Contrast-enhanced MRI of the subdeltoid, subacromial bursa in
painful and painless rotator cuff tears
1,3R J HODGSON, PhD, FRCR,1,2P J O’CONNOR, FRCR, MRCP,1,3E M A HENSOR, PhD,2D BARRON, FRCR and
1,2P ROBINSON, FRCR, MRCP
1Leeds Musculoskeletal Biomedical Research Unit, University of Leeds, Chapel Allerton Hospital, Leeds, UK,2Department
of Radiology, Chapel Allerton Hospital, Leeds, UK, and3Leeds Institute of Molecular Medicine, University of Leeds,
Chapel Allerton Hospital, Leeds, UK
tears are asymptomatic and are not the cause of the patient’s pain. This may explain the
persistence of symptoms in some patients despite technically successful rotator cuff
repair. It has been proposed that rotator cuff tears cause pain through subdeltoid/
subacromial bursal inflammation. The aim of this study was to determine whether
bursal inflammation seen on MRI is associated with pain in patients with rotator cuff
tears of the shoulder.
Methods:The shoulders of 255 patients were screened with ultrasound. 33 full-
thickness rotator cuff tears (18 with shoulder pain and 15 without pain) were identified
and subsequently studied using contrast-enhanced MRI of the shoulder. Enhancement
of the subacromial bursa was scored independently by two musculoskeletal
radiologists. Logistic regression was used to determine whether bursal enhancement
was independently associated with pain.
Results:There was a significant association between pain and age, with greater
likelihood of pain in younger patients. Bursal enhancement was common in both
painful and painless tears. No statistically significant link between pain and bursal
enhancement was seen, even after accounting for age.
Conclusion:Although enhancement of the subdeltoid/subacromial bursa was
common, no evidence was found to support the hypothesis that bursal enhancement is
associated with pain in rotator cuff tears. It is therefore unlikely to determine reliably
which patients would benefit from rotator cuff repair.
Advances in knowledge:Bursal enhancement and thickening does not reliably
correlate with symptoms or presence of rotator cuff tear.
Although shoulder pain is often associated with rotator cuff tears, many
Received 2 December 2011
Revised 7 April 2012
Accepted 1 May 2012
’ 2012 The British Institute of
Rotator cuff tears are a common cause of pain in the
shoulder. Surgical repair is an effective treatment, but a
significant proportion of patients (5–12.5%) fail to achieve
a satisfactory outcome [1–4]. Long-term outcome of
surgery correlates poorly with the integrity of the cuff
repair [5–7] and persistence of pain is a major factor . In
some cases, this may be because the shoulder pain is not
due to rotator cuff damage at all . Other painful
shoulder pathologies are common, particularly in the
elderly, including glenohumeral and acromioclavicular
rotator cuff tears are common, with increasing incidence
with age and a reported prevalence of up to 80% in
subjects aged over 80 years . A significant proportion
of these are full-thickness tears with one study reporting
full-thickness tears in 28% of people over the age of60.
Rotator cuff tears may remain asymptomatic despite their
large size  and, although the size of tears often
increases, symptoms may develop or resolve with con-
servative treatment [14–16]. As yet there is no clear
consensus regarding the indications for rotator cuff
surgery [17, 18]. A technique to determine whether a
known rotator cuff tear is responsible for an individual
patient’s pain would therefore be of great clinical value in
developing patient management plans. While MRI has
been shown to be accurate for detecting rotator cuff tears
[19, 20], there is no convincing evidence to date that it can
be used to determine whether a full-thickness tear is
symptomatic [12, 21].
The mechanism by which rotator cuff tears cause pain
is poorly understood. Tears are associated with histolo-
gical inflammation of the subdeltoid/subacromial bursa
and this has recently been proposed as a cause of pain
. Synovial inflammation in the bursa in symptomatic
rotator cuff tears could potentially be detected by the
associated enhancement in the inflamed bursa seen on
MRI after the administration of intravenous contrast
agent, in the same way that synovial volume in joints in
inflammatory arthritis has been shown to correlate with
histological measures of inflammation . The aim of
this study was to use contrast-enhanced MRI to assess
subacromial bursitis in patients with painful and pain-
Department, Leeds Teaching Hospitals, Chapel Allerton Hospital,
Leeds LS14 3DX, UK. E-mail: firstname.lastname@example.org
This project was funded by the Royal College of Radiologists, UK,
the British Society of Skeletal Radiologists and the National Institute
for Health Research, UK.
correspondence to:Dr PhilipRobinson,X-Ray
The British Journal of Radiology, 85 (2012), 1482–1487
1482The British Journal of Radiology, November 2012
less rotator cuff tears in order to test the hypothesis that
synovial enhancement at the subacromial bursa is
greater in patients with shoulder pain.
