 Good morning. I am Dr. Weber Goyal from Teethankar Mahavir Medical College and Research Center, Muradabad. Thank you MRI teaching course for giving me this opportunity to present my paper on roll-off ultrasound delastrography in evaluation of rototagraph tendons in patient with shoulder pain and its comparison with magnetic resonance imaging. Most common cause of shoulder pain are rototagraph disease, accounting for 85% of the cases. Other causes are acromic labular joint disorder and glenohumeral joint disorders. Rototagraph disease has been classically described as a progressive disorder of the rototagraph tendons, which begins with an acute tendonitis, then progresses through tendinosis with degeneration and partial thickness tear, and finally resulting in full thickness rupture. Among the rototagraph tendons, supraspinitis is the most common tendon involved in tendinopathy or tendon tear, followed by combination of supraspinitis and infraspinitis tendon. Ultrasonic B-mode imaging and MRI are currently applicable tools for pre-operative planning and post-operative monitoring of the rototagraph repair, and are mainly used to assess the tear size, gross structures and the presence of the fatty degeneration in the rototagraph muscles. Low cost, wide availability and scan dynamics are the advantages of ultrasonography. MRI has multi-planar capability, which provides greater soft tissue information and is proven to have both higher sensitivity and specificity for evaluation of rototagraph tears, but it is costly and has limited availability. However, altered material properties of the muscle or tendon cannot be assessed adequately by the above modalities, which is why sonolastrography may add further knowledge to conventional shoulder imaging. Since tendon qualities are a prognostical factor for rototagraph repair, information about tendon stiffness could be beneficial for the surgeon. Shia-vibelastrography material is based on so-called shear waves generated within the tissue by using a conventional ultrasound wave that interacts with the tissue and it uses horizontally directed shear waves that propagate through the tissues. The velocity of these shear waves can be quantified by using ultra-fast algorithm to evaluate tissue composition and elasticity. Aim of the study, to study role of ultrasound elastrography in evaluation of rototagraph tendons in patient with shoulder pain in its comparison with magnetic resonance imaging. Objective of the study, to evaluate morphology of rototagraph tendons in patient with shoulder pain on high-resolution b-mode U.S.G. and MRI, to evaluate tissue stiffness of rototagraph tendons, supraspinitis and infraspinitis on ultrasound elastrography in patient with shoulder pain. To compare greyskier rototagraph and elastrography fundings of rototagraph tendons with MRI in patient with shoulder pain and to assess the diagnostic accuracy of ultrasound elastrography in the evaluation of rototagraph tendons in patient with shoulder pain. Selection of the patients, inclusion criteria. All patients complaining of shoulder pain with suspected rototagraph disease referred from orthopedics department to department of radio diagnosis for shoulder MRI. Exclusion criteria. Patient who had undergone previous surgery on rototagraph tendons or shoulder joint. Patients having absolute contraindication for undergoing MRI. Patient with grossly-cassified tendon. And patient who is unwilling to give consent or uncomperative push. Metal and materials. This is prospective observational study of 20 patients. Prior written consent after proper explanation of procedure will be obtained from the patients. MRI examination will be performed on 1.5 tesla MRI machine Siemens-Magnetown-Eventotim.system using shoulder coil with the following protocols. Exiled proton-density fat saturation, coronal oblique T1 fast pinnico, coronal oblique T2 fast pinnico, sagittal oblique T2 fat saturation stir, and coronal oblique T2 fat saturation. Conventional MRI images will be obtained first followed by greyskiel ultrasound and ultrasound elastrography of rototagraph tendons of shoulder. Radiologist performing ultrasound will be blinded towards the results of MRI. MRI findings will be assessed for each tendon and will be recorded as follows. Tendon degeneration, showing increased signal intensity on T2 weighted images in coronal planes. Partial tier, showing focal areas of tendon discontinuity with T2 bright fluid signal. Full thickness tier, showing focal or complete discontinuity of tendon fibers from articulate to basal surfaces. Ultrason and ultrasound elastrography will be performed using Equson S3000 Siemens medical solution device using Siemens 9L4 linear array ultrasound probe as per shoulder protocol. Beamer ultrasound of tendon pathologies will be categorized as follows. Tendinosis without tier, showing hypoechoic areas with loss of cellular architecture in the presence of intersubstance clefts. Tendon thickening or fraying will be considered as Tendinosis. Partial tier includes basal, articular or intersubstance discrete hypoechoic defects that will not involve the full thickness of the tendon. And the full thickness tier which includes discreetly marginated hypoechoic defect that will involve the full tendon thickness. We will perform the shear wave elastrography of supraspinitis and intraspinitis tendons using Equson radiation force impulse pulses in long axis only. Parametric shear wave velocity estimates within the region of interest will be derived automatically from raw radiofrequency data by software implemented in the S3000 scanner, virtual touch imaging quantification and will be displaced as colorized map. Meteorite provides an image-based assessment of shear wave velocity using color coded scales. It will be used to classify tendons on the basis of the stiffness. Tendons will be classified into three types depending on the stiffness, low rigidity showing blue color, intermediate rigidity showing two curves to yellow and high rigidity showing the red