Anterior versus posterior, and rim-rent rotator cuff tears: prevalence and MR sensitivity

Purpose. To determine the relative distribution of the locations of rotator cuff tears, and the sensitivity of anterior versus posterior tears on MR images. Patients and methods. We identified 110 consecutive patients who had a shoulder MR and either a partial-thickness or a small full-thickness rotator cuff tear diagnosed at arthroscopy. From the arthroscopy videotapes, we classified the tears as centered in the anterior or posterior half of the cuff, and as either in the critical zone or adjacent to the bony insertion. The original MR interpretation was compared with the arthroscopic findings. MR sensitivity and patient age were compared between patients with tears in the anterior and posterior halves of the cuff. In addition, in patients with partial tears less than 2 cm in diameter, an age comparison between those with tears in the critical zone and those with articular surface tears adjacent to the bony insertion (rim-rent tear) was performed. Results. The tear was centered in the anterior half of the rotator cuff in 79% of the patients younger than 36 years old, and in 89% of the patients 36 years old and over. The average age of the patients with tears in the anterior half (44 years) was not significantly different from the average age of those with posterior tears (40 years)(P=0.23). The sensitivity of MR for anterior tears was 0.69, and for posterior tears it was 0.56 (P=0.17). The average age of the 9 patients with rim-rent tears was 31 years, while that of the 28 patients with similarly-sized partial tears not involving the insertion was 40 years old (P=0.048). Five of the nine rim-rent tears (0.56) were interpreted correctly on the original MR report; two of the other tears were misinterpreted as intratendinous fluid but were diagnosable in retrospect. Conclusion. Even in patients less than 36 years old, most partial and small full-thickness rotator cuff tears are centered in the anterior half of the supraspinatus. Although our figure for MR sensitivity for these tears is lower than in recent articles, we found no significant difference between the sensitivity of MR for diagnosing posterior tears versus tears in the anterior half of the supraspinatus tendon. Rim-rent tears can be mistaken for intratendinous signal, and should be carefully looked for in younger patients with shoulder pain.     

Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings

OBJECTIVE: Our goal in this study was to evaluate by means of MRI the clinical significance of tendon integrity, muscle fatty degeneration, and muscle atrophy in surgically repaired massive rotator cuff tears and to correlate these and other prognostic factors with intraoperative and clinical findings. MATERIALS AND METHODS: Twenty-eight surgically proven massive rotator cuff tears were retrospectively included in the study. Twenty-two patients underwent complete repair, and six patients underwent partial repair. Preoperative and postoperative clinical assessment was performed by using the University of California at Los Angeles score. Preoperative and postoperative MRI studies were evaluated for the presence and extent of rotator cuff tear and for the degree of fatty degeneration and atrophy of the rotator cuff muscles. RESULTS: At a mean 44.4 months' follow-up, 20 patients (71.4%) had a favorable result. A total of 25 patients (89.2%) showed postoperative full-thickness rotator cuff tear, 19 of which were reruptures. A sagittal preoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 100% for predicting a favorable outcome. A coronal postoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 85.7% and a positive predictive value of 92.9% for predicting a favorable outcome. A postoperative fatty degeneration of infraspinatus muscle less than or equal to 2 had a specificity of 87.5% and a positive predictive value of 90.9% for predicting a favorable outcome. CONCLUSION: Open repair of massive rotator cuff tears may reach a favorable outcome in a significant proportion of patients, despite a high rate of recurrent or residual tears. Oblique coronal sizes of the recurrent or residual tear of less than or equal to 34 mm and postoperative fatty degenerations of infraspinatus muscle of less than or equal to 2 may allow a favorable outcome.     

MRI of internal impingement of the shoulder

OBJECTIVE: Internal impingement is a condition that occurs in athletes in which the shoulder is put in extreme abduction and external rotation during overhead movements. During this motion, the posterior fibers of the supraspinatus tendon, anterior fibers of the infraspinatus tendon, or both can get impinged between the humeral head and the posterior glenoid. The purpose of this study was to evaluate the ability of MRI to show the findings of internal impingement of the shoulder. CONCLUSION: As opposed to our six patients with clinically and surgically diagnosed internal impingement, the control patients had isolated pathology in the rotator cuff, labrum, or humeral head. We found that the constellation of findings of undersurface tears of the supraspinatus or infraspinatus tendon and cystic changes in the posterior aspect of the humeral head associated with posterosuperior labral pathology is a consistent finding diagnostic of internal impingement.     

