RESEARCH ARTICLE

Quantitative diagnosis of rotator cuff tears

based on sonographic pattern recognition
Ruey-Feng Chang1,2, Chung-Chien Lee1,3,4*, Chung-Ming Lo ID5,6*
1 Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei,
Taiwan, 2 Department of Computer Science and Information Engineering, National Taiwan University, Taipei,
Taiwan, 3 Department of Orthopedic Surgery, New Taipei City Hospital, New Taipei City, Taiwan,
4 Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan, 5 Graduate
Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University,
Taipei, Taiwan, 6 Graduate Institute of Library, Information and Archival Studies, National Chengchi
University, Taipei, Taiwan

a1111111111 * leecc@ntu.edu.tw; buddylo@tmu.edu.tw

a1111111111
a1111111111
a1111111111
a1111111111 Abstract
The lifetime prevalence of shoulder pain is nearly 70% and is mostly attributable to subacro-
mial disorders. A rotator cuff tear is the most severe form of subacromial disorders, and
most occur in the supraspinatus. For clinical examination, shoulder ultrasound is recom-
OPEN ACCESS mended to detect supraspinatus tears. In this study, a computer-aided tear classification
Citation: Chang R-F, Lee C-C, Lo C-M (2019) (CTC) system was developed to identify supraspinatus tears in ultrasound examinations
Quantitative diagnosis of rotator cuff tears based
and reduce inter-operator variability. The observed cases included 89 ultrasound images of
on sonographic pattern recognition. PLoS ONE 14
(2): e0212741. https://doi.org/10.1371/journal. supraspinatus tendinopathy and 102 of supraspinatus tear from 136 patients. For each
pone.0212741 case, intensity and texture features were extracted from the entire lesion and combined in a
Editor: Terry K. Koo, New York Chiropractic binary logistic regression classifier for lesion classification. The proposed CTC system
College, UNITED STATES achieved an accuracy rate of 92% (176/191) and an area under receiver operating charac-
Received: February 25, 2018 teristic curve (Az) of 0.9694. Based on its diagnostic performance, the CTC system has
promise for clinical use.
Accepted: February 8, 2019

Published: February 28, 2019

Copyright: © 2019 Chang et al. This is an open

access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
Introduction
author and source are credited.
Rotator cuff disorders are the most common cause (up to 70%) of shoulder pain [1], with a life-
Data Availability Statement: All relevant data is
available within the paper and its Supporting
time prevalence approaching 70% [2]. The financial burden of shoulder pain on the United
Information files. States health care system is estimated at $7 billion annually [3], and the substantial loss of pro-
ductivity is often underestimated. The mechanisms of rotator cuff diseases are believed to pos-
Funding: The authors would like to thank the
Ministry of Science and Technology (MOST 107-
sess a dynamic pathology, with subacromial impingement as the initial stage and rotator cuff
2221-E-004-013), New Taipei City Hospital tear as the final stage [4]. Rotator cuff disorders include tendinopathy, calcific tendinitis, tears,
(NTCH104-001) of Taiwan, the Republic of China, bursitis, and bursal reactions [5]. Among these disorders, rotator cuff tears, which have a prev-
for financially supporting this research. alence rate of 20.7%, are the most severe forms [6]. Individuals suffering from rotator cuff
Competing interests: The authors have declared tears may have severe shoulder pain, weak forward elevation, abduction or external rotation,
that no competing interests exist. which can detrimentally affect the activities of daily life.

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 Quantitative diagnosis of rotator cuff tears

