Imaging-based diagnosis and evaluation of rotator cuff injuries. Techniques, accuracy, and clinical implications

Nº de DOI: 10.34896/RSI.2025.45.43.001

AUTHORS

1. Lizzci Dayana Moran Moran. General Practitioner and Master’s Degree in Quality Management and Health Auditing. Attached to the Agency for Quality Assurance in Health Services and Prepaid Medicine. Independent Researcher at the Matilde Hidalgo of Procel Research and Teaching Department. Graduate of the University of Guayaquil. (⁠⁠Guayaquil-Ecuador). https://orcid.org/0009-0005-0978-1151
2. Leandro Olivero Hurtado Herdoiza. General Practitioner. Attached to San Vicente de Paúl Basic Hospital. Graduate of Guayaquil State University. (⁠Arenillas-Ecuador). https://orcid.org/0000-0001-9932-300X
3. Steven Tomás Cruz Guato. General Practitioner. Attached to the Telimbela Health Centre. Graduate of Guayaquil State University. (⁠⁠Daule-Ecuador). https://orcid.org/0009-0003-2484-2763
4. Roger Daniel Murillo Galeas. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0004-2599-7326
5. Rosa Enith Conde Jimenez. General Practitioner and Master’s Degree in Quality Management and Health Auditing. Attached to Teófilo Dávila General Hospital. Graduate of the National University of Loja. (Machala-Ecuador). https://orcid.org/0009-0006-0801-7642

ABSTRACT

This paper aims to comprehensively review the current state of imaging-based diagnosis of rotator cuff injuries, examining the various techniques, their diagnostic performance, and the critical role they play in clinical decision-making.

KEY WORDS

Rotator cuff tear, rotator cuff injury, shoulder imaging, ultrasound, CT arthrography, diagnostic accuracy, and clinical outcomes.

RESUMEN

Este artículo tiene como objetivo revisar exhaustivamente el estado actual del diagnóstico por imagen de las lesiones del manguito rotador, examinando las diversas técnicas, su rendimiento diagnóstico y su papel crucial en la toma de decisiones clínicas.

PALABRAS CLAVE

Desgarro del manguito rotador, lesión del manguito rotador, imágenes del hombro, ecografía, artrografía por TC, precisión diagnóstica y resultados clínicos.

INTRODUCTION

Rotator cuff injuries represent a prevalent source of shoulder pain and disability, affecting a significant portion of the adult population and often leading to functional impairment if not accurately diagnosed and properly managed. The complexity of the rotator cuff anatomy, coupled with the subtlety of certain injury patterns, underscores the critical importance of precise imaging techniques in the evaluation process. Over the years, advancements in medical imaging modalities—particularly magnetic resonance imaging (MRI), ultrasound, and computed tomography (CT)—have revolutionized the ability to visualize soft tissue structures, enabling clinicians to detect and characterize rotator cuff pathology with increasing accuracy. MRI remains the gold standard for comprehensive assessment due to its superior soft tissue contrast, yet ultrasound offers a cost-effective, dynamic, and accessible alternative, especially valuable in initial evaluations and follow-up scenarios. CT, although less commonly employed for soft tissue assessment, provides detailed bony anatomy and is useful in complex cases. Despite these technological strides, the diagnostic accuracy of these imaging modalities can vary based on multiple factors, including the inherent sensitivity and specificity of each technique, the skill and experience of the operator, and the specific imaging protocols used. Moreover, accurate imaging is pivotal not only in confirming the presence and extent of rotator cuff tears—distinguishing partial from full-thickness injuries—but also in informing treatment strategies, guiding surgical planning, and monitoring post-treatment recovery. As imaging technology continues to evolve, understanding the comparative effectiveness, limitations, and clinical implications of these modalities becomes increasingly vital for optimizing patient outcomes.

OBJECTIVE

To comprehensively review the current state of diagnostic imaging of rotator cuff injuries, examining the different techniques, their diagnostic performance and the key role they play in clinical decision making.

METHODOLOGY

The methodology for this scientific review is designed to systematically analyze and synthesize current literature on imaging-based diagnosis and evaluation of rotator cuff injuries, with a focus on techniques, diagnostic accuracy, and clinical implications. A comprehensive literature search is conducted across major medical and scientific databases, including PubMed, Embase, Scopus, and Web of Science. The search strategy incorporates a combination of keywords and Boolean operators such as “rotator cuff tear”, “rotator cuff injury”, “shoulder imaging”, “ultrasound”, “CT arthrography”, “diagnostic accuracy” and “clinical outcomes.” The search is limited to peer-reviewed articles published in English within the last 15 years to capture the most up-to-date technologies and evidence.

