Subscapularis Tendon Tears – Usefulness of Written MRI Reports for Guiding Patient Referral to Shoulder Specialists

Abstract

Introduction Rotator cuff tears are one of the most common reasons for shoulder pain, and patients often present initially to general practitioners. However, subscapularis tears are especially difficult to diagnose and hence adequate therapy is often delayed. General practitioners or non-specialist orthopedic surgeons need reliable MRI findings to allow timely referral of patients to shoulder specialists. The purpose of this study was to determine the validity of the written MRI report of patients with arthroscopically proven subscapularis tendon tears.

Method In this retrospective study, 97 patients (mean age 62.4 ± 10 years, 63 men) who underwent arthroscopic subscapularis repair between April 2013 and January 2015 by two experienced shoulder surgeons and who underwent a preoperative 1.5 T MRI study were included. All of these patients had high-field strength (i. e., ≥ 1.5 T) standard MRI scans performed within 4–164 (mean 57.4 ± 38.4) days before their arthroscopic procedures.

Results and Conclusion Subscapularis tendon tears, verified by arthroscopy, were correctly identified in only 37 of 97 cases in the written report of the preoperative MRI. This resulted in an overall low sensitivity of 38.1 %. Correctly predicted lesions were as follows: Fox and Romeo I 29.4 % (5/17 patients), Fox and Romeo II 20 % (7/35 patients), Fox and Romeo III 46.7 % (14/30 patients) and Fox and Romeo IV 73.3 % (11/15 patients). In contrast, concurrent supraspinatus tendon tears were identified correctly in 88.2 % of patients (60/68 cases, sensitivity 88.2 %, specificity 96.5 %). Preoperative written radiology reports provided by a heterogeneous group of 39 presumably non-MSK-specialized radiologic centers do not reliably detect subscapularis tendon tears and are not sufficient for guiding patients to specialist centers. Compared to other rotator cuff injuries, this study shows difficulties in the correct diagnosis of subscapular tendon injuries. However, this is necessary to provide patients with timely therapy. It can be assumed that MRI review by musculoskeletal-specialized radiologists would more often than not lead to the correct diagnosis.

Key Points: 

• Subscapularis tendon ruptures are difficult to diagnose on standard shoulder MRI.

• Written MRI reports from non-musculoskeletal-specialized radiologists are not reliable, especially for smaller lesions.

• Reliable findings are required for referral allocation to shoulder specialists (specialized musculoskeletal radiologists).

Citation Format

• Lenz R, Kircher J, Schwalba K et al. Subscapularis Tendon Tears – Usefulness of Written MRI Reports for Guiding Patient Referral to Shoulder Specialists. Fortschr Röntgenstr 2021; 193: 797 – 803

Zusammenfassung

Hintergrund Risse der Rotatorenmanschette sind einer der häufigsten Gründe für Schulterschmerzen. In der Mehrzahl der Fälle stellen sich die Patienten zunächst bei nicht spezialisierten Ärzten (meist beim Hausarzt) vor. Insbesondere Subscapularissehnenrupturen sind jedoch schwer zu diagnostizieren, sodass eine adäquate Therapie oft verzögert wird. Insbesondere der Hausarzt oder nichtspezialisierte Orthopäden benötigen eine verlässliche MRT-Befundung, um eine rechtzeitige Überweisung der Patienten an Schulterspezialisten zu ermöglichen. Daher war es Ziel dieser Studie, die Wertigkeit des schriftlichen MRT-Berichts anhand arthroskopisch nachgewiesener Subscapularissehnenrupturen zu untersuchen.

Methoden In diese retrospektive Studie wurden 97 Patienten (Durchschnittsalter 62,4 Jahre, 63 Männer) eingeschlossen. Zwischen April 2013 und Januar 2015 erhielten sie eine arthroskopische Subscapularissehnenrekonstruktion durch 2 erfahrene Schulterchirurgen. Alle Patienten hatten Standard-MRT-Scans (≥ 1,5 Tesla) innerhalb von 4–164 Tagen (durchschnittlich 57,4 Tage) vor ihren arthroskopischen Eingriffen.

