Rotator cuff tears are a common pathology, with a varied prevalence reported.

A literature review was undertaken to determine the cadaveric and radiological (ultrasonography and magnetic resonance imaging [MRI]) prevalence of rotator cuff tear. The radiological studies were subdivided into symptomatic and asymptomatic subjects.

Cadaveric rotator cuff tears were found in 4629 shoulders of which only 2553 met the inclusion criteria. The prevalence of full-thickness tears was 11.75% and partial thickness 18.49% (total tears 30.24%). The total tear rate in ultrasound asymptomatic was 38.9% and ultrasound symptomatic 41.4%. The total rate in MRI asymptomatic was 26.2% whilst MRI symptomatic was 49.4%.

The unselected cadaveric population should contain both symptomatic and asymptomatic subjects. A prevalence of tears between the symptomatic and asymptomatic radiological groups would be expected. However, apart from the MRI asymptomatic group, the radiological prevalence of rotator cuff tears exceeds the cadaveric.

Rotator cuff tears are frequently asymptomatic. Tears demonstrated during radiological investigation of the shoulder may be asymptomatic. It is important to correlate radiological and clinical findings in the shoulder.

Rotator cuff tears are a common problem causing significant morbidity in terms of pain, activity limitation and sleep disturbance. A wide variation in the prevalence of cuff tears have been reported in cadaveric and radiological studies; as with other tendon failure, it is likely that this increases with age.1

The population in cadaveric studies tends to be older than the general population; consequently, a higher prevalence of cuff tears is likely. Furthermore, as no clinical data are available for the cadaveric population, it is reasonable to assume that, as in any large sample, some had symptomatic shoulders. The prevalence of rotator cuff tear in asymptomatic subjects determined by magnetic resonance imaging (MRI) and ultrasonography should be lower than the cadaveric population. Conversely, the radiological prevalence of rotator cuff tears in a population with symptomatic shoulders should be higher. This study reviewed the literature in an attempt to test this hypothesis.

A Medline search was performed using the key words: rotator cuff tear, prevalence, cadaver, MRI and ultrasound. The search was widened using references from these articles. All publications up to the time of the search were used.

The results were split into the following categories: cadaveric studies, ultrasound studies and MRI studies. The radiological studies were further categorised into asymptomatic and symptomatic.

Data were collected on the total number of shoulders, the mean age of the group, the sex distribution, the number of full-thickness tears (FTTs) and partial thickness tears (PTTs). In articles that did not differentiate between the FTTs and PTTs, the total number of cuff tears was used. FTTs were defined as complete tears through the supraspinatus tendon. PTTs included bursal side tears, intratendinous tears and joint side tears. Data from articles where the pathology in patient groups had been preselected, for example all partial cuff tears,2 were excluded from analysis.

In the radiological studies, asymptomatic patient groups had a clinical history and examination that revealed no significant symptoms or signs in the shoulder. Symptomatic patient groups had a history of shoulder pain with a number of diagnoses (tendonitis, cuff pathology, frozen shoulder, calcification or unspecified).

The total number of cadaveric studies was 30, ranging from Smith3 in 1834 to Jiang et al.4 in 2002. There are many studies relating to ultrasound and MRI use. For the purposes of this review, 11 ultrasound studies were included from 1988 to 2000 and 14 MRI studies from 1987 to 1999. The findings are summarised in Tables 14.

Table

Table 1 Cadaveric prevalence of rotator cuff tears

Table 1 Cadaveric prevalence of rotator cuff tears

Author(s) Year Shoulders Age (mean) Male Female FTT PTT
Smith3 1834 80 7 0
Keyes7 1933 73 10 Excl
Codman8 1934 200 144 56 33 31
Keyes9 1935 192 63 4 20
Skinner10 1937 100 6 12
Lindblom11 1939 28 Excl 9
Wilson & Duff12 1943 216 24 22
Grant & Smith13 1948 190 170 20 36/19
Cotton & Rideout5 1964 212 7 60
Neer6 1983 500 25 Excl
De Palma14 1983 96 72 26 9/96
Refior & Melzer15 1984 195 124 71 22 Excl
Petersson16 1984 99 74 55 44 14 18
Bigliani et al.17 1986 142 74.4 74 68 34 Excl
Uhthoff et al.18 1987 306 59.4 170 156 61 Excl
Salter et al.19 1987 53 26 28 6/53
Yamanaka20 1988 268 171 97 18 37
Ozaki et al.21 1988 200 72 130 70 27 69
Ogata & Uhthoff22 1990 76 69.3 32 44 19 36
Jerosch et al.23 1991 122 79 42 80 37 35
Kolts24 1992 37 17 20 6/37
Hijioka et al.25 1993 160 69.3 112 48 18 13
Lehman et al.26 1995 456 64.7 170 286 78 Excl
Itoi et al.27 1995 41 84 18 12
Panni et al.28 1996 80 58.4 4 10
Yamanaka et al.2 1997 227 57 144 83 18 33
Sakurai et al.29 1998 52 76.3 34 18 16 10
Pieper & Radas30 1998 124 75.4 60 64 19 30
Sano et al.31 1999 82 64 46 36 6 17
Jiang et al.4 2002 22 11 11 5 7
Totals 4629 69.3 1804 1326 587 481