MR evaluation of subscapularis tears.

PURPOSE: The purpose of this work was to describe the MR appearance of tears of the subscapularis tendon and compare the usefulness of different imaging planes as well as note the association of subscapularis tears with other rotator cuff tears and biceps tendon dislocations. METHOD: MR studies at 1.5 T over an 8 year interval were retrospectively assessed for the presence of a rotator cuff tear and/or tear of the subscapularis tendon. Images that showed a subscapularis tear were reviewed for the presence of a visible tear separately on the axial, coronal, and sagittal images. The MR studies were also evaluated for associated tears of the supraspinatus, infraspinatus, and teres minor muscles as well as biceps tendon dislocation and the "naked humerus sign" on coronal images. Last, clinical records and surgical reports were reviewed. RESULTS: Forty-five (2%) of 2,167 rotator cuff tears involved the subscapularis; 27% were partial and 73% were complete tears. Tears were best seen in the sagittal oblique plane. Almost all subscapularis tears were an extension of typical rotator cuff tears: supraspinatus in 35 patients (79%), extending into infraspinatus tears in 25 (56%) and into teres minor tears in 2 patients (4%). Bicipital dislocations were seen in 22 patients (49%), and three complete tears of the biceps (7%) were noted as well. The naked humerus sign was demonstrated in 31 patients (69%). Surgical reports that confirmed the MR findings were available for 15 patients. CONCLUSION: About 2% of rotator cuff tears involve the subscapularis tendon. Most subscapularis tears are extensions of supraspinatus tears and frequently involve the biceps tendon.     

Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff

OBJECTIVE: This study was performed to examine the relationship and association of abnormalities seen in the long head of the biceps brachii tendon to abnormal findings in the rotator cuff. MATERIALS AND METHODS: One hundred eleven patients underwent MR imaging for shoulder pain followed by arthroscopic or open shoulder surgery from January 1997 to December 2000. Patients were identified by a retrospective search, and all consecutive patients having undergone both MR imaging and surgery were included in the patient cohort. Official MR imaging interpretations were compared with operative reports, and all findings were recorded. RESULTS: Twenty-three patients were identified with partial- or full-thickness tears of the long head of the biceps tendon. The sensitivity, specificity, and accuracy of unenhanced MR imaging of the shoulder for detecting these bicipital tears were 52%, 86%, and 79%, respectively. When a tear was present in the biceps tendon, the prevalence of supraspinatous, infraspinatus, and subscapularis tendon tears was 96.2%, 34.6%, and 47.1%, respectively. Patients with biceps tendon tears were significantly more likely to also have subscapularis tendon tears (p < 0.0001) and supraspinatous tendon tears (p < 0.008) than those patients who did not have biceps tendon tears. No significant relationship was found between the presence or absence of a biceps tendon tear and the presence or absence of a infraspinatus or teres minor tendon tear (p = 0.17). CONCLUSION: Tears of the long head of the biceps tendon have a statistically significant association with tears of the anterior and superior rotator cuff and are highly correlated with tears of the supraspinatous and subscapularis tendons. When tears of these tendons are detected, specific attention directed toward the long biceps tendon is warranted to characterize the status of this structure that provides additional stability to the shoulder joint.     

Rotator cuff tears: assessment with MR arthrography in 275 patients with arthroscopic correlation