The accurate diagnosis of rotator cuff disorders is important to determine treatment strat-
egy, especially differentiating tears from other types of tendinopathies [7, 8]. The presence of
rotator cuff full-thickness tears influence the decision to undertake the surgical repair or
arthroplasty [9]. Furthermore, the measurement of size and location of rotator cuff tear is nec-
essary for pre-operative planning. Clinically, imaging examinations such as shoulder ultra-
sound, roentgenogram, magnetic resonance imaging (MRI), and magnetic resonance
arthrography (MRA) are necessary for assessing rotator cuff tears because physical examina-
tions and clinical symptoms may be unreliable [10, 11]. Compared to other imaging modali-
ties, shoulder ultrasound has the advantages of being inexpensive, conducted in real-time, and
convenient to operate. Nevertheless, using ultrasound is operator dependent which relies on
adequate training and experience in diagnosing rotator cuff tears. Especially, differentiating
partial and full-thickness tears from other tendinopathies is a challenge [12]. According to pre-
vious literature [13–19], the diagnostic sensitivity and specificity of shoulder ultrasound on
tear detection has a range of 46%-95% and 50%-95%, respectively. The variabilities are highly
correlated with the level of experience of the operator and the patterns of the rotator cuff tears
[20]. Experienced musculoskeletal radiologists or shoulder orthopedic surgeons possess a
higher accuracy than general radiologists and ultrasonographers in diagnosing rotator cuff
tears via shoulder ultrasound [20]. From this viewpoint, the inter-observer variability in diag-
nosing rotator cuff tears between operators with different professions or levels of experience is
substantial, and higher variability is demonstrated in the diagnosis of partial-thickness tears
[21, 22]. The introduction of quantitative and automated diagnostic procedures could poten-
tially reduce the impact of variability.
Computer-aided diagnosis systems provide an objective, quantitative assessment of lesion
type and grade [23–26]. After defining the lesion area with manual or semi-automatic segmen-
tation, quantitative features can be extracted and combined in an artificial intelligence classi-
fier. By considering a broad range of relevant features, sonographic patterns such as
echogenicity and textures are modeled and used to recognize incoming cases [27]. A previous
study demonstrated that the likelihood estimation of a computer-aided diagnosis system can
be used to reduce observer variability [28]. In this research, consistently high performance in
the differentiation of breast tumors was achieved with the assistance of a computer-aided diag-
nosis system. For residents, the specificity of the breast tumor diagnosis was improved from
20% to 40% (p-value < 0.01) and the κ value from 0.09 to 0.53 (p-value < 0.001). For dedicated
breast imagers, the specificity was increased from 34% to 43% (p-value = 0.16) and the κ value
from 0.21 to 0.61 (p-value < 0.001).
In this study, a computer-aided tear classification (CTC) system based on the quantitative
intensity and texture features was proposed to classify rotator cuff tears in shoulder ultra-
sounds. The establishment of the CTC system is expected to provide consistent and objective
recommendations to junior physicians for clinical examinations.

Materials and methods

Patients and data acquisition
This study was approved by the Institutional Review Board of New Taipei City Hospital, and
informed consent was waived. Between January 2012 and February 2016, patients attending
the orthopedic department in New Taipei City Hospital with shoulder symptoms who under-
went shoulder ultrasound examination were selected to this study. All these patients followed
the indication of shoulder ultrasound examination. All shoulders were imaged using an
ALOKA alpha-6 ultrasound scanner (Hitachi-Aloka Medical, Tokyo, Japan) with a linear
array probe (scan width: 36 mm) ranging from 5 to 13 MHz by an orthopedic shoulder

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 Quantitative diagnosis of rotator cuff tears