Ergebnisse und Schlussfolgerung Durch Arthroskopie verifizierte Subscapularissehnenrupturen wurden im schriftlichen Bericht der präoperativen MRT-Scans nur in 37 von 97 Fällen korrekt identifiziert. Dies führte zu einer insgesamt geringen Sensitivität von 38,1 %. Korrekt beschriebene Läsionen wurden wie folgt gefunden: Fox/Romeo I 29,4 % (5/17 Patienten), Fox/Romeo II 20 % (7/35 Patienten), Fox/Romeo III 46,7 % (14/30 Patienten) und Fox/Romeo IV 73,3 % (11/15 Patienten). Im Gegensatz dazu wurden gleichzeitige Supraspinatussehnenrupturen in 88,2 % (60/68 Fälle, Sensitivität 88,2 %, Spezifität 96,5 %) korrekt identifiziert. Präoperative schriftliche MRT-Berichte einer heterogenen Gruppe von 39 überwiegend nicht muskuloskelettal spezialisierten radiologischen Zentren beschreiben Subscapularissehnenrupturen nicht zuverlässig. Damit gelten sie als unzureichend, um Patienten spezialisierten Zentren zuzuführen. Diese Studie zeigt, im Vergleich zu anderen Verletzungen der Rotatorenmanschette, Schwierigkeiten in der korrekten Befundung von Subscapularissehnenverletzungen auf. Diese ist allerdings notwendig, um die Patienten einer rechtzeitigen Therapie zuzuführen. Es ist anzunehmen, dass eine Befundung durch muskuloskelettal spezialisierte Radiologen häufiger zu korrekten Befunden führen würde.

Kernaussagen: 

• Subscapularissehnenrupturen sind im Standard-Schulter-MRT schwer zu diagnostizieren.

• Schriftliche MRT-Berichte nicht muskuloskelettal spezialisierter Radiologen sind insbesondere bei kleineren Läsionen nicht zuverlässig.

• Für zielgerichtete Zuweisung zu Schulterspezialisten ist eine zuverlässige Befundung erforderlich (spezialisierte muskuloskelettale Radiologen).