Methods and materials
A group of patients with rotator cuff tears and
shoulder pain was recruited from consecutive primary
care clinical referrals to the shoulder ultrasound service
for shoulder pain with sonographic evidence of a full-
thickness rotator cuff tear.
A group of patients with a rotator cuff tear without
shoulder symptoms was recruited from consecutive
referrals for ultrasound of other regions. Ultrasound of
the shoulder was performed and those patients with an
incidental full-thickness rotator cuff tear were included
in the study. Participants were questioned about the
presence of any shoulder symptoms and excluded if they
reported any symptoms within the preceding year, there
was a history of trauma to the shoulder or the patient
had a clinical diagnosis of arthritis involving the
shoulder or any other joint.
The study was approved by the local research ethics
committee and informed consent was obtained from all
Participants completed a shoulder rating questionnaire
to assess shoulder pain and its limitation of activity,
recreation and work . The global domain score is
measured on a 10 cm visual analogue score line ranging
from 0 (very poorly) to 10 (very well). The remaining
domain scores are calculated from the responses to
various questions measured on rating scales; each has a
minimum of two (indicating the most severe symptoms)
and a maximum of 10 (indicating no symptoms).
Ultrasound was performed by an experienced con-
sultant musculoskeletal radiologist using an Antares
ultrasound machine with a 13.5 MHz linear array
transducer (Siemens Healthcare, Erlangen, Germany).
The presence or absence of a full-thickness rotator cuff
tear was determined using the local standardised
ultrasound scanning protocol .
MRI images of the shoulder were acquired using a
Netherlands) and a dedicated shoulder coil with the
arm by the side in the neutral position. The following
images were acquired:
proton density-weighted coronal-oblique: repetition
time (TR), 2628 ms; echo time (TE), 15 ms; slice
thickness, 3mm; field of view, 16cm; 2566177 matrix
5332ms; TE, 100ms; slice thickness, 3mm; field of
view, 16613cm; 2566201 matrix)
N STIR sagittal-oblique: TR, 1200ms; TE, 15ms; slice
thickness, 4mm; field of view, 16613cm; 2566204
T1weighted images were acquired before and after the
administration of 0.1mmolkg21gadopentetate dimeglu-
mine (Magnevist, Bayer Schering, Leverkusen, Germany)
in the coronal-oblique (TR, 500ms; TE, 15ms; slice
thickness, 3mm; field of view, 16613cm; 2566154
matrix) and sagittal (TR, 375ms; TE, 14ms, slice
thickness, 3mm; field of view, 16613cm; 2566154
matrix) planes. Contrast-enhanced images were acquired
with fat suppression.
MRI images were assessed independently by two
blinded to symptoms. Enhancement of the subacromial
bursa was assessed using T1 weighted fat-suppressed
sagittal-oblique and coronal-oblique contrast-enhanced
images. Images were scored on a scale of 0–2 depending
on the maximum thickness of enhancing tissue: 0, no
abnormal enhancement; 1, up to 3mm thickness of
enhancing tissue; 2, 3mm or more enhancing tissue
(Figures 1 and 2).
To compare agreement between the two observers, the
kappa statistic was calculated for the subacromial bursal
enhancement scores, in addition to prevalence-adjusted,
bias-adjusted kappa (PABAK)  and the proportion of
scores over which the raters were in exact agreement
representing the probability that the second scorer
would place a subject in that specific category given
that the first scorer placed them in that category, were
To determine whether subacromial bursal enhance-
ment was linked to shoulder pain, exact binary logistic
regression was performed with age, sex and bursal
enhancement as independent variables; adjusted odds
ratios (ORs) and 95% confidence intervals (CIs) were
calculated for each. Analyses were conducted in SPSSH
v. 18.0.3 (SPSS Inc., Chicago, IL) and LogXactH v. 8.0
(Cytel Inc., Cambridge, MA).
