Rotator cuff pathology is one of the most common causes of shoulder pain, functional limitation, and reduced quality of life, particularly among middle-aged and elderly individuals. It represents a significant proportion of musculoskeletal disorders affecting the shoulder and may interfere with daily activities, occupational performance, and overall functional ability.[1] The rotator cuff is a complex musculotendinous unit comprising the supraspinatus, infraspinatus, subscapularis, and teres minor tendons, which provide dynamic stability to the glenohumeral joint and facilitate coordinated shoulder movements.[2] Injury or degeneration of these structures due to acute trauma, repetitive mechanical stress, or age-related changes may result in conditions ranging from tendinopathy and partial-thickness tears to complete tendon rupture. The prevalence of rotator cuff injuries increases with advancing age due to progressive tendon degeneration and reduced tissue resilience.[3] Repetitive overhead activities, sports participation, occupational shoulder loading, and manual labour further increase the risk of tendon damage. Patients commonly present with shoulder pain, weakness, restricted range of motion, difficulty performing overhead activities, and varying degrees of functional impairment.[4] However, the severity of clinical symptoms does not always correspond with the extent of structural tendon abnormalities, making accurate imaging assessment essential for diagnosis and management.[5] Diagnosis of rotator cuff injuries requires integration of clinical evaluation, physical examination, and radiological assessment. Clinical tests such as the Neer impingement test, Hawkins–Kennedy test, painful arc test, and drop arm test provide important diagnostic information but may have variable accuracy depending on lesion characteristics. [6,7] Imaging plays a crucial role in confirming diagnosis, determining the extent of injury, and guiding appropriate treatment strategies.[8] Magnetic resonance imaging (MRI) has become the preferred non-invasive imaging modality for evaluation of rotator cuff injuries due to its excellent soft tissue contrast, multiplanar capability, and ability to demonstrate detailed tendon and muscle abnormalities. [9,10] MRI allows assessment of tendon integrity, tear location, tear thickness, tear size, tendon retraction, muscle atrophy, fatty infiltration, bursitis, and associated intra-articular lesions.[11] These parameters provide important information regarding disease severity, prognosis, and surgical planning. Rotator cuff tears are classified as partial-thickness or full-thickness tears depending on the extent of tendon involvement.[12] Partial-thickness tears may involve the articular surface, bursal surface, or the tendon substance, whereas full-thickness tears demonstrate complete disruption of tendon fibers. MRI findings such as tendon discontinuity, increased signal intensity on fluid-sensitive sequences, tendon retraction, fatty degeneration, and muscle atrophy are important indicators of chronicity and severity of disease.[13,14] Although MRI provides detailed anatomical assessment, the correlation between imaging findings and clinical presentation remains complex.[15] Some patients may demonstrate extensive rotator cuff abnormalities with minimal symptoms, while others with smaller lesions may experience significant pain and functional restriction. Therefore, evaluating the relationship between MRI findings and clinical severity is essential for accurate interpretation of imaging abnormalities and individualized patient management.[16] Clinical severity assessment involves evaluation of pain, muscle strength, range of motion, and functional status using standardized scoring systems such as the Constant–Murley score and American Shoulder and Elbow Surgeons (ASES) score. Correlating these clinical parameters with MRI findings helps determine the functional significance of structural abnormalities and improves decision-making regarding treatment.[17] The present study, titled “MRI Evaluation of Rotator Cuff Injuries and Correlation with Clinical Severity,” was conducted to evaluate MRI findings in patients with rotator cuff injuries and determine their association with clinical severity. This assessment may contribute to improved diagnostic accuracy, treatment planning, and prognostic evaluation of patients with rotator cuff disorders.