surgeon who is also specialized in musculoskeletal ultrasound. The acquisition frequency was
8 MHz and depth of scanning was 4 cm with the focus of supraspinatus layer. All patients
selected to this study underwent only drug control or other conservative treatment before
ultrasound examination. The patients with post-operative intervention and recent injection
including hyaluronic acid, steroid and platelet-rich plasma (PRP) injection were excluded. The
patient population (n = 136) included 61 males and 75 females between 25 and 86 years of age,
with a mean age of 58.7 years, and 32 of them underwent bilateral shoulder ultrasound evalua-
tion due to bilateral shoulder symptoms. In 23 shoulders, because the shoulder morphology
appeared non-uniform, two ultrasound images of different long-axis cut were captured from a
shoulder. The image database was composed of 191 shoulder images including 89 images of
supraspinatus tendinopathy and 102 images of supraspinatus tear. Forty-two of 102 supraspi-
natus tears were full-thickness tears. Image selection and diagnosis of 191 shoulder ultrasound
images were all confirmed by an orthopedic shoulder surgeon and a physical medicine and
rehabilitation (PM&R) physician who was specialized in shoulder musculoskeletal ultrasound.
During the ultrasound examination, patients were placed in a standard sitting position with
shoulder extended, internally rotated, and a routine ultrasound procedures were followed. The
settings of the ultrasound scanner, such as time gain compensation, were consistent for all
patients. The acquired shoulder ultrasound images were stored as 8-bit images with gray-scale
values ranging from 0 to 255. According to previous meta-analysis study, diagnostic accuracy
of supraspinatus tears is high while performed by musculoskeletal radiologists and shoulder
orthopedic surgeons [20]. As the gold standard in the evaluation of the proposed CTC system,
an orthopedic shoulder surgeon and a PM&R physician who was specialize in shoulder muscu-
loskeletal ultrasound classified the lesions into 89 cases of supraspinatus tendon tendinopathy
and 102 cases of supraspinatus tear. Lesion areas were delineated by the same orthopedic
shoulder surgeon to enclose the necessary tissues while avoiding normal tendons. Image J was
the software used in showing ultrasound images and delineating. The delineation of supraspi-
natus lesion areas was also confirmed by the PM&R physician to obtain the consensus. Fig 1
provides ultrasound images of a case of tendinopathy and a case of a tear.

Feature extraction
The normal supraspinatus tendon is a convex beak-shaped hyperechoic structure in long-axis
view [29]. After the delineation of the lesion area in the supraspinatus tendon, the sonographic
appearance of the enclosed tissues was analyzed according to their echogenic properties.
Supraspinatus tendinopathies were irregular, and loss of homogeneous texture was observed.
Supraspinatus tears appeared to have irregular margins with hypoechoic areas [30, 31]. These
tears, particularly those associated with tendon thickness, can be full-thickness tears or partial-
thickness tears from the bursal to the articular surface [32]. Consequently, intensity and tex-
ture features were proposed to analyze the tissues enclosed in the delineated lesion area.
Intensity features. The gray-scale distribution of tissues in the lesion can be presented by
a probability distribution and form a histogram. The statistical characteristics of the histogram
can be quantified by the histogram moments [33, 34]. The quantitative moments provide
objective measures of the histogram, expressing the intensity difference between tendinopa-
thies and tears. These include the mean, variance, skewness, and kurtosis, namely, the first-,
second-, third-, and fourth-order central moments of a histogram. The mean, at the center of a
distribution, can be obtained by summarizing total pixel values and dividing the sum by the
pixel number. Variance indicates how uniform the gray-scale values are spread out. Skewness
estimates the symmetry of the value distribution such as a bias to one side or not. Taking nor-
mal distribution as a reference, kurtosis is a single-peaked shape with heavily weighted tails.

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 Quantitative diagnosis of rotator cuff tears

Fig 1. Supraspinatus tendon shown in ultrasound images. (a) A case of tendon tendinopathy. (b) A case of
supraspinatus tear. (c) and (d): The lesion contours of (a) and (b), respectively, which were delineated by a shoulder
orthopedic surgeon using ImageJ.
https://doi.org/10.1371/journal.pone.0212741.g001

Texture features. Another category of quantitative features proposed in computer-aided

diagnosis systems for tissue characterization is texture feature [24], as tendinopathy generally
appears to have heterogeneous patterns and tears appear to have hypoechoic echogenicities.
The gray-scale intensities of echogenicities and statistical correlation between pixel values
would provide useful information for differentiating lesion types. In this study, the gray-scale
co-occurrence matrices (GLCM) [35, 36], which calculated the second-order statistics of ultra-
sound texture inside the lesion area, were proposed as features. The statistics revealed the cor-
relations between adjacent pixels with different combinations of gray-scales.
Originally, the pixel values ranged from 0 to 255. These values can be separated into
reduced intensity bins to achieve computational efficiency. Therefore, the first step was to
quantize the original image to be the image G with 8 levels. For clinical diagnosis, 8 levels is
enough to interpret the patterns human can distinguish. More levels would lead to unneces-
sary computation loading which may not suitable in clinical use. Afterward, the 8×8 co-