We assessed the diagnostic performance of magnetic resonance (MR) arthrography in the diagnosis of articular-sided partial-thickness and full-thickness rotator cuff tears in a large symptomatic population. MR arthrograms obtained in 275 patients including a study group of 139 patients with rotator cuff tears proved by arthroscopy and a control group of 136 patients with arthroscopically intact rotator cuff tendons were reviewed in random order. MR imaging was performed on a 1.0 T system (Magnetom Expert, Siemens). MR arthrograms were analyzed by two radiologists in consensus for articular-sided partial-thickness and full-thickness tears of the supraspinatus, infraspinatus, and subscapularis tendons. At arthroscopy, 197 rotator cuff tears were diagnosed, including 105 partial-thickness (93 supraspinatus, nine infraspinatus, three subscapularis) and 92 full-thickness (43 supraspinatus, 20 infraspinatus, 29 subscapularis) tendon tears. For full-thickness tears, sensitivity, specificity, and accuracy were 96%, 99%, and 98%, respectively, and for partial tears 80%, 97%, and 95%, respectively. False negative and positive assessments in the diagnosis of articular-sided partial-thickness tears were predominantly [78% (35/45)] observed with small articular-sided (Ellman grade1) tendon tears. MR arthrography is highly accurate in the diagnosis of full-thickness rotator cuff tears and is accurate in the diagnosis of articular-sided partial-thickness tears. Limitations in the diagnosis of partial-thickness tears are mainly restricted to small articular-sided tears (Ellman grade 1) due to difficulties in differentiation between fiber tearing, tendinitis, synovitic changes, and superficial fraying at tendon margins.     

Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals--initial experience

PURPOSE: To assess the magnetic resonance (MR) imaging appearance of the successfully repaired rotator cuff in an asymptomatic population. MATERIALS AND METHODS: Fifteen subjects who had undergone clinically successful rotator cuff repair were included in the study. All underwent functional testing of the affected shoulder and had good to excellent scores on the Constant scale. Standard MR imaging sequences were performed at 1.5 T, including oblique coronal fast spin-echo T2-weighted MR imaging with fat saturation. RESULTS: Three (10%) of 30 supraspinatus and infraspinatus tendons had normal signal intensity, and 16 (53%) had mildly increased signal intensity on fast spin-echo T2-weighted fat-saturated images, compatible with tendonitis or tendinosis. Three partial and four complete tears of the supraspinatus tendon and two partial and two complete tears of the infraspinatus tendon were seen. Other findings included subacromial-subdeltoid effusion (10 subjects), joint effusions (five subjects), and bone marrow edema (six subjects). CONCLUSION: Postoperative signal intensity changes consistent with tendonitis or tendinosis were common, and clinically "silent" partial and complete rotator cuff tears were seen. Such postoperative MR imaging findings should be interpreted with caution, and meticulous correlation with symptoms and clinical results is recommended.     

Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study

OBJECTIVE: To determine the prevalence and clinical impact of rotator cuff tears in asymptomatic volunteers. MATERIALS AND METHODS: Sonographic examinations of the shoulder of 212 asymptomatic individuals between 18 and 85 years old were performed by a single experienced operator. The prevalence and location of complete rotator cuff tears were evaluated. The clinical assessment was based on the Constant Score. Magnetic resonance imaging (MRI) of the shoulder was obtained in those patients where US showed rotator cuff pathology. RESULTS: Ultrasound showed a complete rupture of the supraspinatus tendon in 6% of 212 patients from 56 to 83 years of age (mean: 67 years). MRI confirmed a complete rupture of the supraspinatus tendon in 90%. All patients reported no functional deficits, although strength was significantly lower in the patient group with complete supraspinatus tendon tear (P < 0.01). CONCLUSION: There is a higher prevalence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living.     

Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: a statistical analysis of sixty cases

BACKGROUND: Prevalence and clinical significance of partial tears of the subscapularis tendon have not been widely studied. PURPOSE: To determine prevalence of and clinical factors associated with partial tears of the subscapularis tendon at arthroscopy. STUDY DESIGN: Case control study. METHODS: During arthroscopic procedures on 314 consecutive shoulders, the arthroscopically visible portion of the subscapularis tendon was probed. Patients with and without partial tears were compared for prospectively identified variables. RESULTS: Partial tears were found in 60 of the 314 patients (19%). Increasing age and dominant arm involvement were significant variables for partial tears. Significantly associated factors included supraspinatus tendon tears (54 of 60; 90%), rotator cuff disease (44 of 60, 73%), and posterosuperior labral fraying (34 of 47, 72%). Increasing age, dominant arm involvement, and coexisting infraspinatus tendon tears were strong independent risk factors for partial tears. CONCLUSION: Partial tears of the subscapularis tendon are not uncommon findings during shoulder arthroscopic procedures and are associated with extensive rotator cuff disease. They do not appear to be associated with glenohumeral instability, but a possible association with atypical forms of instability (subclinical or superior instability) cannot be excluded by this study. The absence of a significant association between the lesion and specific subjective symptoms or physical findings suggests that caution should be taken when attributing a specific symptom to this condition.     