curve. Sample will also be taken from any area of abnormal softening in the above tendons and the shear wave velocity will be measured in meter per second or kilopascal in the dynamic range for shear wave velocity measurement will be set as 0.5 to 10 meter per second. This MRI image is showing the normal supraspinitis tendon. On USG the supraspinitis tendon appears smooth and on elastrography the tendon shows high velocity and a map of red scale suggesting normal stiff tendon. This is the T1 fat set coronal image and this is the PDFS sagittal image. Near the footprint the supraspinitis tendon appears bulky and shows signal alteration. On ultrasound the tendon appears mildly bulky. On elastrography the tendon shows reduced velocity near the footprint in the range of 5.27 to 5.32 meter per second and a color map of near green scale. This is the T1 term coronal image and this is the PDFS sagittal image. High signal fluid intensity is noted in the anterior and middle fibers of supraspinitis tendon. The posterior fibers of supraspinitis and anterior fibers of infraspinitis tendon shows tendonosis. On USG at insertion there is full thickness partial with tear of anterior and middle supraspinitis tendon fibers and fluid can be seen at the insertion site of supraspinitis tendon suggesting full thickness partial with tear. On elastrography it shows reduced velocity in the range of 3.47 to 4.64 meter per second in and around the region of tear and a color map of near blue scale. Now the results. This table shows the frequency of MRI in patients with shoulder pain compared with ultrasonography and elastrography. The tendonopathy were found in 9 patients on MRI and 6 patients in ultrasound and 7 patients on soloelastrography. The partial thickness tear was found on 5 patients on MRI, 5 patients on ultrasound and 5 patients on soloelastrography. Full thickness tear was found on 6 patients on MRI, 5 patients on ultrasound and 6 patients on soloelastrography. This table is showing the degree of agreement of MRI with both ultrasonography and soloelastrography in patient with shoulder pain. The correlation coefficient between the MRI and the USG is 0.67 which is statistically significant. The correlation coefficient between MRI and sonolastrography is 0.7 which is also statistically significant. And the correlation coefficient between the sonolastrography and the ultrasound is 0.85 which is also statistically significant. This table shows the performance of ultrasonography and sonolastrography for diagnosis of rototovap tendonopathy in tears in relation to and in agreement with findings of MRI as a gold standard. On ultrasonography the sensitivity for tendonopathy was 83.33 percent, for partial tear was 80 percent, full thickness tear it was 83.33 percent. The specificity for tendonopathy was 92.86 percent, for partial thickness tear it was 93.33 percent, for full thickness tear was 100 percent. The positive productive value for tendonopathy was 83.33 percent, for partial thickness tear 80 percent and for full thickness tear 100 percent. Negative productive value for tendonopathy was 92.86 percent, for partial thickness tear 93.33 percent, for full thickness tear it was 93.33 percent. On sonolastrography the sensitivity for tendonopathy was 85.71 percent, for partial thickness tear 100 percent and for full thickness tear was 100 percent. And the specificity for tendonopathy was 92.31 percent, for partial thickness tear 93.33 percent, for full thickness tear it was 93.33 percent. The positive productive value for tendonopathy was 85.71 percent, for partial thickness tear 83.33 percent, for full thickness tear it was 85.71 percent. And the negative productive value for tendonopathy was was 92.31% for partial thickness tier 100% and for full thickness tier 100%. And the accuracy in case of ultra sonography for tendonopathy was 90%. In case of partial thickness tier it was 90%. For full thickness tier it was 95%. And in case of sonorelastography the accuracy for tendonopathy was 90%. For partial thickness tier 95%. For full thickness tier it was 95.24%. And the p-value according to the Fischer exactives were significant. And according to this table the sonorelastography is slightly, slightly have better sensitivity than the ultrasoundography. Conclusion, ultrasoundelastography is an ultrasound based new technique permitting qualitative visual and quantitative numeric measurements of mechanical tissues, properties and for assessment of differences in tissue stiffness. It could be used as an objective imaging implement for early diagnosis of tendonopathy prior to any detectable alterations in thickness or echogenicity of tendons on b-mode USG. As sometimes it is difficult to detect tendonopathy by conventional b-mode USG as it presents with same echogenicity as the surrounding healthy tissues. Other pitfall of b-mode ultrasound is anisotropy. Tendons appear echogenic when the beam is perpendicular to long axis of the tendon resulting in an error in hypo echogenicity which may be mistaken for tendonosis or partial tiers. The major advantage of sonolastography is that it can provide both quantitative and qualitative analysis about tissue elasticity offering greater sensitivity for deeper structures and better spatial resolution than manual palpation and can be used to differentiate between healthy and pathological tissues as pathological tissues softer than normal tissue. The main finding in this study is that sonolastography could detect areas of tendon softening in case of tendonopathy as regions of altered color changes within normal tendon. Sonolastography also showed better correlation with MRI than conventional USG in detection of different rototocop lesions and sonolastography improved sensitivity when added to conventional USG in detection of rototocop tendonopathy and rototocop tears. The limitations of this study was that the sample size was small and the sonolastography is highly operator dependent and manual compression may affect reliability. These are my references. Thank you.