm of the medial
footprint were treated with limited debridement, and 2 patients (5.3%) with
significant partial-thickness tears (>6 mm) were treated with arthroscopic
repair. These results, along with the accompanying interpretations of the
radiologists and surgeon, are included in Table 2. No patient was found to have
a full-thickness rotator cuff tear intraoperatively.
Of the 15 cases preoperatively interpreted by the radiologists as
having partial-thickness rotator cuff tears, only 3 were confirmed
intraoperatively. The surgeon predicted a partial-thickness tear in 1 case, and
in this patient no tear was found intraoperatively. Radiologists predicted
full-thickness rotator cuff tears in 7 patients; however, 6 of these 7 patients
had no rotator cuff pathology and only 1 had a partial-thickness tear. The
surgeon also interpreted 7 cases of full-thickness rotator cuff tears, and only
2 of these patients had partial-thickness tears. Both of these tears were
significant, however, and both were repaired at the time of arthroscopic
capsular release. The Figure demonstrates a representative case in which the
radiologist interpreted a full-thickness rotator cuff tear, while
intraoperative findings demonstrated the bursal and articular surfaces of the
rotator cuff to be intact. One of the 16 patients with a radiologist reading of
an intact rotator cuff was found to have a partial-thickness tear
intraoperatively. This MRI had been interpreted as high-grade tendinopathy with
an intact rotator cuff, and this patient had a minimal articular-sided tear of
the supraspinatus involving <3 mm of the footprint.
||Figure: Preoperative coronal
T2-weighted MRI interpreted by the radiologist as a small full-thickness
rotator cuff tear (A). The same patient was found to have a normal rotator cuff
on the articular (B) and bursal (C) surfaces intraoperatively.
The fellowship-trained shoulder surgeon preoperatively interpreted 8
cases of significant rotator cuff tears (7 full-thickness and 1
partial-thickness) in which repair was anticipated, while only 2 of these 8
cases (25%) were actually found to have significant rotator cuff tears, which
were then repaired at the time of surgery. The surgeon correctly interpreted
the presence or absence of a rotator cuff tear in 29 of 38 cases overall
(76.3%), compared to 19 of 38 cases (50%) by the radiologists. These results
are summarized in Table 3.
Overall, the radiologists and surgeons preoperative MRI
interpretations predicted a 57.9% and 21.1% incidence of partial- and
full-thickness rotator cuff tears, respectively, while operative findings
revealed an incidence of only 13.2% (all of which were partial-thickness
tears). There were 18 cases where the radiologists interpreted a rotator cuff
tear and the surgical findings revealed no tear, while there was only 1 case
where the radiologist interpreted no rotator cuff pathology and a rotator cuff
tear was visualized intraoperatively (P<.0001). The surgeon predicted
a rotator cuff tear in 6 cases where surgical findings revealed no tear, while
in 3 of the 30 instances in which the surgeon predicted no tear, there was a
partial-thickness tear (none of which required repair). There were 18 cases
where the radiologists interpreted a rotator cuff tear and the surgical
findings revealed no tear, while there was only 1 case where the radiologist
interpreted no rotator cuff pathology and a rotator cuff tear was visualized
intraoperatively. Compared to the gold standard of direct surgical
visualization, the radiologists and surgeons preoperative MRI
evaluations had sensitivities of 80% (95% CI, 28%-99.5%) and 40% (95% CI,
7%-83%), respectively; specificities of 45% (95% CI, 28%-64%) and 82% (95% CI,
64%-92%), respectively; positive predictive values of 18% (95% CI, 5%-40%) and
25% (95% CI, 44%-64%), respectively; and negative predictive values of 94% (95%
CI, 70%-99.8%) and 90% (95% CI, 72%-97%), respectively, for detecting rotator
cuff tears in patients undergoing arthroscopic capsular release for
recalcitrant adhesive capsulitis.
The diagnosis of adhesive capsulitis is made clinically and is
characterized by a loss of both active and passive glenohumeral motion.
Adhesive capsulitis may be subdivided into 3 distinct entities for descriptive
purposes: idiopathic adhesive capsulitis, secondary adhesive capsulitis, and
postoperative stiffness. The present study examined only patients with
idiopathic adhesive capsulitis to exclude potentially confounding data. As has
been commonly accepted, treatment options for adhesive capsulitis include
benign neglect, physical therapy (home-based or supervised), intra-articular
steroid injections, manipulation under anesthesia, and arthroscopic capsular
release.1,3,4,6,10-12 As adhesive capsulitis is a clinical
diagnosis, preoperative MRIs are often not necessary to validate the diagnosis.