Excl, author of study excluded either FTTs or PTTs from data.

Numbers expressed as fractions indicate FTTs and PTTs not differentiated.

Table

Table 2 Ultrasound prevalence of rotator cuff tears

Table 2 Ultrasound prevalence of rotator cuff tears

Author(s) Symptoms Year Shoulders Age (mean) Male Female FTT PTT
Milgrom et al.33 A 1995 180 86 94 32 31
Tempelhof et al.32 A 1999 411 191 220 96 Excl
Mack et al.36 S 1985 72 38/72
Middleton et al.41 S 1986 106 47 75 31 37/106
Crass et al.39 S 1988 500 112 47
Hodler et al.42 S 1988 51 38 12 35 4
Miller et al.38 S 1989 57 55 30 26 17/57
Soble et al.37 S 1989 75 31/75
Brandt et al.35 S 1989 58 52 45 13 22/58
Nelson et al.43 S 1991 19 3 4
Teefey et al.40 S 2000 100 65 15

Excl, author of study excluded either FTTs or PTTs from data.

A, asymptomatic subjects; S, symptomatic subjects.

Numbers expressed as fractions indicate FTTs and PTTs not differentiated.

Table

Table 3 MRI prevalence of rotator cuff tears

Table 3 MRI prevalence of rotator cuff tears

Author(s) Symptoms Year Shoulders Age Male Female FTT PTT
Chandnani et al.44 A 1992 20 0 1
Sher et al.45 A 1995 96 53 47 49 14 19
Needell et al.49 A 1996 100 54 49 51 14 22
Kneeland et al.50 S 1987 26 15 10 20 2
Seeger et al.51 S 1987 107 18/107
Evancho et al.52 S 1988 31 8 2
Kieft et al.53 S 1988 10 0 0
Burk et al.47 S 1989 38 22/38
Zlatkin et al.54 S 1989 32 20 0
Rafii et al.55 S 1990 80 47.8 58 22 30 20
Iannotti et al.56 S 1991 88 36 14
Nelson et al.43 S 1991 21 42 16 5 6 8
Torstensen & Hollinshead46 S 1999 57 41 33 24 40/57

A, asymptomatic subjects; S, symptomatic subjects.

Numbers expressed as fractions indicate FTTs and PTTs not differentiated.

Table

Table 4 Composite table of results

Table 4 Composite table of results

Group Total number Mean age (years) FTTs prevalence (%) PTTs prevalence (%) Total prevalence (%)
Total cadaveric 4629 69.3 12.7 10.4 23.1
Full data cadaveric 2553 70.1 11.8 18.5 30.3
Ultrasound asymptomatic 591 21.7 17.2 38.9
Ultrasound symptomatic 1038 50.4 34.7 6.7 41.4
MRI asymptomatic 271 44.3 10.3 15.9 26.2
MRI symptomatic 490 43.6 40.8 8.6 49.4
Cadaveric studies

The total number of cadaveric shoulders was 4629. The prevalence of FTTs was 12.68% and PTTs was 10.39%. The overall prevalence of any tear in the rotator cuff was 23.07%.

Only nine studies reported all of the data relating to total number of shoulders, mean age, gender, full thickness and partial thickness tears. Therefore, it was decided to look at studies with a data set for total number of shoulders, number of FTTs and number of PTTs. This reduced the total number of shoulders to 2553 with 11.75% FTTs and 18.49% PTTs. The mean age was 70.1 years (age not recorded for every study). The total prevalence of any tear was 30.24% (Table 1).

