Rotator cuff tears are a leading source of shoulder pain and functional limitation, particularly affecting middle-aged and older adults, with global prevalence estimates ranging from 20% to 54% in symptomatic individuals [1]. Accurate diagnosis is critical for guiding management decisions and predicting outcomes; while Magnetic Resonance Imaging (MRI) is considered the reference standard for comprehensive tendon evaluation, it is relatively expensive and not universally accessible [2].

In recent years, high-resolution musculoskeletal ultrasound (US) has emerged as a viable, cost-effective alternative. It offers comparable accuracy to MRI in both full- and partial-thickness tears of the supraspinatus tendon, with meta-analyses reporting no significant difference in sensitivity or specificity between the two modalities [3]. Multiple studies have demonstrated that US sensitivity in detecting full-thickness tears ranges from 90% to 100% and specificity from 85% to 94% when performed by well-trained operators and compared against MRI or surgical findings [4][5]. Such findings underline the potential value of US as a first-line imaging modality in rotator cuff pathology.

The advantages of ultrasound include its wide availability, absence of ionizing radiation, and capacity for real-time dynamic assessment, making it particularly helpful in outpatient and resource-limited settings [6]. However, ultrasound remains operator-dependent and may offer less comprehensive evaluation than MRI in complex or concomitant shoulder pathologies, such as labral tears or muscular atrophy [2][3].

Despite growing evidence supporting US, there is a need for larger, direct comparison studies in diverse populations to determine its diagnostic performance relative to MRI. This study addresses that gap by evaluating the accuracy of ultrasound compared with MRI in detecting rotator cuff tears, aiming to inform imaging strategies for shoulder injuries.

This hospital-based cross-sectional study was conducted over a period of 18 months in the Department of Orthopaedics and Radiodiagnosis at a tertiary care center in India. A total of 234 patients aged ≥18 years, presenting with shoulder pain and clinical suspicion of rotator cuff injury, were included after obtaining written informed consent.

Inclusion criteria were: (1) patients with clinically suspected rotator cuff pathology based on symptoms such as shoulder pain, restricted range of motion, or weakness; and (2) those who underwent both ultrasound (US) and magnetic resonance imaging (MRI) for diagnostic evaluation. Exclusion criteria included: history of prior shoulder surgery, recent fracture or dislocation, generalized inflammatory joint diseases, and incomplete imaging data.

All included patients first underwent a standardized ultrasound examination using a high-frequency linear transducer (7–12 MHz). Dynamic real-time scanning in multiple planes was performed, evaluating the supraspinatus, infraspinatus, subscapularis, and teres minor tendons, as well as the biceps tendon and subacromial-subdeltoid bursa. Findings were categorized as full-thickness tear, partial-thickness tear, tendinosis, or no tear.

Subsequently, all patients underwent MRI of the shoulder, performed using a 1.5 Tesla scanner. Standard axial, coronal, and sagittal T1- and T2-weighted sequences were obtained. MRI findings were interpreted by another blinded radiologist, with categorization similar to that of ultrasound. MRI served as the reference standard for diagnostic comparison.

Data on patient demographics, clinical symptoms, imaging findings, and side of involvement were recorded and analyzed. Statistical analysis was carried out using SPSS software version 26.0. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy of ultrasound in detecting rotator cuff tears were calculated with MRI findings as the gold standard.

The present study analyzed a total of 234 patients with clinically suspected rotator cuff injuries to compare the diagnostic utility of MRI and ultrasound. The demographic characteristics of the study population are presented in Table 1. The most commonly affected age group was 46–60 years (35.04%), followed by 31–45 years (28.21%). Males comprised a higher proportion of the study population (58.55%) than females. Right-sided shoulder involvement was more prevalent (64.96%) compared to the left.

The clinical presentation of patients is detailed in Table 2. Shoulder pain was the most frequently reported symptom (93.59%), followed by restricted range of motion (75.21%) and weakness in abduction (52.99%). Night pain was noted in 44.02% of cases. A history of trauma was documented in nearly one-third of the patients, while signs of chronic degenerative changes were observed in 38.03%.