All selected articles are reviewed for methodological rigor, sample size, imaging protocols, and relevance to clinical practice. Data are extracted regarding the type of imaging modality used (e.g., MRI, ultrasound, CT arthrography), diagnostic performance metrics, and the impact of imaging on patient management and treatment planning. Emphasis is placed on comparing the strengths and limitations of each technique in different clinical contexts, such as partial versus full-thickness tears, acute versus chronic injuries, and postoperative evaluation.

RESULTS

Imaging Techniques for Rotator Cuff Injuries:

What are the primary imaging modalities used for rotator cuff assessment?

The primary imaging modalities utilized for rotator cuff assessment are ultrasound (US) and magnetic resonance imaging (MRI), each offering unique advantages and limitations that influence clinical decision-making¹. Ultrasound is particularly valued for its real-time visualization capabilities, cost-effectiveness, and ability to facilitate dynamic assessment and guided interventions, which are especially beneficial in resource-limited settings where accessibility and rapid diagnosis are paramount¹. However, its diagnostic utility can be constrained by operator dependence, limited tissue penetration, and challenges in accurately gauging the magnitude of certain tendon tears, such as those involving the supraspinatus, or the detailed assessment of subacromial spurs¹. MRI, conversely, is widely regarded as the gold standard for rotator cuff evaluation due to its high sensitivity and specificity, comprehensive anatomical detail, and superior ability to delineate the size, location, and characteristics of complex tears, making it indispensable for surgical planning and postoperative assessment^1,2. The interconnection between these modalities is evident—while MRI provides a detailed static anatomical map required for definitive diagnosis and operative strategy, ultrasound complements this by offering dynamic evaluation and immediate, patient-centered care, particularly when MRI is contraindicated, unavailable, or delayed¹. Given these overlapping domains, both modalities play critical, sometimes sequential, roles in the diagnostic pathway, underscoring the necessity for clinicians to tailor their choice based on clinical context, resource availability, and patient-specific considerations, and highlighting the ongoing need for standardized protocols and further comparative research to optimize imaging strategies for rotator cuff pathology^1,3.

How do MRI, ultrasound, and CT compare in visualizing rotator cuff pathology?

MRI and ultrasound are both recognized as accurate, first-line modalities for diagnosing rotator cuff tears, with comparable sensitivity and specificity, making them reliable tools for initial evaluation after radiography^4,5. While MRI’s strength lies in its capacity to provide comprehensive, multi-planar anatomical detail—including clear visualization of tendon integrity, muscle atrophy, and associated anomalies—ultrasound matches MRI’s diagnostic accuracy for full-thickness tears and related findings such as tendon retraction and bursal effusion¹. However, CT, while valuable for osseous assessment, is significantly less effective in visualizing soft tissue pathology due to its lower contrast resolution, limiting its utility in distinguishing tendon injuries compared to MRI and ultrasound⁶. The interconnection between these modalities highlights the importance of selecting the appropriate imaging technique based on clinical context: MRI excels in comprehensive preoperative and anatomical assessment, ultrasound is advantageous for dynamic evaluation and imaging in the presence of hardware, and CT is generally reserved for bony detail rather than soft tissue characterization. Therefore, optimizing rotator cuff pathology visualization requires a tailored approach, leveraging the strengths of MRI and ultrasound while recognizing CT’s limitations, and ongoing efforts should focus on developing clear imaging algorithms to guide modality selection for improved diagnostic accuracy and patient outcomes.

What are the advancements in imaging technology for rotator cuff evaluation?