There are times, however, when the diagnosis of idiopathic versus secondary
adhesive capsulitis may be elusive. It is in these instances where MRI may be
used by some clinicians as a diagnostic adjunct to provide additional objective
insight into the shoulder condition. It has been consistently emphasized in the
literature that treating clinicians must always carefully scrutinize
radiologists MRI interpretations, correlate them to clinical findings,
and be aware of the diagnostic accuracy of MRIs in different clinical
Numerous studies have demonstrated the efficacy of MRI in
characterizing rotator cuff tears, with sensitivities and specificities ranging
from 85% to 100% for both partial- and full-thickness tears.18-23
The accuracy of detecting rotator cuff pathology by MRI has, however, been
shown to be less reliable in some more complex clinical
situations.17,24 Wnorowski et al17 studied 39 shoulders
that were considered difficult cases (ie, referrals from other surgeons or
diagnostic dilemmas) and compared MRI interpretations with arthroscopic
findings. They evaluated both community radiologists and
musculoskeletal-trained radiologists interpretations and compared each
groups interpretations with surgical findings. The sensitivity,
specificity, positive predictive value, and negative predictive value were
calculated for each group to be 85%, 52%, 50%, 87% (community radiologists) and
71%, 71%, 59%, and 81% (musculoskeletal-trained radiologists), respectively.
The authors concluded that MRIs were not reliably as accurate as arthroscopy in
these clinical situations. Magnetic resonance imaging was most helpful in cases
where no rotator cuff pathology was interpreted, and an MRI interpretation of a
partial tear of the rotator cuff was of little value in these difficult
Motamedi et al24 studied 37 shoulders in patients with
continued pain and dysfunction after rotator cuff repair by correlating
musculoskeletal-trained radiologists MRI interpretations with surgical
findings.24 The sensitivity and specificity for MRI diagnosis of a
recurrent tear was 91% and 25%, respectively, and radiologists incorrectly
reported a recurrent tear in 75% of the intact rotator cuffs. These studies
suggest that radiologists interpretations of MRIs in complex and/or
revision situations have decreased diagnostic value.
Other studies have documented MRI findings in asymptomatic shoulders,
thereby warning of potential hazards in relying on MRI alone as a determinant
of operative intervention.9,13-16 Sher et al16 studied 96
asymptomatic shoulders and found MRI evidence of rotator cuff tear in 54% of
patients older than 60 years, 28% of patients aged 40 to 60 years, and 4% of
patients aged 19 to 39 years. The overall rate of MRI findings suggesting
rotator cuff tears was 34%. Miniaci et al15 evaluated 30
asymptomatic shoulders with an average age of 29 years with MRIs and found a
100% incidence of grade 1 signal changes (focal, linear, or diffuse
intermediate signal within the tendon) and a 23% incidence of grade 2 signal
changes (high-signal intensity less than full thickness); no shoulders had
full-thickness tears. Connor et al13 performed an MRI study of
asymptomatic elite overhead athletes younger than 40 years and found a 40%
incidence of partial- or full-thickness rotator cuff tears in dominant
shoulders compared to a 0% incidence in nondominant shoulders. In addition,
none of these athletes demonstrated subjective shoulder symptoms or required
any further evaluation or treatment of their dominant shoulders at the
studys 5-year follow-up.