The present study was conducted as a prospective observational study to evaluate rotator cuff injuries using magnetic resonance imaging (MRI) and to assess the correlation between MRI findings and clinical severity. The study was carried out in the Department of Radiodiagnosis at a tertiary care hospital. Study Population A total of 60 patients presenting with clinical suspicion of rotator cuff injury were included in the study. All participants underwent MRI evaluation of the affected shoulder and clinical assessment for determining the severity of symptoms and functional impairment. Inclusion Criteria Patients fulfilling the following criteria were included in the study: • Patients with clinical suspicion of rotator cuff injury presenting with shoulder pain, weakness, or restricted shoulder movements. • Patients belonging to different age groups with suspected rotator cuff pathology. • Patients willing to participate in the study and provide informed consent. • Patients referred for MRI evaluation of the shoulder joint. Exclusion Criteria Patients with the following conditions were excluded from the study: • Previous shoulder surgery or history of rotator cuff repair. • History of fracture or major trauma causing altered shoulder anatomy. • Patients with contraindications to MRI examination. • Patients unwilling to provide informed consent. • Patients with incomplete clinical or imaging data. Clinical Evaluation All included patients underwent detailed clinical assessment before MRI examination. Demographic details, presenting complaints, duration of symptoms, mechanism of injury, and relevant clinical history were recorded. Physical examination included assessment of pain severity, shoulder range of motion, muscle strength, and functional limitation. Clinical severity was evaluated using standardized shoulder assessment parameters, including the Constant–Murley score and/or American Shoulder and Elbow Surgeons (ASES) score, wherever applicable. MRI Protocol and Image Acquisition MRI examination of the affected shoulder was performed using a dedicated shoulder protocol. Patients were positioned supine with the arm in a neutral position. MRI sequences included multiplanar imaging in axial, coronal oblique, and sagittal oblique planes. The MRI protocol included: • T1-weighted sequences for anatomical evaluation. • Proton density/fat-suppressed sequences for tendon and soft tissue assessment. • T2-weighted and fluid-sensitive sequences for detection of tendon tears, inflammation, and associated abnormalities. MRI images were evaluated for rotator cuff integrity, type and extent of tear, tendon involvement, tear size, tendon retraction, muscle atrophy, fatty infiltration, subacromial-subdeltoid bursitis, and associated intra-articular abnormalities. MRI Assessment of Rotator Cuff Injuries Rotator cuff abnormalities were categorized based on MRI findings. Tears were classified as: • Partial-thickness tears: Involvement of a portion of tendon thickness without complete disruption. • Full-thickness tears: Complete disruption of tendon fibers with communication between the joint space and subacromial-subdeltoid bursa. Additional MRI parameters including tendon location, tear dimensions, degree of retraction, muscle quality, and associated degenerative changes were documented. Correlation Between MRI Findings and Clinical Severity MRI findings were correlated with clinical severity parameters to assess the relationship between structural abnormalities and functional impairment. The association between tear characteristics, severity of tendon damage, and clinical scores was analyzed to determine the clinical significance of MRI findings. Statistical Analysis The collected data were entered into a computerized database and analyzed using SPSS.25statistical software. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. The association between categorical variables was assessed using the Chi-square test or Fisher’s exact test. Correlation between MRI findings and clinical severity scores was evaluated using Pearson’s or Spearman’s correlation coefficient depending on data distribution. A p-value <0.05 was considered statistically significant.

A total of 60 patients with clinically suspected rotator cuff injuries were included in the present study and underwent MRI evaluation of the affected shoulder. The demographic profile, clinical characteristics, MRI findings, and correlation between imaging severity and clinical parameters were analyzed.

The mean age of the study population was 49.6 ± 12.4 years. The majority of patients belonged to the 41–60 years age group (51.7%), followed by those aged >60 years (28.3%). Males constituted the majority of cases (65.0%), while females accounted for 35.0% of patients.

Regarding symptom duration, most patients presented with symptoms for 3–6 months (38.3%), followed by >6 months (35.0%). The most common presenting complaint was shoulder pain (100%), followed by restricted shoulder movements (73.3%) and weakness during overhead activities (60.0%). Details of demographic and clinical characteristics are presented in Table 1.

Table 1: Demographic and Clinical Characteristics of Study Participants (n=60)

A traumatic mechanism of injury was reported in 38.3% of patients, whereas degenerative/insidious onset was observed in 61.7% of cases. The mean Constant–Murley score was 54.8 ± 14.6, indicating moderate functional impairment among study participants. Based on clinical severity grading, moderate impairment was observed in the majority of patients (51.7%), followed by severe impairment (28.3%) and mild impairment (20.0%) (Table 2).

Table 2: Mechanism of Injury and Clinical Severity Assessment (n=60)

MRI evaluation revealed supraspinatus tendon involvement as the most common abnormality, observed in 88.3% of patients, followed by infraspinatus involvement (35.0%) and subscapularis involvement (28.3%). Rotator cuff tears were identified in 54 patients, while 6 patients demonstrated tendinopathy without definite tear.

Among tear patterns, full-thickness tears were observed in 31.7% of cases, while partial-thickness tears accounted for 58.3%. MRI findings are summarized in Table 3, Figure 1

Table 3: Distribution of MRI Findings in Rotator Cuff Injuries (n=60)

Figure 1 Distribution of MRI Findings in Rotator Cuff Injuries (n=60)

Among patients with rotator cuff tears, the majority demonstrated small-to-moderate sized tears. Tendon retraction was absent or minimal in most cases, while advanced retraction was observed in a smaller proportion of patients. Fatty infiltration and muscle atrophy were more frequently associated with full-thickness tears.

The distribution of tear characteristics according to MRI assessment is shown in Table 4, Figure 2

Table 4: MRI Characteristics of Rotator Cuff Tears (n=54)

Figure 2 MRI Characteristics of Rotator Cuff Tears (n=54)

A significant correlation was observed between MRI-based severity of rotator cuff injury and clinical functional impairment. Patients with full-thickness tears demonstrated significantly lower Constant–Murley scores compared with those having partial-thickness tears or tendinopathy.

