Point/Counterpoint Shoulder Ultrasound vs MRI for Rotator Cuff Pathology CASE SCENARIO A 36-year-old, right-handed husband of a physician presented to a physiatrist with a 2-week history of right shoulder pain that began at the end of a downhill ski trip. He re- ported that the pain began after he traversed a flat ski trail using ski poles for propulsion. The pain was worsened with activities that required shoulder abduction and internal rotation. Pain was located over the deltoid region, and he denied complaints of catching or clicking. He felt generally weak in the shoulder. No other associated symptoms were pres- ent such as numbness or tingling. On physical examination, passive range of motion of both shoulders was symmetric and without limitations. Active range of motion of the left shoulder was normal. Active range of motion of the right shoulder was limited by pain with abduction at 90° and internal rotation at 10°. Active external rotation with the elbow held at the side of the thorax was limited to 10° because of pain. Provocation tests, including load and shift, active compression test, and apprehension test, were not painful bilaterally. Im- pingement test of the right shoulder was painful. Manual muscle testing of the supraspina- tus was 4+/5 and associated with pain. All other muscles in the upper limb were 5/5 in strength. Upper limb muscle stretch reflexes, sensation, and cervical spine range of motion were normal. Radiographs of the right shoulder (anteroposterior, true anteroposterior, axil- lary, and Y-views) were normal. Ice, relative rest, acetaminophen, and physical therapy were prescribed. A diagnostic ultrasound (US) was ordered but was not available for 3 weeks. A week after the initial presentation, the patient complained of intractable night pain despite using opioids. The patient’s wife pointed out that he failed to mention in the initial presentation that he sustained a hard fall on the ski trip, although the patient still did not relate the fall to the onset of pain. An earlier appointment for an US was still unavailable and therefore a noncontrast magnetic resonance imaging (MRI) was ordered, which suggested a bursal side partial thickness tear and superimposed severe supraspinatus tendinopathy as well as subacromial-subdeltoid bursitis (Figure 1). A subacromial lidocaine and steroid injection was then administered for pain control and physical therapy was restarted. A week later, the patient called to cancel the US because he was feeling better, although he still did not describe full shoulder range of motion or normal strength. The physiatrist recommended keeping the US appointment in anticipa- tion of using US to follow the degree of healing of the presumed incomplete rotator cuff over time. A week later, the US was performed and a complete rotator cuff tear (vs extensive partial-thickness tear extending into the substance of the cuff) was found. The US further showed a markedly hypoechoic and heterogeneous supraspinatus tendon, which was interpreted as representing intratendinous hemorrhage rather than severe tendinopathy (Figures 2, 3). The patient was referred to a shoulder surgeon and underwent shoulder arthroscopy. A 50% partial surface to partial undersurface articular-sided tear of the supraspinatus tendon was noted. This was debrided from the articular side. On the subacromial side, there was a partial-thickness tear of the bursal side with only a bridge of 10% of the tendon connected. Because of this, the tear was completed and primary repair with subacromial decompres- sion was performed. The patient is now 10 months postsurgery with full pain-free range of motion and normal upper limb strength. He and his wife are now debating whether he will participate in an upcoming ski trip. If you were managing this patient, which initial imaging study would you have ordered? How do US and MRI compare in assessing for complete and incomplete rotator cuff tears? What are the values and shortcomings of each of these tests? Guest Discussants: Sharlene A. Teefey, MD Diagnostic Ultrasound, Abdominal Imaging Section, Washington University School of Medicine, St Louis, MO Disclosure: nothing to disclose Brian Petersen, MD Department of Radiology and Orthopedics, Musculoskeletal Radiology, University of Colorado Denver School of Medicine, Aurora, CO Disclosure: nothing to disclose Senior Editor: Heidi Prather, DO Section of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8233, St Louis, MO 63110. Address correspondence to: H.P.; e-mail: pratherh@wudosis.wustl.edu Disclosure: nothing to disclose PM&R © 2009 by the American Academy of Physical Medicine and Rehabilitation 1934-1482/09/$36.00 Vol. 1, 490-495, May 2009 Printed in U.S.A. DOI: 10.1016/j.pmrj.2009.03.013 490