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 Quantitative diagnosis of rotator cuff tears

occurrence matrices P = [p(i,j|d,θ)] were generated by scanning the pixels and their neighbors
in G. The matrix element P = [p(i,j|d,θ)] represented the frequency of two adjacent pixels with
values of i and j at a distance (d) and a direction (θ). Based on the matrix, 14 GLCM texture
features were calculated [36]. Fig 2 illustrates the distance d = 1 and the direction θ = 0˚, 45˚,
90˚, or 135˚ in the consideration of texture composition. d = 1 was used to better describe the
details of some lesions having less than 0.5 cm. For four co-occurrence matrices with different
angles which included all the combination of two adjacent neighbors, the means of the above
statistic features were calculated and extracted from the lesion areas and were combined with
intensity features in the classifier to express tissue characteristics, such as brightness, contrast,
and heterogeneity.

Statistical analysis
According to the sonographic appearance of supraspinatus tendinopathy and tear, the corre-
sponding quantitative features were proposed for classification. In the evaluation, several test
methods were used to determine whether these features can distinguish between tendinopa-
thies and tissue tears. First, a Kolmogorov-Smirnov test [37] was used to determine if the value
distribution of a feature was normal or not. Normally distributed features were then tested by
Student’s t-test [37], and non-normally distributed features were evaluated by a Mann-Whit-
ney U-test [37]. The resulting p-values <0.05 indicated whether a feature was statistically sig-
nificant in distinguishing between the supraspinatus tendinopathy and tear. To generate a
prediction model based on the combination of various quantitative features, different feature
combinations were evaluated in the logistic regression classifier by stepwise backward elimina-
tion to discover the most relevant combination of features with the lowest error rate. The equa-
tion of feature combination in the logistic regression classifier is:
Tear probability ¼ 1=ð1 þ expð 1 � ðf1 � C1 þ � � � fn � Cn constantÞÞÞ ð1Þ

where f1, fn are different features which multiply different C1, Cn as coefficients.
Due to the limited number of collected cases, the generalization ability of the prediction
model was assessed by leave-one-out cross-validation. A case picked from N cases (the total
number of collected cases) was used to test the model trained by the remaining N-1 cases.
Summarizing the classification result of the N cases accomplished the prediction performance.
In the performance evaluation, each case was given a probability indicating the likelihood
of tears. Cases with probability values � 0.5 were classified as tears, and those < 0.5 were clas-
sified as tendinopathy. According to the gold standard established by an orthopedic shoulder

Fig 2. The illustration of texture analysis considering neighboring pixel pairs of four directions: 0˚, 45˚, 90˚, and
135˚ and distance = 1.
https://doi.org/10.1371/journal.pone.0212741.g002

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 Quantitative diagnosis of rotator cuff tears

surgeon and a PM&R physician, the following five performance indices were generated: accu-
racy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value
(NPV). The tradeoffs between the sensitivity and specificity were calculated and illustrated
using a receiver operating characteristic (ROC) curve. Az, the area under the ROC curve, was
analyzed using ROCKIT software (C. Metz, University of Chicago, Chicago, IL, USA). Other
statistical testing methods were performed using SPSS (version 16 for Windows; SPSS, Chi-
cago, IL, USA).

Results
Tables 1 and 2 show whether the proposed image features, including intensity and texture fea-
tures, can be significant in tear classification. As a result, four intensity and 11 texture features
obtained a statistically significant p-value less than 0.001. After feature selection, the relevant
image features were selected and combined in the classifier to generate a prediction model.
Three performance results of the CTC system based on different feature sets are shown in
Table 3. After backward elimination, three of four intensity features including Mean, Skewness,
Kurtosis were selected and combined in the classifier. The intensity feature set attained an
accuracy of 91%, a sensitivity of 92%, and a specificity of 91%. For texture features, Correlation,
Information measure of correlation, and Inverse difference normalized were selected to be the
most relevant according to their combination performance. The texture feature set attained an
accuracy of 89%, a sensitivity of 89% and, a specificity of 89%. Benefiting from complementary
advantages, the combined intensity and texture feature sets including selected Mean, Kurtosis,
Inverse difference normalized, and Inverse difference moment achieved an accuracy of 92%,
which is better than using intensity and texture feature sets individually.
Fig 3 demonstrates a supraspinatus tear case that was misclassified by the texture feature set
but correctly classified by the combination of texture and intensity feature sets. In Fig 4, the
trade-offs between sensitivity and specificity are illustrated using ROC curves, with corre-
sponding Az values.