Ultrasonography

There were two papers on asymptomatic subjects and nine on symptomatic subjects in this group. In the asymptomatic group, there were a total of 591 subjects. Tempelhof et al.32 studied 411 volunteer shoulders, all of whom were asymptomatic. Milgrom et al.33 recruited volunteers with asymptomatic shoulders and no history of shoulder problems. The prevalence of FTTs was 21.7% and PTTs 17.2% (only differentiated in one study). The total prevalence of tears was 38.9%.

In the symptomatic group, there were 1038 subjects. These were patients with clinical suspicion of a cuff tear,3438 heterogeneous rotator cuff symptoms,39 and non-specific shoulder pain.40 The mean age, where recorded, was 50.4 years. The prevalence of FTTs was 34.7% and PTTs 6.7% (differentiated in four studies). The total prevalence of tears was 41.4% (Table 2).

Magnetic resonance imaging

There were four asymptomatic papers and twelve symptomatic papers. In the asymptomatic papers, there were 271 subjects, who had never had any shoulder symptoms.44,45 The prevalence was FTTs 10.33% and PTTs 15.87%. The total prevalence was 26.2%. The mean age was 44.3 years.

In the symptomatic papers, there were 490 subjects, presenting in a variety of ways, for example; pain,43 multiple provisional diagnosis which were not all rotator cuff disease,46 and clinical suspicion of a rotator cuff tear.47 The prevalence of FTTs was 40.81% and PTTs 8.57%. The total prevalence was 49.38%. The mean age was 43.6 years (Table 3).

Discussion

The prevalence of rotator cuff tears has been widely assessed.32,33,57,58 Estimates vary, but can be as high as 80% of 80-year-olds.33 This study reviewed the prevalence of rotator cuff tears in the cadaveric, symptomatic and asymptomatic populations. The total prevalence of rotator cuff tears in the full cadaveric data group was 30.3%, partial thickness tears 18.5% and full-thickness tears 11.8%.

It would be expected that the cadaveric population would include subjects that had been symptomatic and asymptomatic. Therefore, a prevalence of tears between the symptomatic and asymptomatic radiological groups would be expected. In the literature, the cadaveric population tends to be older than those in the radiological studies. This should increase the prevalence of tears. However, apart from the MRI asymptomatic group the radiological prevalence of rotator cuff tears exceeds the cadaveric.

The prevalence of partial thickness tears in the symptomatic MRI and ultrasound groups is lower than the asymptomatic and cadaveric groups. This may be due to a number of factors: the limitations of the investigation or partial thickness tears may be less commonly symptomatic than full thickness. Certainly, partial thickness tears are a heterogeneous group in terms of symptoms, territory, depth and involvement of other tissues. The size of tear has been shown to increase with time in cadaveric59 and in vivo studies.60 The level of symptoms attributed to tears has been shown to alter with time.61 Yamaguchi61 used ultrasound to study the asymptomatic shoulders of patients presenting with unilateral cuff tears; 51% of the asymptomatic shoulders with a rotator cuff tear on ultrasound became symptomatic over 2.8 years. There is a possibility that the asymptomatic tears in the radiological studies may represent a presymptomatic stage.

The prevalence of ultrasound-proven full-thickness tears is higher in the symptomatic than the asymptomatic. However, the total prevalence of rotator cuff tears differs by only 2.5%, which may also imply propagation of tears and changing symptoms.

It is possible that partial and full thickness tear configuration is an important factor in the production of symptoms. Tears which have a preserved rotator cable62 or an intact anterior supraspinatus with less disruption of the tendon footprint may produce less symptoms. Other factors, which may influence symptoms, for example the long head of biceps or subacromial inflammation, are not commonly discussed in the radiological studies.

Another variable to consider was the difference in the mean age of the three groups. However, it is clear from the tables that the age was frequently not recorded and it is not appropriate to reach any conclusions relating to age. It is likely that, as with tendon disease in general, the total prevalence of cuff tears would increase with age.1

The ideal study to compare the various investigations would comprise a large number of cadavers, which would have ultrasound and MRI before definitive dissection and determination of pathology. In many papers, partial thickness tears were excluded from analysis due to the difficulty in defining their appearance consistently. There remain problems in defining ultrasound and MRI criteria for PTTs.

Rotator cuff tears are common pathology and are frequently asymptomatic. Rotator cuff tears demonstrated radiologically during investigation of the shoulder may well not be responsible for the presenting symptoms. It is important to correlate radiological and clinical findings in the shoulder.

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