Although MRIs are not routinely used in the evaluation of patients
with adhesive capsulitis, studies evaluating MRI arthrography and MRI with
intravenous gadolinium have described the shoulder MRI findings associated with
this condition. Manton et al25 evaluated 28 shoulders (9 with
adhesive capsulitis and 19 controls) with MRI arthrography and found no
consistent differences in the adhesive capsulitis group as compared to
controls. Mengiardi et al,26 however, found thickening of the
coracohumeral ligament and rotator interval capsule, as well as loss of the
subcoracoid fat triangle to be characteristic of adhesive capsulitis in 22 MRI
arthrographies. Jung et al27 studied 28 shoulders (14 with adhesive
capsulitis and 14 controls), also using MRI arthrography, and suggested that
thickness of the capsule and synovium in the axillary recess
.3 mm is highly accurate in
diagnosing adhesive capsulitis. Abnormal signal within the rotator interval
tissue was found to be highly sensitive but nonspecific in the diagnosis of
adhesive capsulitis.27 No studies using MRI arthrography of the
shoulder have compared the MRI evaluation of rotator cuff status with surgical
Shoulder MRI with intravenous gadolinium has been advocated by some as
a means to evaluate patients shoulders with adhesive capsulitis and
specifically to help differentiate adhesive capsulitis from other causes of
shoulder pain and/or stiffness.8,9,28 Carrillon et al8
found post-gadolinium enhancement of the joint capsule and synovium in the
rotator interval in 25 of 25 patients and enhancement in the axillary recess in
22 of 25 of patients with adhesive capsulitis. The same study reported 8 of 25
patients with MRI evidence of rotator cuff tears, including 6 with
partial-thickness and 2 with full-thickness tears.8 Connell et
al9 found rotator interval enhancement after intravenous gadolinium
in 22 of 24 shoulders with a clinical diagnosis of adhesive capsulitis. They
also reported 3 of 24 shoulders had MRI evidence of partial-thickness rotator
cuff tears.9 Neither of these studies, however, reported surgical
findings of rotator cuff pathology.
The findings of the present study do not definitively answer the
question as to whether the incidence of false positive rotator cuff tears are a
reflection of the limitations of MRI in and of itself in the setting of
adhesive capsulitis or the result of a tendency to over-report rotator cuff
tears in this setting. Clark and Harrymans29 gross and
histologic study of the rotator cuff demonstrated that the deepest surface of
the 5 layers of the rotator cuff is the capsule. Thus, with adhesive
capsulitis, the pathologic process affecting the capsule may potentially cause
increased signal in the rotator cuff and thereby create an appearance on the
MRI of rotator cuff pathology that does not exist. This close anatomic
relationship of the rotator cuff-capsule complex may be a potential explanation
for the findings of this study.
The results of the present study suggest that radiologists MRI
interpretations of shoulders in patients with adhesive capsulitis may provide
misleading information in regard to rotator cuff pathology. In this series,
radiologists MRI interpretations substantially overestimated the presence
of rotator cuff pathology (57.5% vs 13.2% found intraoperatively; positive
predictive value, 18%). Although the surgeon more accurately interpreted the
presence or absence of rotator cuff tears on preoperative MRIs, there were
still 6 false positive interpretations of rotator cuff tears (15.8% of all
patients) by the surgeon. Therefore, the question is whether the findings of
this study reflect merely a tendency to over-report rotator cuff tears in this
patient population, an issue with the actual findings of shoulder MRI scans in
this setting, or a combination of these 2 factors. Although further research is
needed to elucidate potential reasons for this phenomenon in this patient
population, clinicians should be wary of making a diagnosis and providing
treatment based solely on the radiologists interpretation of rotator cuff
integrity in patients with adhesive capsulitis to avoid a potentially
unnecessary or aggravating surgical intervention.
The present study has several limitations. Magnetic resonance imaging
studies were not standardized, thus resulting in variability in the quality of
the studies performed. In addition, the MRI interpretations were performed by
many different radiologists with variability in their level of experience in
interpreting these studies. However, this variability is representative of this
centers tertiary referral practice, as well as that of many other
orthopedic practices, and therefore is of practical value to orthopedic
surgeons whose patients MRIs are performed at different locations and
interpreted by various radiologists.
In the present study, it may be difficult to directly compare the
radiologists and surgeons preoperative MRI interpretations, as the
surgeons interpretations may have been influenced by the patients
history and physical examination findings. A future study evaluating a
standardized group of blinded radiologist and surgeon MRI interpretations may
further elucidate whether it is the MRI itself or the interpretations thereof
that contribute to the high false positive rate of rotator cuff tears in
patients with adhesive capsulitis observed in this
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Dr Loeffler is from the Department of Orthopedic Surgery, Carolinas
Medical Center, Charlotte, North Carolina; Dr Brown is from Rome Orthopaedic
Clinic, Rome, Georgia; and Drs DAlessandro, Fleischli, and Connor are
from OrthoCarolina Sports Medicine Center, Charlotte, North Carolina.
Drs Loeffler, Brown, DAlessandro, Fleischli, and Connor have no
relevant financial relationships to disclose.
Correspondence should be addressed to: Patrick M. Connor, MD,
OrthoCarolina Sports Medicine Center, 1915 Randolph Rd, Charlotte, NC 28207