Discussion
The proposed CTC system based on intensity and texture features was established to interpret
tissue echogenicities of shoulder ultrasound images. The prediction model built by a logistic
regression classifier achieved an accuracy of 92% for identifying rotator cuff tears and tendino-
pathies. The high accuracy suggests that the proposed CTC system is useful for assessing the
presence of rotator cuff tears. The classification result was obtained via leave-one-out cross-
validation due to the limited cases. The accuracy presented in this study provides us a direction
that the proposed CTC system works well in tear classification while the morphology features
are useless for differentiation in the observation. With respect to the selected features, Tears

Table 1. The test results of intensity features using the Mann-Whitney U-test.

Features Tendinopathy Tear p-value

Median Median
Mean 116.56 42.58 <0.001�
Variance 507.71 292.98 <0.001�
Skewness 0.26 1.19 <0.001�
Kurtosis 2.94 5.14 <0.001�

�
p-value<0.05 indicates a statistically significant difference.

https://doi.org/10.1371/journal.pone.0212741.t001

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 Quantitative diagnosis of rotator cuff tears

Table 2. The test results of texture features using student’s t-test (mean) or the Mann-Whitney U-test (median).

Features Tendinopathy Tear p-value

Mean±SD Median Mean±SD Median
Autocorrelation 1.496 1.132 <0.001�
Contrast 0.0179± 0.006 0.0115± 0.005 <0.001�
Correlation 0.973± 0.012 0.929± 0.029 <0.001�
Cluster Prominence 106.48 16.04 <0.001�
Cluster Shade 11.81 1.92 <0.001�
Dissimilarity 0.006 0.004 <0.001�
Energy 0.962 0.976 <0.001�
Entropy 0.136 0.090 <0.001�
Homogeneity 0.997 0.998 0.101
Difference variance 0.0179± 0.006 0.0115± 0.005 <0.001�
Difference entropy 0.028 0.025 0.156
Information measure of correlation -0.869 -0.827 <0.001�
Inverse difference normalized 0.9994 0.9995 <0. 01�
Inverse difference moment 0.99980 0.99987 <0.001�

�
p-value<0.05 indicates a statistically significant difference.

https://doi.org/10.1371/journal.pone.0212741.t002

tend to be darker due to its higher value of mean intensity and centralized with higher kurtosis
value. Besides, high Inverse difference normalized, and Inverse difference moment mean the
gray-scale distribution is uniform and lacking variance.
The proposed CTC system focused on the diagnosis of supraspinatus tears. It is believed
that ultrasound has a high diagnostic accuracy for calcific tendinitis, although few studies have
assessed this [16, 38]. Calcific tendinitis has several forms, including microcalcification, large
soft calcification without acoustic shadow, and large hard calcification appearing as hypere-
choic convex with acoustic shadows. All forms of calcific tendinitis of supraspinatus are
detected with little difficulty through ultrasound examination [32]. A limitation of the clinical
practice of shoulder ultrasound is the inter-observer variability in diagnosing rotator cuff
tears. The inter-observer agreement of diagnosing rotator cuff tears, especially partial thickness
tears, is only poor to moderate [10] and should be improved for clinical application of the
shoulder ultrasound. Therefore, this study proposed a customized CTC system for the diagno-
sis of rotator cuff tears. Although how much improvement of inter-operator variability was
not presented in this study. Future experiment will be performed with scheduled people and

Table 3. The performance comparisons of intensity features, texture features, and the combination of both feature sets.