Repair of tears of the subscapularis tendon

Tears of the subscapularis are much less common than tears of the supraspinatus and infraspinatus. Subscapularislesions are usually traumatic in etiology and occur in younger patients. These lesions can be complete or limited to the superior insertion of the subscapularis, and they may be isolated or occur with other rotator cuff lesions. In most instances, treatment of subscapularis tears is surgical. In this article, we present the clinical and radiographic findings, discuss operative indications, and illustrate our preferred surgical technique for tears of the subscapularis tendon.     

Severe atrophy and fatty degeneration of the infraspinatus muscle due to isolated infraspinatus tendon tear

Atrophy of both the supraspinatus and infraspinatus muscles is usually caused by chronic rotator cuff tear, but may also derive from suprascapular nerve entrapment at the spinoglenoid notch. Isolated infraspinatus muscle atrophy is uncommon, and typically associates with suprascapular nerve entrapment occurring distal to the spinoglenoid notch. However, isolated atrophy of the infraspinatus muscle due to insertional tear of the infraspinatus tendon may also occur. We present a case of a 43-year-old male with isolated infraspinatus muscle atrophy and fatty degeneration following an isolated full-thickness infraspinatus tendon tear at the insertion site on the humerus. While it is important to rule out other causes of infraspinatus muscle atrophy, such as concomitant rotator cuff tendon/muscle pathology or suprascapular nerve palsy, we present this case to increase awareness of this uncommon clinical presentation and the potential implications for treatment.     

Rotator cuff disorders: How to write a surgically relevant magnetic resonance imaging report?

Evaluation of rotator cuff is a common indication for magnetic resonance imaging (MRI) scanning of the shoulder. Conventional MRI is the most commonly used technique, while magnetic resonance (MR) arthrography is reserved for certain cases. Rotator cuff disorders are thought to be caused by a combination of internal and external mechanisms. A well-structured MRI report should comment on the relevant anatomic structures including the acromial type and orientation, the presence of os acromiale, acromio-clavicular degenerative spurs and fluid in the subacromial subdeltoid bursa. In addition, specific injuries of the rotator cuff tendons and the condition of the long head of biceps should be accurately reported. The size and extent of tendon tears, tendon retraction and fatty degeneration or atrophy of the muscles are all essential components of a surgically relevant MRI report.     

Cystic changes at supraspinatus and infraspinatus tendon insertion sites: association with age and rotator cuff disorders in 238 patients

PURPOSE: To retrospectively determine the frequency of posterior and anterior cystic abnormalities at rotator cuff insertion site on the greater tuberosity and to determine their relationship to patient age and rotator cuff disorders. MATERIALS AND METHODS: Institutional review board approval was given; informed consent was waived. The study was HIPAA compliant. In 238 patients with rotator cuff diagnoses at surgery, preoperative magnetic resonance (MR) imaging studies were reviewed to localize osseous cystic changes as anterior (supraspinatus insertion site) or posterior (infraspinatus insertion site) on the greater tuberosity. If rotator cuff tear was present, tendon retraction and location of partial tear (articular or bursal surface) were recorded. Two radiologists reached conclusions by consensus. Locations of cysts were correlated to surgical cuff diagnoses: no tear, tendinopathy, partial-thickness tear, and complete tear. Prospective interpretations from original MR reports were compared with surgical results. Statistical analyses included one-way analysis of variance, chi(2), Fisher exact, and Student t tests, as well as logistic regression and receiver operating characteristic curve comparison. RESULTS: There were 238 consecutive patients (150 men, 88 women; mean age, 43 years). Cysts were located at or near footprint of cuff tendon and demonstrated fluid or soft-tissue signal intensities. Posterior cysts occurred in 56.7% of shoulders and showed no statistical correlation to age or cuff diagnosis. Anterior cysts occurred in 22.7% of shoulders and were strongly associated with cuff disorders (P<.001). Controlling for cuff disorders, there was no relationship between anterior cysts and age (P>.50). Anterior cysts were more common in partial-thickness articular (48%) than in bursal (13%) tears (P<.001). CONCLUSION: Posterior cysts were more common than anterior cysts and showed nearly random distribution among patients, regardless of age and cuff diagnosis. Anterior cysts were closely associated with cuff disorders.     