The MRI findings, considered the reference standard in this study, are summarized in Table 3. Nearly half of the patients (47.86%) were diagnosed with full-thickness rotator cuff tears, and another 32.48% had partial-thickness tears. Tendinosis was identified in 13.25%, whereas 6.41% showed no evidence of a tear.

In comparison, ultrasound findings (Table 4) showed a slightly lower detection rate for full-thickness tears (43.16%) and partial-thickness tears (29.49%). However, ultrasound detected tendinosis in a greater number of cases (17.52%) and failed to detect any abnormality in 9.83% of patients.

The diagnostic performance of ultrasound was evaluated against MRI as the gold standard (Table 5 and Figure 1). The sensitivity and specificity of ultrasound were 90.64% and 71.43%, respectively. The positive predictive value (PPV) was 89.61%, while the negative predictive value (NPV) was 73.77%. The overall diagnostic accuracy of ultrasound in detecting rotator cuff pathology was found to be

Table 1: Demographic Profile of Study Participants (N = 234)

Table 2: Clinical Presentation of Shoulder Injuries (N = 234)

Table 3: MRI Findings in Suspected Rotator Cuff Tear Patients (N = 234)

Table 4: Ultrasound Findings in the Same Patients (N = 234)

Table 5: Diagnostic Comparison between MRI and Ultrasound (Gold Standard: MRI)

This study evaluated the diagnostic performance of ultrasound compared to MRI in a cohort of 234 patients with clinically suspected rotator cuff tears. Our ultrasound sensitivity (90.64%) and specificity (71.43%) in detecting rotator cuff pathology align closely with prior meta-analyses indicating no significant difference between MRI and ultrasound in diagnosing full‑ or partial‑thickness tears [7]. The overall diagnostic accuracy of ultrasound in our cohort (85.47%) also supports its role as a reliable initial screening tool, particularly for full-thickness tears.

A study from North India, though smaller in sample size, reported sensitivities around 86.7% for full-thickness and 89.7% for partial-thickness tears, with near-perfect agreement (kappa ~0.9) between ultrasound and MRI [8]. Similarly, another study found excellent correlation—sensitivity of 91.2%, specificity of 81.8%, and overall accuracy of 88.6% between ultrasound and MRI findings in rotator cuff injuries [9]. These results confirm the high reliability of ultrasound when performed by skilled operators.

Despite its advantages, ultrasound's lower specificity (71.4% in our study) relative to MRI points to potential false positives and limitations in evaluating complex or subtle pathologies [8]. MRI remains superior in mapping tear extent, detecting associated intra-articular conditions, and guiding surgical planning [10]. In resource-limited settings, however, ultrasound's availability, cost-effectiveness, and dynamic real-time imaging make it a practical first-line imaging modality.

The demographic trends observed—predominance of patients aged 46–60 and right-sided involvement—mirror established epidemiological patterns for degenerative rotator cuff disease [11]. Clinically, more than 90% reported shoulder pain, with most cases showing restricted motion and functional impairment, consistent with other epidemiological studies in similar populations [11-15].

Limitations include the single-center design and lack of arthroscopic or surgical confirmation in all cases, which precludes definitive gold-standard comparison. Furthermore, ultrasound is operator-dependent, and results may vary by examiner expertise.

This study demonstrates that ultrasound has high sensitivity and diagnostic accuracy in detecting rotator cuff tears, making it a valuable screening tool, particularly for full-thickness tears. Despite MRI being the gold standard, ultrasound offers a cost-effective, readily available, and non-invasive alternative, especially in resource-constrained settings. MRI remains superior in evaluating complex tear patterns and associated intra-articular pathologies. The findings support the integration of musculoskeletal ultrasound in routine orthopedic diagnostic pathways. Further studies with surgical correlation are recommended to validate diagnostic accuracy across varying clinical scenarios.

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