Nearly all adult participants aged 41 to 76 years had at least one rotator cuff abnormality on magnetic resonance imaging, according to a recent study.
In a population-based cross-sectional analysis of 602 participants from Finland’s nationally representative Health 2000 cohort, investigators reported that 98.7% (n = 595) of the participants had at least one rotator cuff abnormality on magnetic resonance imaging (MRI), including 25% with tendinopathy, 62% with partial-thickness tears, and 11% with full-thickness tears, with minimal difference between symptomatic and asymptomatic shoulders.
The Finnish Imaging of Shoulder study was conducted from February 2023 to April 2024. Eligible participants underwent structured interviews, validated shoulder-specific questionnaires, and standardized clinical examinations performed by shoulder surgeons with more than 10 years of experience, followed by bilateral 3-Tesla MRI without intra-articular contrast. Three musculoskeletal radiologists independently evaluated each of the four rotator cuff tendons and classified the findings as normal, tendinopathic, partial-thickness tear, or full-thickness tear according to prespecified criteria. The radiologists were blinded to demographic and clinical data and to one another’s interpretations, and interobserver agreement was high. Statistical analyses incorporated inverse probability weighting to address nonparticipation, multiple imputation for missing data, and multinomial logistic regression models adjusting for demographic characteristics, coexisting MRI-detected shoulder abnormalities, and positive clinical rotator cuff tests.
The investigators found that rotator cuff abnormalities increased in prevalence and severity with age. Full-thickness tears weren't observed in the participants younger than 45 years but increased to 28% among those aged 70 years or older. Among 1,204 shoulders examined, 96% of the asymptomatic shoulders and 98% of the symptomatic shoulders had at least one rotator cuff abnormality. Although full-thickness tears were more frequent in symptomatic shoulders in unadjusted analyses (14.6% vs 6.5%), this association was attenuated after adjustment for demographic variables, other imaging findings, and clinical examination results (absolute difference = 0.8%). Tendinopathy and partial-thickness tears didn't meaningfully differ between symptomatic and asymptomatic shoulders. The findings indicated that MRI-detected rotator cuff abnormalities are common age-related structural changes rather than reliable markers of symptomatic disease.
The investigators noted several limitations. Because the sample was population-based rather than derived from specialty care settings, large or traumatic tears were uncommon, limiting conclusions regarding more advanced pathology. The age range of 41 to 76 years restricted generalizability to younger patients, in whom acute traumatic tears may be more prevalent. In addition, participation required fluency in Finnish or Swedish, which may have limited applicability to more diverse populations. “In this cross-sectional study, MRI examination of the shoulder found that [rotator cuff] abnormalities are present in nearly all individuals over 40 years of age, irrespective of symptoms,” noted lead study author Thomas Ibounig, MD, of the Finnish Centre for Evidence-Based Orthopaedics at the University of Helsinki in Finland, and colleagues.
In an invited commentary, Edgar Garcia-Lopez, MD, and Brian T. Feeley, MD, of the Department of Orthopedic Surgery at the University of California, San Francisco, wrote that the findings call into question the ability to distinguish clinically meaningful MRI abnormalities from incidental age-related changes and highlighted the risk of overtreatment. They noted that degenerative rotator cuff findings are common in asymptomatic patients and that management decisions should be guided by history, physical examination, and functional limitation. The commentators supported a watch-and-wait approach for atraumatic shoulder pain, recommending 6 to 8 weeks of conservative therapy prior to advanced imaging in most cases. They noted that MRI may be useful to confirm but not establish a diagnosis and could be used to help plan a surgical intervention rather than determine whether surgery is going to be helpful.
This study was supported by the Academy of Finland, the Social Insurance Institution of Finland, state funding for university-level health research in Finland, and the Helsinki University Research Fund. Co–study author Rachel Buchbinder, MD, PhD, is supported by an Australian National Health and Medical Research Council Leadership Fellowship. Full disclosures can be found in the study.
Source: JAMA Internal Medicine, Invited Commentary