Evaluation of Rotator Cuff Tendon Tears: Comparison of Multidetector CT Arthrography and 1.5-T MR Arthrography

Purpose: To compare the diagnostic performance of multidetector computed tomographic (CT) arthrography and 1.5-T magnetic resonance (MR) arthrography in the evaluation of rotator cuff lesions, with arthroscopic correlation. Materials and Methods: This study was approved by the institutional ethical committee, and informed consent was obtained from all patients. CT and MR arthrographic images prospectively obtained in 56 consecutive patients, following the same arthrographic procedure, were independently evaluated by two radiologists. Arthroscopy, performed within 1 month of the imaging, was used as the reference standard. Sensitivity and specificity of CT and MR arthrography were compared by using the McNemar test. Interobserver and intertechnique agreement for detecting rotator cuff lesions were measured and compared with κ and Z statistics. The Bland-Altman method was used to determine interobserver and intertechnique agreement for measuring tendon tears. For grading fatty infiltration of rotator cuff muscles, κ and Z statistics were used. Results: There was no statistically significant difference in sensitivity and specificity between CT arthrography and MR arthrography in depiction of rotator cuff lesions. The respective sensitivity and specificity of CT arthrography were 92% and 93%-97% for the supraspinatus, 100% and 77%-79% for the infraspinatus, 75%-88% and 85%-90% for the subscapularis, and 55%-65% and 100% for the biceps tendon. The respective sensitivity and specificity of MR arthrography were 96% and 83%-93% for the supraspinatus, 88%-100% and 81%-83% for the infraspinatus, 75%-88% and 90%-100% for the subscapularis, and 65%-85% and 100% for the biceps tendon. Interobserver agreement was substantial to almost perfect (κ = 0.744-0.964 for CT arthrography; κ = 0.641-0.893 for MR arthrography), and intertechnique agreement was almost perfect (κ > 0.819). CT and MR arthrography both yielded moderate interobserver and intertechnique agreement for measuring rotator cuff tears and grading muscle fatty infiltration. Conclusion: Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears. ? RSNA, 2012.     

Infraspinatus muscle atrophy: implications?

PURPOSE: To evaluate associated findings in patients who exhibited atrophy of infraspinatus muscle at magnetic resonance (MR) examination of their shoulders to clarify implications of this abnormality. MATERIALS AND METHODS: With an electronic database search, cases of advanced infraspinatus muscle atrophy in patients who underwent MR imaging during a 1-year period for evaluation of shoulder pain or dysfunction were identified. The analysis was restricted to cases interpreted by one reader who applied a standardized method of reporting. Associated MR imaging findings in these cases were tabulated. RESULTS: Advanced infraspinatus muscle atrophy was encountered in 51 (4.3%) of 1,191 MR examinations of the shoulder. Tears of the infraspinatus tendon were present in only 27 (53%) of 51 cases. In 46 (90%) of 51 cases, a full-thickness tear was present in the anterior portion of the rotator cuff. In 10 (20%) of 51 cases with infraspinatus muscle atrophy, cuff muscle atrophy was confined to the infraspinatus muscle. Cuff muscle atrophy was isolated to the infraspinatus muscle in four (17%) of 24 cases in which atrophy of the infraspinatus muscle was present despite an intact tendon. In none of the 51 cases was there a mass in the suprascapular or sphenoglenoid notch. CONCLUSION: Infraspinatus muscle atrophy typically occurs with tendon tears in the anterior aspect of the rotator cuff. Concomitant atrophy in the supraspinatus muscle often is present, but infraspinatus muscle atrophy can occur in isolation, and this finding does not imply that the infraspinatus tendon is ruptured.     