Intensity Texture Combined Combined Combined

vs. vs.
Intensity Texture
(p-value) (p-value)
Accuracy 91% (175/191) 89% (171/191) 92% (176/191) 0.8514 0.3752
Sensitivity 92% (94/102) 89% (91/102) 91% (93/102) 0.8000 0.6377
Specificity 91% (81/89) 89% (80/89) 93% (83/89) 0.5776 0.4183
PPV 92% (94/102) 91% (91/100) 93% (93/99) 0.6197 0.4323
NPV 91% (81/89) 87% (80/91) 90% (83/92) 0.8548 0.6172
Az 0.9682 0.9469 0.9694 0.9701 0.0610

https://doi.org/10.1371/journal.pone.0212741.t003

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 Quantitative diagnosis of rotator cuff tears

Fig 3. Tear classification results with probabilities higher than 50% were classified to be tear. (a) a moderate
supraspinatus near full thickness tear with unobvious characteristics in the ultrasound image (hypoechoic area near the
tendon insertion indicated by a white arrow) was misclassified by the texture feature set (42%) but correctly classified
by the combination of texture and intensity feature sets (100%). (b) a small supraspinatus partial thickness tear at
bursal surface was misclassified by the intensity feature set (9%) but correctly classified by the combination of texture
and intensity feature sets (68%).
https://doi.org/10.1371/journal.pone.0212741.g003

time. A previous study used a portion of the lesion (30×60 pixels) for tissue characterization to
classify 80 rotator cuff lesions into groups and achieved 92.5% accuracy [39]. The numerous
features used in the experiment included the fractal dimension, the texture spectrum, the sta-
tistical feature matrix, the texture feature coding method, and the gray-level co-occurrence
matrix. Compared to the previous study, our system collected the whole lesion area of 102
tears rather than a sub-region of 20 tears to provide more representative distribution for the
evaluation. Using only intensity and texture features in this study is expected to be more effi-
ciency for clinical use. With the proposed system, promising recommendations can be pre-
sented to different operator professionals with varying experiences in identifying rotator cuff
tears and tendinopathy. The diagnosis of rotator cuff full-thickness tears influences the deci-
sion to undertake the surgical repair or arthroplasty.
In the literature, the assessment of full thickness rotator cuff tears is shown to have better
sensitivity and specificity compared to partial-thickness rotator cuff tears [20, 40, 41]. A contro-
versial and uncertain issue is whether the accuracy of ultrasound examinations for the assess-
ment of partial-thickness rotator cuff tears is sufficient [16, 42, 43]. With ultrasound
examinations, partial-thickness tears are diagnosed when there is a focal hypoechoic or
anechoic defect inside of the tendon, involving either the articular or the bursal surface and

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 Quantitative diagnosis of rotator cuff tears

Fig 4. The trade-offs between the sensitivity and specificity of the computer-aided tear classification system using
different feature sets are illustrated by receiver operating characteristic curves. (“Moment” is referred to intensity
model; “GLCM” is referred to texture model; and “Moment + GLCM” is referred to a combined model.)
https://doi.org/10.1371/journal.pone.0212741.g004

manifested in at least two perpendicular planes. Limited knowledge of anatomy, inexperience

with examination techniques, and patient-related factors (e.g., obesity or muscularity and lim-
ited shoulder motion) limit the diagnostic accuracy of partial-thickness rotator cuff tears [44].
The accuracy variation of partial thickness rotator cuff based on shoulder ultrasound images
limits the current application of shoulder ultrasounds. In the proposed CTC system, whole
lesion areas of either partial-thickness or full thickness rotator cuff tears were delineated to
extract lesion features. Lesion features of rotator cuff tears, especially for partial-thickness rup-
ture, are thought to provide less reliable diagnostic information with less-experienced physi-
cians. This is also a limitation of the proposed CTC system. In the future experiment, we will
explore the possibility of automatically extracting the lesion area for more detailed classification.
The current CTC system was proposed to provide consistent and objective recommendations
to less-experienced operators for clinical examinations. Lesion areas were delineated by the
orthopedic shoulder surgeon and confirmed by the PM&R physician to obtain the consensus to
ensure whole lesion area. Further experiments will be necessary to analyze the diagnostic perfor-
mance based on lesion area delineated from less-experienced operators and even by automatic

