The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review

Dinnes J, Loveman E, McIntyre L, Waugh N
Record ID 32003001158
Authors' objectives:

To evaluate the evidence for the effectiveness and cost-effectiveness of the newer diagnostic imaging tests as an addition to clinical examination and patient history for the diagnosis of soft tissue shoulder disorders.

Authors' results and conclusions: Ultrasound: Thirty-eight cohort studies investigating the accuracy of ultrasound were identified. Ultrasound was most accurate when used for the detection of full-thickness tears, although results were heterogeneous: pooled sensitivity 0.87 (95% CI: 0.84 to 0.89) and specificity 0.96 (0.94 to 0.97). Sensitivity was lower for detection of partial-thickness tears (0.67, 95% CI: 0.61 to 0.73) although specificity remained high, and studies were again very heterogeneous. Statistically, several possible reasons for the differences in sensitivity estimates between studies were identified, including prevalence and mean age. The number of studies available limited the power of the subgroup analyses. It remains to be determined whether or not ultrasound can provide such conclusive evidence for the value of a negative ultrasound finding in ruling out the presence of a tear. Magnetic Resonance Imaging (MRI): Twenty-nine cohort studies were included, most using conventional MRI pulse sequences as opposed to fat-suppressed MRI. For full-thickness tears, overall pooled sensitivities and specificities were high (0.89, 95% CI: 0.86 to 0.92; and 0.93, 95% CI: 0.91 to 0.95, respectively) and the studies were not statistically heterogeneous. For detection of partial-thickness rotator cuff tears (RCTs), pooled sensitivity estimate was much lower (0.44, 95% CI: 0.36 to 0.51) although specificity again remained high (0.90, 95% CI: 0.87 to 0.92). Where tear prevalence is relatively high, a negative magnetic resonance finding may be sufficient to rule out the presence of a full-thickness tear, but between study heterogeneity means that similar conclusions cannot yet be drawn regarding a positive test result. Magnetic Resonance Arthrography (MRA): Six studies investigating the accuracy of MRA were included. The type of MRI, views and contrast used varied considerably between studies, making any conclusions difficult. The pooled results suggest that MRA may be very accurate for detection of full-thickness RCTs [overall pooled sensitivity 0.95 (95% CI: 0.82 to 0.98) and specificity 0.93 (95% CI: 0.84 to 0.97), both estimates homogeneous]. Its performance for the detection of partial-thickness tears is less consistent. There is also some suggestion that MRA performs better than ultrasound or MRI, but any such benefit must be set against the invasiveness and potential discomfort to patients of the procedure Direct comparisons of tests: Direct evidence for the performance of one test compared with another is very limited. Further research is needed to determine the place of these imaging tests in the diagnosis of RC disorders.
Authors' recommendations: Our results suggest that clinical examination by specialists can rule out the presence of a RCT, and that either MRI or ultrasound could equally be used for detection of full-thickness RCTs. Although still not by any means accurate, ultrasound may be better at picking up partial tears. Given the large differential in the cost of the two procedures, the implication from current evidence is that ultrasound is the more cost-effective test to use in a specialist hospital setting for identification of full-thickness tears. Whether or not these results are transferable to settings with lower prevalence, different spectra of disease and less-specialised clinicians, such as in primary care, remains to be determined.
Authors' methods: Systematic review
Project Status: Completed
URL for project:
Year Published: 2003
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: England, United Kingdom
MeSH Terms
  • Arthrography
  • Arthroscopy
  • Costs and Cost Analysis
  • Magnetic Resonance Imaging
  • Pain
  • Ultrasonography
  • Shoulder
Organisation Name: NIHR Health Technology Assessment programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
Contact Name:
Contact Email:
Copyright: 2009 Queen's Printer and Controller of HMSO
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.