不同MRI组合序列及扫描方位对肩袖损伤诊断分级及脂肪浸润评分的影响

目的：探讨不同磁共振成像（MRI）组合序列及扫描方位对肩袖损伤诊断分级及脂肪浸润评分的影响。 方法：选择蚌埠医学院附属连云港市第二人民医院2018年1月至2019年1月收治的100例经临床诊断为肩袖损伤患者作为研究对象,对患者进行不同MRI组合序列及扫描方位,进行肩袖损伤的诊断和肩袖损伤脂肪浸润程度评分。 结果：斜冠状位MRI对肩胛袖损伤的检出率最高,斜冠状位SITR序列在肩关节检查中对肩袖损伤显示最佳（χ²=19.425,P<0.001）;斜冠状位SITR序列对肩胛袖损伤中冈上肌肌腱（51例）、冈下肌肌腱（34例）、肩胛下肌肌腱（15例）检出例数均明显高于斜冠状T₁WI检出序列数（12、28、6例）和T₂WI的检出例数（37、19、9例）。斜冠状术前MRI肩袖脂肪浸润程度评分较术中明显升高[（2.58±0.23）分vs.（1.72±0.17）分],差异有统计学意义（t=7.320,P=0.002）。 结论：斜冠状位SITR序列在肩袖损伤的诊断分级及脂肪浸润程度评分均优其他序列,对肩袖损伤的诊断率较高,更有助于提高诊断正确率。     

Intramuscular rotator cuff cysts: association with tendon tears on MRI and arthroscopy

OBJECTIVE: This study was designed to explore the relationship between intramuscular cysts and rotator cuff tendon tears. CONCLUSION: Intramuscular cysts are strongly associated with rotator cuff tendon tears. Identification of such a cyst should prompt a search for a rotator cuff tear. Findings on MR arthrography and surgery suggest that a delaminating component of the rotator cuff tear may lead to the development of these cysts and may explain the occasional discrepancy between location of tears and location of cysts.     

Magnetic resonance imaging in acute and chronic rotator cuff tears

Magnetic resonance imaging has been assessed in patients with acute rotator cuff tears and normal radiographs (9 cases) and those with chronic tears and changes of cuff arthropathy (9 cases). All images were obtained using a low field strength system (FONAR 0.3 T). Particular attention was placed on the appearances of the tendon and the cuff muscles themselves. Six complete acute tears were clearly identified, but MRI failed to demonstrate two partial tears. Muscle bulk was preserved in all patients in this group. In contrast, all patients with cuff arthropathy had complete tears of the supraspinatus tendon with marked tendon retraction and associated muscle atrophy: these changes precluded primary surgical repair. MRI should be used to assess muscle atrophy preoperatively in those patients with acute tears. When plain radiographs demonstrate cuff arthropathy, the MRI appearances are predictable and primary repair is unlikely to be successful. Further imaging is therefore not indicated.     

肩袖全层撕裂的MRI表现

目的 总结肩袖全层撕裂的MRI表现。材料与方法 回顾性分析21例肩关节MR造影证实的肩袖全层撕裂的MR图像。结果 21例肩袖全层撕裂均发生在冈上肌腱。在T2W序列上,6例（28．9％）表现为冈上肌腱断裂并断裂端的回缩;12例（57．1％）表现为冈上肌腱变薄或增粗并伴有贯穿冈上肌腱全层的高信号;1例（4．7％）表现为冈上肌腱增厚并未贯穿全层的下表面高信号;2例（9．3％）冈上肌腱的形态和信号未见异常。结论 冈上肌腱的断裂并回缩以及冈上肌腱形态增粗或变细并伴 有贯穿肌腱全层的异常高信号为全层撕裂的主要MRI表现。     

Ultrasonography of the tendons of the shoulder

The purpose of the present study was to compare ultrasonographic signs with macroscopic and histological findings in lesions of the rotator cuff and the biceps tendon. Twenty-six shoulder joints from 10 male and 3 female cadavers, ranging in age from 40 to 89 years (mean 65.9), were examined with a linear array real-time ultrasonographic scanner provided with a 7.5 MHz transducer. Arthrotomy and histological preparations were made after ultrasonography. Thinning and discontinuity of echogenic homogenicity of the tendons of the rotator cuff were the most reliable ultrasonographic signs of a total tear of the tendon, but focal hyper- and hypo-echogenic changes of the tendons of the rotator cuff were unreliable criteria. Partial tears of the rotator cuff were difficult to determine with static ultrasonograms. Ultrasonography readily revealed discontinuity of echogenic homogenicity of the biceps tendon as a sign of a rupture of the tendon, which was commonly associated with rotator cuff tears.