18 rotator cuff tears were found out of a total of 53
patients undergoing ultrasonography for shoulder pain.
31 rotator cuff tears were found out of a total of 202
patients undergoing ultrasonography of other regions; 11
met exclusion criteria and 5 patients were unable to
tolerate MRI, leaving 15 patients with painless tears.
Symptomatic patients were younger on average (mean
MRI of the subacromial bursa in rotator cuff tears
The British Journal of Radiology, November 20121483
95% CI561.1–69.3) and a much larger proportion were
female (proportion symptomatic572%
CI549–88%; asymptomatic513% (2/15), 95% CI53–38%).
MRI confirmed the presence of a full-thickness tear of
the rotator cuff in all patients diagnosed on ultrasound
(e.g. Figure 3). The mean size of the rotator cuff tear was
2.462.3cm in the asymptomatic group and 2.162.0cm
in the symptomatic group.
The results of the shoulder symptoms questionnaire
are shown in Table 1. Two subjects did not complete
the questionnaire. One subject in the asymptomatic
group subsequently reported mild symptoms on the
questionnaire. As expected, scores were considerably
lower in the subjects with pain.
The kappa statistic for interobserver agreement of the
subdeltoid/subacromial bursal enhancement score was
0.61 (95% CI50.22–1.00). The prevalence index (the
imbalance in the distribution of scores) was 72.7%; when
this was accounted for the adjusted kappa was higher
(PABAK50.82). The raters exactly agreed over the
majority of scores (PEA590.9%); however, the agree-
ment was poorer for Grade 2 (66.7%) than for Grade 1
Subdeltoid/subacromial enhancement (>Grade 1) was
seen in all patients in both the symptomatic and
asymptomatic group. Grade 2 enhancement was seen
in most shoulders (29/33; 88% overall), including 12/15
(80%) of asymptomatic and 17/18 (94%) of symptomatic
Exact binary logistic regression indicated that the odds
of a tear being symptomatic reduced with age (OR50.84,
95% CI50.69–0.98, p50.021) and may be increased in
females (OR58.91, 95% CI50.83–460.48, p50.082), but
having controlled for these factors there was no clear
association between pain and subacromial enhancement
(OR520.44, 95% CI50.03–22347.73, p51.00).
The aim of the current study was to determine
whether shoulder pain was associated with contrast
enhancement at the subacromial bursa in patients with
rotator cuff tears. There was no significant evidence for a
link between pain and enhancement, with only slightly
greater enhancement in the group with shoulder pain.
No significant association was found between pain and
enhancement despite taking into account the age and sex
differences between the symptomatic and asymptomatic
patient groups, although increased age was associated
Figure 1. Grade 2 subacromial bursitis. There is enhancing tissue .3mm in thickness in the subacromial bursa.
Figure 2. Grade 1 subacromial bursitis. There is enhancing
tissue ,3mm in thickness in the subacromial bursa.
R J Hodgson, P J O’Connor, E M A Hensor et al
1484 The British Journal of Radiology, November 2012
with painless rotator cuff tears. Were more subjects to be
included in a future study, a statistically significant
emerge, but assuming the same large proportion of
patients had Grade 2 subacromial enhancement its
predictive utility would nevertheless be limited. The
high level of enhancement in asymptomatic patients
(80% showed Grade 2 enhancement) means subdeltoid/
subacromial enhancement is unlikely to be useful for
discriminating between painful and painless rotator cuff
These results have implications for understanding the
mechanisms for pain in rotator cuff tears. Since bursitis
was common in the asymptomatic group, it seems
unlikely that the presence of subacromial bursitis (as
determined by MRI) is the sole determinant of pain in
patients with rotator cuff pathology. This is consistent
with a previous study that looked at the volume of fluid
in the subdeltoid/subacromial bursa using indirect
magnetic resonance arthrography , finding no rela-
tionship to shoulder symptoms. Other studies have
looked at other factors that may be related to rotator
cuff pain and have shown mixed results for tear size,
with a link between symptoms and tear size demon-
strated in larger studies compensating for age [28, 29].