The mean Constant–Murley score decreased progressively with increasing MRI severity, indicating greater functional impairment with advanced structural damage. The correlation between MRI severity grade and clinical score was statistically significant (r = -0.62, p <0.001) (Table 5).

Table 5: Correlation Between MRI Severity and Clinical Functional Score (n=60)

Patients with larger tears, tendon retraction, muscle atrophy, and fatty infiltration demonstrated significantly higher frequency of severe pain and functional restriction compared with patients without these findings. A significant association was observed between tear type and severity of clinical symptoms (p<0.05).

The association between MRI parameters and clinical severity is presented in Table 6, Figure 3

Table 6: Association Between MRI Findings and Clinical Severity (n=60)

Figure 3 Association Between MRI Findings and Clinical Severity (n=60)

Rotator cuff injuries are a common cause of shoulder pain and functional disability, particularly among middle-aged and elderly individuals due to progressive tendon degeneration. MRI plays an important role in evaluating rotator cuff pathology because of its excellent soft tissue contrast and ability to assess tendon integrity, tear characteristics, muscle changes, and associated abnormalities. The present study evaluated MRI findings of rotator cuff injuries and their correlation with clinical severity among 60 patients. In the present study, the mean age of participants was 49.6 ± 12.4 years, with the majority belonging to the 41–60 years age group (51.7%). Males represented the majority of cases (65.0%). Similar demographic trends have been reported in previous studies, with rotator cuff disorders being more common among middle-aged and elderly individuals with male predominance. Khalid et al. [18] also observed a higher frequency of rotator cuff tears among patients above 40 years, with male predominance. This increased prevalence may be related to age-related tendon degeneration, reduced vascularity, and cumulative mechanical stress. In the present study, shoulder pain was reported by all patients (100%), while restricted movements and weakness were observed in 73.3% and 60.0% of cases, respectively. These findings confirm that pain and functional limitation are the predominant clinical manifestations of rotator cuff disorders. However, clinical symptoms alone may not accurately determine structural severity, highlighting the importance of MRI evaluation for precise characterization of tendon pathology. A degenerative/insidious onset was observed in 61.7% of patients, whereas traumatic onset accounted for 38.3% of cases. This suggests that chronic degenerative changes contribute significantly to rotator cuff injury development, with repetitive mechanical stress and age-related tendon weakening acting as important risk factors. MRI assessment revealed that the supraspinatus tendon was the most frequently involved structure (88.3%), followed by infraspinatus (35.0%) and subscapularis (28.3%). Similar findings have been reported by Khalid et al. [18], who identified supraspinatus as the predominant tendon involved in rotator cuff pathology. The higher susceptibility of supraspinatus may be attributed to its anatomical position beneath the acromion and its increased exposure to impingement-related stress. Partial-thickness tears were observed in 58.3% of patients, while full-thickness tears were identified in 31.7%. Sharma et al. [19] reported high diagnostic accuracy of MRI for detecting rotator cuff tears, with accuracy rates of 93.1% for full-thickness tears and 91.1% for partial-thickness tears, supporting the reliability of MRI in tendon assessment. The predominance of partial-thickness tears in the present study may represent earlier stages of tendon degeneration before progression to complete rupture. Regarding tear characteristics, medium-sized tears (1–3 cm) were most common (44.4%), followed by small tears (40.7%). Most patients demonstrated absent or minimal tendon retraction (70.4%). Assessment of tear size, retraction, and muscle quality using MRI provides valuable information for treatment planning and prediction of functional outcomes. A significant correlation was observed between MRI severity and clinical impairment. Patients with full-thickness tears had lower Constant–Murley scores (38.9 ± 9.8) compared with partial-thickness tears (58.7 ± 10.4) and tendinopathy (72.4 ± 8.6). MRI severity showed a significant negative correlation with functional score (r = -0.62, p<0.001), indicating that increasing structural damage was associated with worsening shoulder function. Similar studies have demonstrated significant associations between tear severity, tear size, and clinical disability. Muscle atrophy (33.3%) and fatty infiltration (27.8%) were important associated MRI findings and were significantly related to severe clinical impairment. These changes are recognized prognostic indicators as they may adversely affect tendon healing and postoperative functional recovery.

MRI is an effective and reliable imaging modality for comprehensive evaluation of rotator cuff injuries, providing detailed assessment of tendon tears, retraction, muscle atrophy, and associated abnormalities. The present study demonstrated a significant correlation between MRI severity parameters and clinical impairment, with advanced tears showing greater functional limitation. MRI findings, when combined with clinical assessment, provide valuable information for diagnosis, treatment planning, and prognostic evaluation. Therefore, MRI plays an essential role in the individualized management of patients with rotator cuff disorders.

Limitations

The present study was limited by the relatively small sample size of 60 patients and was conducted at a single tertiary care centre, which may restrict the generalizability of the findings. The study focused on MRI-based assessment and clinical correlation without long-term follow-up to evaluate treatment outcomes. Further multicentric studies with larger populations and extended follow-up are required to validate the findings.

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