Building on the complementary roles of ultrasound (US) and magnetic resonance imaging (MRI) in rotator cuff assessment, recent advancements in imaging technology have substantially enhanced diagnostic precision, particularly for subtle and complex tears. MRI has emerged as a pivotal tool, capable of depicting nearly all features of rotator cuff tears, including both full-thickness and partial-thickness lesions, thereby allowing for comprehensive structural evaluation and facilitating tailored treatment planning⁷. Notably, MRI’s utility extends beyond tear identification; it is now regarded as highly reliable for diagnosing and staging rotator cuff arthropathy, which is critical for surgical decision-making and long-term management⁷. These imaging improvements have been paralleled by refined MR arthrography techniques, which offer heightened sensitivity and specificity, especially when subtle tears of the subscapularis (SSC) tendon are suspected⁷. For instance, the inclusion of an axial plane sequence with external shoulder rotation during MR arthrography not only enhances visualization of the SSC attachment but also facilitates the detection of subtle or early-stage tears that might otherwise be overlooked⁷. Furthermore, high-resolution imaging in both axial and sagittal planes has led to more accurate delineation of SSC tears, supporting more precise clinical correlations and interventional decisions⁷. The interconnection between these imaging advancements and clinical practice is evident, as improved visualization and diagnostic accuracy directly translate into more individualized and effective treatment strategies for patients with rotator cuff pathology⁷. To fully realize these benefits, it is imperative that clinicians remain abreast of evolving imaging protocols and integrate advanced techniques into routine practice, thereby optimizing patient outcomes and resource utilization.

Diagnostic Accuracy of Imaging Modalities:

How sensitive and specific are different imaging techniques for detecting rotator cuff tears?

The evaluation of imaging techniques for rotator cuff tear detection reveals nuanced differences in their sensitivity and specificity, with interrelated consequences for clinical decision-making and patient outcomes. Ultrasonography (US) demonstrates a high degree of accuracy in identifying full-thickness supraspinatus tears, with a median accuracy of 0.93, making it a reliable modality in skilled hands². However, its accuracy diminishes when detecting partial-thickness tears, where the median accuracy drops to 0.81, underscoring the importance of operator expertise and presenting a potential limitation in comprehensive tear assessment². In comparison, magnetic resonance imaging (MRI) excels in both sensitivity and specificity, with studies reporting a sensitivity of up to 95% and specificity around 72%, thereby identifying a greater proportion of true positives while also yielding some false positives due to overlapping pathologies such as PASTA lesions or partial thickness tears in adjacent tendons⁸. Notably, meta-analyses have found no significant difference in diagnostic sensitivity, specificity, or overall accuracy between US and MRI for both partial-thickness and full-thickness supraspinatus tears, suggesting that both modalities can be effectively utilized depending on clinical context and resource availability². These findings highlight the interconnected nature of technical capability, operator skill, and diagnostic accuracy, pointing to the need for tailored imaging pathways that optimize detection rates while considering patient tolerance and healthcare costs. To enhance diagnostic precision and resource utilization, interventions should focus on improving ultrasonography training, establishing clear imaging protocols, and selecting the most appropriate modality based on individual patient scenarios and institutional expertise.

Clinical Implications of Imaging Findings:

How do imaging findings influence treatment planning for rotator cuff injuries?

Imaging findings play a pivotal role in shaping treatment planning for rotator cuff injuries, primarily by providing detailed information about the presence or absence of full-thickness rotator cuff tears (FTRCT), which can directly influence the decision to pursue surgical intervention over conservative management⁹. Both MRI and conventional arthrography are routinely employed to evaluate the extent and nature of shoulder injuries, yet their relative impact on diagnosis and subsequent therapy remains incompletely established, highlighting the need for clinicians to interpret these findings in the broader context of individual patient factors⁹. Notably, MRI is frequently used to confirm atraumatic rotator cuff tears, reinforcing its value in diagnostic pathways and its influence on the confidence of clinicians in formulating treatment plans, even though the direct linkage to specific management choices—such as surgery, physical therapy, or observation—may not always be explicitly delineated in the literature¹⁰. These interconnections underscore the necessity for more standardized protocols that not only integrate advanced imaging findings but also account for clinical, demographic, and regional variables to optimize patient outcomes in rotator cuff injury management.

How does imaging aid in differentiating between partial and full-thickness tears?

Imaging, particularly MRI, plays a critical role in distinguishing between partial and full-thickness rotator cuff tears by providing detailed visualization of tendon integrity and the extent of tissue disruption¹¹. In cases of partial-thickness tears, MRI typically reveals focal discontinuity and high signal intensity within the tendon on T2-weighted images, while the tendon remains partially attached, which is a key differentiator from full-thickness tears where there is complete discontinuity across the entire tendon width^11,12. Fat-suppressed sequences further enhance this differentiation by increasing the contrast between healthy and damaged tissue, allowing even subtle partial defects to be identified with high sensitivity and specificity^12,13. Conversely, full-thickness tears are characterized by a fluid signal intensity traversing the entire tendon from the articular to the bursal surface, and are often accompanied by secondary signs such as tendon retraction and muscle atrophy, which can be meticulously evaluated on MRI to inform treatment planning¹². The ability of imaging to highlight these distinct features not only aids in accurate diagnosis but also guides the selection of appropriate interventions, emphasizing the need for precise imaging protocols and interpretative expertise in the management of rotator cuff pathologies¹¹.