Our study showed an incidence of full-thickness
rotator cuff tears on shoulder ultrasound of 15% without
shoulder symptoms referred for ultrasound for other
reasons. The mean age of these patients was 66 years.
This is consistent with a large previously reported study
of full-thickness tears in asymptomatic volunteers over
50 years of age, which showed an overall incidence of
8%, with a strong dependence on age .
Logistic regression was used in the current study to
allow the relationship between bursal enhancement and
pain to be studied independently of patient age. In this
study population, the age of patients in the group with
shoulder pain was lower than that of patients without
pain. A similar age difference was seen in a recent
publication comparing symptomatic and asymptomatic
tears , although this has not been present in all
studies , possibly reflecting differences in underlying
study populations. In particular, it seems likely that
younger patients with symptoms may be referred more
commonly for ultrasound assessment at our institution.
Interobserver reproducibility for subacromial bursal
enhancement assessed using the three-point scoring
system presented was fair to good (k50.61) . The
high levels of bursitis identified in both symptomatic and
asymptomatic patients (.85% patients scoring the
maximum in both groups) might suggest a grading
system with more points (subdividing Group 2) could be
used, but the authors felt this would reduce interobser-
ver agreement. Direct volume measurement of enhan-
cing bursitis might be an alternative, as for joint synovitis
, and has the advantage of providing a continuous
measure with the potential to discriminate better
between groups; however, the high surface area of the
Table 1. Shoulder rating questionnaire results
9.7 (8.1–10.0), n514
10.0 (10.0–10.0), n514
All scored 10, n514
All scored 10, n514
All scored 10, n513
2.8 (2.0–4.9), n516
5.0 (3.9–5.5), n517
6.0 (5.2–6.5), n517
5.3 (4.0–6.0), n517
7.5 (3.5–8.9), n510
Data show median (interquartile range in parentheses).
Greater symptoms resulted in lower scores (maximum 10
for each domain).
Figure 3. Example of an asymptomatic patient with a large rotator cuff tear and marked changes, including reduction of the
distance between the acromion and the humeral head, supraspinatus atrophy, subacromial, glenohumeral and acromiocla-
vicular enhancement, and subchondral oedema.
MRI of the subacromial bursa in rotator cuff tears
The British Journal of Radiology, November 2012 1485
subdeltoid/subacromial bursa would be likely to impact
on the reproducibility of such measurements.
A limitation of this study is the small size of the
groups, and particularly the asymptomatic group, which
consisted of only 15 subjects, despite screening over 200
participants. This study would allow the formal power-
ing of a larger study to detect statistically significant
differences between symptomatic and asymptomatic
groups. Such a study would also benefit from age-
matching of the symptomatic and asymptomatic groups.
Nevertheless, given the high levels of synovitis demon-
strated in patients without shoulder pain in the current
study and the inability to detect a significant difference
between groups of 15–18 subjects, it is clear that the
presence of enhancing synovitis is extremely unlikely to
be clinically useful for determining whether pain in a
particular patient is the result of an underlying rotator
cuff tear. Another limitation of the study to be
considered is the underlying assumption that bursal
Although the link between MRI enhancement and
histological markers of inflammation has been demon-
strated in the knee in rheumatoid arthritis, this has not
been proven for subacromial bursitis , and dynamic
contrast-enhanced MRI may be a better measurement of
inflammatory activity [34–37].
In conclusion, this study showed enhancement in the
subdeltoid/subacromial bursa is common in the pre-
sence of a rotator cuff tear both in patients with shoulder
pain and in patients without pain. No evidence was
found to support the hypothesis that pain is closely
related to synovial enhancement due to subacromial
bursal inflammation. Bursal enhancement is unlikely to
be helpful in determining whether shoulder pain is
arising from a rotator cuff tear.
The authors would like to acknowledge the assistance
of Dr R Sinha, consultant radiologist, Newcastle upon
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R J Hodgson, P J O’Connor, E M A Hensor et al
1486The British Journal of Radiology, November 2012