Key words

subscapularis tear - MRI - sensitivity - healthcare research

Publication History

Received: 20 April 2020

Accepted: 16 November 2020

Article published online:
21 January 2021

• References

• 1 Cofield RH, Parvizi J, Hoffmeyer PJ. et al Surgical repair of chronic rotator cuff tears. A prospective long-term study. J Bone Joint Surg Am 2001; 83-A: 71-77
• 2 Arai R, Sugaya H, Mochizuki T. et al Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy 2008; 24: 997-1004 DOI: 10.1016/j.arthro.2008.04.076.
• 3 Lafosse L, Jost B, Reiland Y. et al Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007; 89: 1184-1193 DOI: 10.2106/jbjs.f.00007.
• 4 Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy 2006; 22: 1076-1084 DOI: 10.1016/j.arthro.2006.05.005.
• 5 Bartl C, Salzmann GM, Seppel G. et al Subscapularis function and structural integrity after arthroscopic repair of isolated subscapularis tears. Am J Sports Med 2011; 39: 1255-1262 DOI: 10.1177/0363546510396317.
• 6 Bartl C, Scheibel M, Magosch P. et al Open repair of isolated traumatic subscapularis tendon tears. Am J Sports Med 2011; 39: 490-496 DOI: 10.1177/0363546510388166.
• 7 Burkhart SS, Brady PC. Arthroscopic subscapularis repair: surgical tips and pearls A to Z. Arthroscopy 2006; 22: 1014-1027 DOI: 10.1016/j.arthro.2006.07.020.
• 8 Fox JA, Noerdlinger MA, Romeo AA. Arthroscopic subscapularis repair. Tech Shoulder Elb Surg 2003; 4: 154-168
• 9 Adams CR, Schoolfield JD, Burkhart SS. Accuracy of preoperative magnetic resonance imaging in predicting a subscapularis tendon tear based on arthroscopy. Arthroscopy 2010; 26: 1427-1433 DOI: 10.1016/j.arthro.2010.02.028.
• 10 Adams CR, Brady PC, Koo SS. et al A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans. Arthroscopy 2012; 28: 1592-1600 DOI: 10.1016/j.arthro.2012.04.142.
• 11 Lo IK, Burkhart SS. The etiology and assessment of subscapularis tendon tears: a case for subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis. Arthroscopy 2003; 19: 1142-1150 DOI: 10.1016/j.arthro.2003.10.024.
• 12 Garavaglia G, Ufenast H, Taverna E. The frequency of subscapularis tears in arthroscopic rotator cuff repairs: a retrospective study comparing magnetic resonance imaging and arthroscopic findings. Int J Shoulder Surg 2011; 5: 90-94 DOI: 10.4103/0973-6042.91000.
• 13 Foad A, Wijdicks CA. The accuracy of magnetic resonance imaging and magnetic resonance arthrogram versus arthroscopy in the diagnosis of subscapularis tendon injury. Arthroscopy 2012; 28: 636-641 DOI: 10.1016/j.arthro.2011.10.006.
• 14 Jung JY, Jee WH, Chun CW. et al Diagnostic performance of MR arthrography with anterior trans-subscapularis versus posterior injection approach for subscapularis tendon tears at 3.0T. Eur Radiol 2017; 27: 1303-1311 DOI: 10.1007/s00330-016-4467-3.
• 15 Sakurai G, Ozaki J, Tomita Y. et al Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: cadaveric and clinical studies. J Shoulder Elbow Surg 1998; 7: 510-515
• 16 Ryu HY, Song SY, Yoo JC. et al Accuracy of sagittal oblique view in preoperative indirect magnetic resonance arthrography for diagnosis of tears involving the upper third of the subscapularis tendon. J Shoulder Elbow Surg 2016; 25: 1944-1953 DOI: 10.1016/j.jse.2016.02.038.
• 17 Furukawa R, Morihara T, Arai Y. et al Diagnostic accuracy of magnetic resonance imaging for subscapularis tendon tears using radial-slice magnetic resonance images. J Shoulder Elbow Surg 2014; 23: e283-e290 DOI: 10.1016/j.jse.2014.03.011.
• 18 Lin L, Yan H, Xiao J. et al The diagnostic value of magnetic resonance imaging for different types of subscapularis lesions. Knee Surg Sports Traumatol Arthrosc 2016; 24: 2252-2258 DOI: 10.1007/s00167-014-3335-4.
• 19 Malavolta EA, Assunção JH, Guglielmetti CL. et al Accuracy of preoperative MRI in the diagnosis of subscapularis tears. Arch Orthop Trauma Surg 2016; 136: 1425-1430 DOI: 10.1007/s00402-016-2507-8.
• 20 Walch G, Nové-Josserand L, Boileau P. et al Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998; 7: 100-108
• 21 Urita A, Funakoshi T, Amano T. et al Predictive factors of long head of the biceps tendon disorders-the bicipital groove morphology and subscapularis tendon tear. J Shoulder Elbow Surg 2016; 25: 384-389 DOI: 10.1016/j.jse.2015.12.015.
• 22 Shi LL, Mullen MG, Freehill MT. et al Accuracy of long head of the biceps subluxation as a predictor for subscapularis tears. Arthroscopy 2015; 31: 615-619 DOI: 10.1016/j.arthro.2014.11.034.
• 23 Naimark M, Zhang AL, Leon I. et al Clinical, radiographic, and surgical presentation of subscapularis tendon tears: a retrospective analysis of 139 patients. Arthroscopy 2016; 32: 747-752 DOI: 10.1016/j.arthro.2015.11.019.
• 24 Smucny M, Shin EC, Zhang AL. et al Poor agreement on classification and treatment of subscapularis tendon tears. Arthroscopy 2016; 32: 246-251, e241 DOI: 10.1016/j.arthro.2015.08.006.
• 25 de Jesus JO, Parker L, Frangos AJ. et al Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. Am J Roentgenol 2009; 192: 1701-1707 DOI: 10.2214/ajr.08.1241.
• 26 Waldt S, Bruegel M, Mueller D. et al Rotator cuff tears: assessment with MR arthrography in 275 patients with arthroscopic correlation. Eur Radiol 2007; 17: 491-498 DOI: 10.1007/s00330-006-0370-7.
• 27 Pfirrmann CW, Zanetti M, Weishaupt D. et al Subscapularis tendon tears: detection and grading at MR arthrography. Radiology 1999; 213: 709-714 DOI: 10.1148/radiology.213.3.r99dc03709.