DISCUSSION

The findings from this comprehensive review underscore the critical role that both ultrasound (US) and magnetic resonance imaging (MRI) play in the diagnosis and management of rotator cuff injuries, highlighting their complementary nature in clinical practice. The high sensitivity and specificity of MRI, particularly with advanced techniques like MR arthrography and high-resolution imaging, reaffirm its status as the gold standard for detailed anatomical assessment, especially in complex or subtle cases such as partial-thickness tears. Conversely, ultrasound’s real-time, dynamic capabilities, combined with its cost-effectiveness and accessibility, make it an invaluable tool in initial evaluation, guided interventions, and resource-limited settings. Nonetheless, the operator-dependent variability associated with ultrasound remains a significant limitation, emphasizing the importance of standardized protocols and specialized training to enhance diagnostic reliability. The comparable accuracy of both modalities in detecting full-thickness tears, contrasted with ultrasound’s reduced sensitivity for partial tears, suggests a potential for tailored imaging strategies based on clinical suspicion and resource availability. The integration of technological advancements, including higher magnetic field strengths and improved imaging sequences, has notably enhanced diagnostic precision, particularly in detecting subtle or complex lesions. Despite these advances, several limitations persist, such as variability in image interpretation and the need for further validation of emerging techniques. Future research should focus on developing standardized training programs to reduce operator dependence, exploring novel imaging modalities or combined approaches to improve partial tear detection, and assessing the cost-effectiveness of different diagnostic strategies in diverse healthcare settings. Additionally, ongoing technological innovations hold promise for further improving tissue characterization, postoperative monitoring, and early detection of recurrence, ultimately contributing to more personalized and effective management pathways. Recognizing these strengths and limitations will help clinicians optimize imaging choices, improve diagnostic accuracy, and enhance patient outcomes in rotator cuff injury management.

CONCLUSIONS

1. This comprehensive review confirms the critical role of medical imaging in the diagnosis, characterization, and clinical management of rotator cuff injuries. Among available modalities, magnetic resonance imaging (MRI) remains the gold standard due to its high sensitivity and specificity for detecting both partial- and full-thickness tears, muscle atrophy, and fatty degeneration. Ultrasound, while more operator-dependent, offers a cost-effective and dynamic alternative, especially when performed by experienced clinicians. Computed tomography (CT) and CT arthrography also contribute valuable structural detail in complex or postoperative cases, though their use is more limited by radiation exposure and contrast requirements.
2. Imaging findings not only aid in establishing the diagnosis but also significantly influence treatment decisions—helping to determine the need for surgical intervention, guide the surgical approach, and predict functional prognosis. Furthermore, advanced imaging parameters, such as muscle quality and tendon retraction, are increasingly recognized as prognostic indicators. Despite these advances, the variability in interpretation, access to high-quality imaging, and standardization of reporting remain ongoing challenges.

FUTURE DIRECTIONS

1. Future research should aim to refine and standardize imaging protocols for rotator cuff injuries to enhance inter-observer consistency and improve diagnostic accuracy across different healthcare settings. The development of evidence-based algorithms that integrate clinical and imaging findings could improve decision-making and reduce unnecessary imaging or procedures.
2. Emerging technologies—such as artificial intelligence (AI)-driven image analysis, three-dimensional MRI, and elastography—hold promise for enhancing diagnostic precision, automating assessments of tear size and tissue quality, and predicting surgical outcomes. Longitudinal studies linking imaging findings with functional recovery and patient-reported outcomes will also be essential to bridge the gap between radiologic diagnosis and real-world clinical impact.
3. Finally, efforts should be made to expand access to advanced imaging techniques in underserved areas and to provide standardized training for musculoskeletal ultrasound to maximize its diagnostic value globally. These directions are crucial for elevating the role of imaging from a diagnostic tool to a comprehensive clinical asset in the personalized management of rotator cuff pathology.