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 Quantitative diagnosis of rotator cuff tears

segmentation to verify the clinical usefulness of the proposed CTC system. Another limitation
is that the collected ultrasound images were generated using a consistent setting. The classifica-
tion result based on the intensity features extracted from these images achieved an accuracy of
91%. According to the result, using intensity features under consistent settings would be useful
in tear classification while the system is customized for a specified ultrasound scanner or setting.
In other situations, if the system targets at multi-center hospitals with various scanners, a cali-
bration procedure or more intensity-invariant features should be adopted [24].
MR arthrography is considered as the most sensitive and specific technique for diagnosis
according to the meta-analysis study when compared to ultrasound and MRI, and MRI and
ultrasound are comparable in accuracy [45]. Nevertheless, the indication and convenience of
MR arthrography is more limited than ultrasound and is an invasive procedure. Furthermore,
not all supraspinatus tears such as partial thickness tears should be treated with surgical or
arthroscopic surgery. Sampling error exists if surgical or arthroscopic findings were used as
the gold standard. According to previous meta-analysis study, diagnostic accuracy of supraspi-
natus tears is high while performed by musculoskeletal radiologists and shoulder orthopedic
surgeons [20], and the accuracy would be higher with the consensus of the experienced opera-
tors. For the reasons specified above, the gold standard was established by the consensus of the
experienced shoulder orthopedic surgeon and PM&R physician who specialize musculoskele-
tal ultrasound in this study.
This study proposed a CTC system which achieved a high accuracy (92%) in identifying
rotator cuff tears, including partial and full thickness tears, by analyzing tissue enclosed in the
lesion area. The proposed CTC system performed similar performance to the experienced
operators in terms of accuracy. According to a meta-analysis of diagnostic accuracy of ultra-
sound for rotator cuff tears [20], diagnostic accuracy may be greatest when operated by mus-
culoskeletal radiologists, followed by orthopedic surgeons. The pooled sensitivity and
specificity under the direction of musculoskeletal radiologists are both 95%. However, sensitiv-
ity is lowered to 46% when the diagnosis of partial thickness tears is given by general radiolo-
gists or radiographers [46, 47]. Consequently, the proposed CTC system can provide clinical
assistance for general radiologists or ultrasonographers who may not have comparable rates of
diagnostic accuracy as musculoskeletal radiologists or orthopedic shoulder surgeons [20].
Additional experiments are needed to explore the clinical application of the proposed CTC
system. In particular, future research should examine how to utilize the CTC system in clinical
examinations to improve the performance of the observer. More specific, meaningful sono-
graphic findings may be needed to convince observers.
In conclusion, this CTC system based on intensity and texture features extracted from the
lesion area in shoulder ultrasound images achieved comparable accuracy in identifying rotator
cuff tears to musculoskeletal radiologists and orthopedic shoulder surgeons. The diagnostic sug-
gestions generated by the proposed CTC would be practical and promising in clinical assessments.

Supporting information
S1 Data. The delineated regions of rotator cuff tears.
(ZIP)

Acknowledgments
The authors would like to thank the Ministry of Science and Technology (MOST 107-2221-E-
004-013), New Taipei City Hospital (NTCH104-001) of Taiwan, the Republic of China, for
financially supporting this research.

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 Quantitative diagnosis of rotator cuff tears

Author Contributions
Conceptualization: Ruey-Feng Chang.
Data curation: Chung-Chien Lee.
Formal analysis: Chung-Chien Lee.
Funding acquisition: Chung-Ming Lo.
Investigation: Chung-Ming Lo.
Methodology: Chung-Ming Lo.
Resources: Chung-Chien Lee.
Validation: Ruey-Feng Chang, Chung-Ming Lo.
Writing – original draft: Chung-Ming Lo.
Writing – review & editing: Ruey-Feng Chang, Chung-Chien Lee.

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