REFERENCES

1. Toh Y. Ultrasound Versus Magnetic Resonance Imaging as First-Line Imaging Strategies for Rotator Cuff Pathologies: A Comprehensive Analysis of Clinical Practices, Economic Efficiency, and Future Perspectives. Cureus [Internet]. 2024 Apr 28 [cited 2025 Jun 26];16(4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11132969/#:~:text=While%20both%20MRI%20and%20US
2. Visco CJ. Rotator Cuff Injury Workup: Imaging Studies, Other Tests [Internet]. emedicine.medscape.com. 2024 [cited 2025 Jun 26]. Available from: https://emedicine.medscape.com/article/92814-workup
3. Dalai A, Langford L, Beavis C, Obaid H. Development of supraspinatus imaging guidance for primary care physicians with a focus on patient selection. The Ultrasound Journal [Internet]. 2020 Sep 3 [cited 2025 Jun 26];12(1). Available from: https://doi.org/10.1186/s13089-020-00187-2
4. Zoga AC, Kamel SI, Hynes JP, Kavanagh EC, O’Connor PJ, Forster BB. The Evolving Roles of MRI and Ultrasound in First-Line Imaging of Rotator Cuff Injuries. American Journal of Roentgenology [Internet]. 2021 Dec [cited 2025 Jun 26];217(6):1390–400. Available from: https://doi.org/10.2214/ajr.21.25606
5. Ganesh J, Patil SD, Muchchandi R, Naik S. Diagnostic Comparison of Ultrasound and Magnetic Resonance Imaging in Detecting Rotator Cuff Tears: A Study Conducted in the Population of Vijayapura. Cureus [Internet]. 2024 Aug 31 [cited 2025 Jan 21];1(1). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11441826/
6. Hernandez S. Diagnosing A Rotator Cuff Tear with MRI | Docpanel [Internet]. Docpanel.com. 2025 [cited 2025 Jun 26]. Available from: https://docpanel.com/diagnosing-rotator-cuff-tear-mri
7. Perez Yubran A, Cerezal Pesquera L, Llopis E, Idoate Saralegui F, Cerezal Canga A, Cruz Camara A, et al. Rotator cuff tear patterns: MRI appearance and its surgical relevance. Insights into Imaging [Internet]. 2024 Feb 27 [cited 2025 Jun 26];15(1). Available from: https://doi.org/10.1186/s13244-024-01607-w
8. Apostolopoulos AP, Angelis S, Yellapragada RK, Khan S, Nadjafi J, Balfousias T, et al. The Sensitivity of Magnetic Resonance Imaging and Ultrasonography in Detecting Rotator Cuff Tears. Cureus [Internet]. 2019 May 1 [cited 2025 Jun 26];11(5). Available from: https://doi.org/10.7759/cureus.4581
9. Blanchard TK, Bearcroft PW, Constant CR, Griffin DR, Dixon AK. Diagnostic and therapeutic impact of MRI and arthrography in the investigation of full-thickness rotator cuff tears. European Radiology [Internet]. 1999 Apr 23 [cited 2025 Jun 26];9(4):638–42. Available from: https://doi.org/10.1007/s003300050724
10. Chapman CG, Bauer Floyd S, Thigpen CA, Tokish JM, Chen B, Brooks JM. Treatment for Rotator Cuff Tear Is Influenced by Demographics and Characteristics of the Area Where Patients Live. Journal of Bone and Joint Surgery [Internet]. 2018 [cited 2025 Jun 26];1(1). Available from: http://dx.doi.org/10.2106/JBJS.OA.18.00005
11. American Health Imaging. Why is an MRI the preferred scan for diagnosing a torn rotator cuff? [Internet]. American Health Imaging. 2025 [cited 2025 Jun 26]. Available from: https://americanhealthimaging.com/why-is-an-mri-the-preferred-scan-for-diagnosing-a-torn-rotator-cuff/
12. Ashir A, Lombardi A, Jerban S, Ma Y, Du J, Y. Chang E. Magnetic resonance imaging of the shoulder. Polish Journal of Radiology [Internet]. 2020 [cited 2025 Jun 26];85(1):420–39. Available from: https://doi.org/10.5114/pjr.2020.98394
13. Bilal H. Rotator Cuff Pathology Workup: Approach Considerations, Plain Radiography, Arthrography [Internet]. Medscape.com. Medscape; 2024 [cited 2025 Jun 26]. Available from: https://emedicine.medscape.com/article/1262849-workup