Rotator cuff tear arthropathy is the term used for shoulder arthritis that develops due to a long-standing, large rotator cuff tear. The abnormal shoulder motion caused by the rotator cuff tear gradually results in significant wear to the bony surfaces.
Your shoulder is made up of three bones: your humerus (upper arm bone), your clavicle (collarbone), and your scapula (shoulder blade).
The head of your humerus fits into the rounded socket in your scapula called the glenoid. Where the humeral head fits into the glenoid is called the glenohumeral joint. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff. There is a second joint in the shoulder called the acromioclavicular joint. This joint commonly has arthritis within it but usually does not require surgery for treatment.
The rotator cuff is made up of four muscles that transition into tendons surrounding the humeral head (the ball of the shoulder). These muscles are attached to the bone by tendons that blend to form a cuff that surrounds the ball. When the rotator cuff muscles contract, their combined action centers the ball in the deepest portion of the shoulder socket. This centering effect is essential for normal shoulder function and allows the arm to be positioned in an incredibly wide range of motion with both strength and stability.
Shoulder arthritis can develop after a large, long-standing rotator cuff tear; this is called “rotator cuff tear arthropathy.” The torn rotator cuff fails to hold the head of the humerus centered in the glenoid socket, and the humerus moves upward and rubs against the undersurface of the acromion. This damages the surfaces of the bones, causing arthritis to develop with resultant shoulder pain and dysfunction.
The combination of a large rotator cuff tear and advanced arthritis can lead to severe pain and weakness, and the patient may not be able to lift their arm away from their body or use their arm to lift objects.
With increasing age, the rotator cuff is prone to tear. Tears can occur from an acute, sudden injury, from accumulated damage over time, and from tendon weakening that occurs from the aging process. If tears go untreated, they may progress and enlarge over time to involve a substantial portion of the rotator cuff. When two or more tendons are involved, cuff tears are considered massive. Such tears have a significant impact on shoulder strength and stability and cause severe shoulder pain. Strength is impaired because the muscle is detached from the bone. Stability is impaired because the cuff no longer centers the ball in the socket. As a result, the humeral head drifts upward in the socket until it abuts against the acromion bone. Over time, this abnormal relationship between the ball and socket leads to erosion of the upper lip of the socket, and arthritis ensues.
The x-ray to the left below shows a normal shoulder. The ball is round and is centered within the socket. The x-ray to the right below shows a shoulder with cuff tear arthropathy. The ball has risen upward, causing erosion of the upper socket and abrasion against the acromion bone. The humeral ball has been rounded off and flattened from this abrasion.
Other changes occur around the shoulder joint that complicate the management of this condition. First, due to a long-standing tear, the rotator cuff muscles atrophy and is replaced by fat. Second, torn tendons undergo further degeneration and thinning both from disuse and abrasion. Third, the bone of the humeral head weakens from disuse. These changes generally make it impossible to repair the rotator cuff, hence the term “irreparable” rotator cuff tear. With time, the bone of the humeral head may become so weak that collapse of the head occurs, and the ball loses its smooth round joint surface.
Cuff tear arthropathy is generally easy to identify by physical examination. Characteristics include:
While these are the typical features of a massive rotator cuff tear, every patient may be affected differently. Despite a massive tear, some patients can raise their arms actively by recruiting the deltoid and other shoulder muscles.
In some cases, the patient’s history and physical exam may be all that is necessary to make a diagnosis of cuff tear arthropathy. Nevertheless, imaging studies are important to assess the degree of arthritis as well as bony relationships.
X-rays are essential to confirm the diagnosis. When these show upward migration of the ball in the socket, a massive, irreparable rotator cuff tear is present. These x-rays also show the degree to which the ball has worn against the upper part of the socket and the undersurface of the acromion. In addition, they show if the ball has undergone any collapse from severe osteoporosis.
If the x-rays suggest that significant wear has occurred against the acromion undersurface, a CT scan may be necessary to evaluate the shoulder further. A CT scan is a special study that takes multiple x-rays in 3 dimensions and provides greater detail of the bone structure. CT scans also provide more detailed information about the relationship of the ball to the socket and the pattern of socket wear and erosion.
MRI scans are also used to evaluate cuff tear arthropathy further. If the ball remains centered in the socket but patients present with severe weakness of arm elevation, then an MRI is helpful to determine if there is a rotator cuff tear present that is repairable. This determination is made based on tear size, tendon retraction, and the degree of muscle atrophy.
Physical Therapy. Therapy may be successful in patients with well-compensated shoulder function and pain that is at a manageable level. Physical therapy may help improve shoulder flexibility and strengthen the muscles around the shoulder girdle that compensate for the torn cuff. These muscles are called the scapular stabilizers and include the serratus anterior, trapezius, rhomboids, latissimus dorsi, and pectoralis major. In addition, deltoid strengthening may improve shoulder function.
Aquatherapy may prove beneficial in allowing patients to exercise in a relatively weightless environment. Water helps support the joint and is also soothing for the sore shoulder.
Physical therapy is less effective in patients with poor function and moderate to severe pain. In these cases, painful abrasion of the bones limits what can be accomplished through range of motion and strengthening exercises.
Non-steroidal Anti-inflammatory Medications (NSAIDS). These medicines include Ibuprofen, Motrin, Advil, Aleve, Celebrex, and others. NSAIDs reduce inflammation and also act as mild pain relievers. They may help keep some patients’ pain at a manageable level. In other cases, arthritis may be severe enough that these medications are of little benefit. Long-term use of NSAIDS may be associated with irritation of the stomach lining, ulcers, and kidney problems. Patients should become informed about the possible short- and long-term side effects of NSAIDs before use. This is especially important for patients who take other medications for blood pressure, heart problems, diabetes, etc. If you have any concerns, speak with Dr. Jurek before you start taking NSAID medication.
Other Medications. Narcotic pain medications, muscle relaxants, and sleeping pills are generally not recommended for rotator cuff tear arthropathy syndrome as prolonged use may diminish their effectiveness and cause medication dependence or even addiction.
Cortisone Injections. Cortisone is a powerful anti-inflammatory medication that can be injected directly into the shoulder joint, allowing it to act locally on the inflamed joint. These injections can provide substantial pain relief. Their duration of effect is variable, and there is no way to predict how long each injection will last. Patients who have had several injections may find that these shots lose their effectiveness. In general, most patients can expect relief to last anywhere between 1 to 6 months, sometimes longer.
Cortisone injections are generally well-tolerated and have minimal side effects. In patients with diabetes, cortisone shots may temporarily elevate the blood sugar, and careful glucose level monitoring is recommended for the first few days after treatment. Repeated injections may cause some weakening of the surrounding bone, and we generally space injections out every 4-6 months to minimize this risk.
The principal goal of surgery is pain relief with a secondary goal of improved function. No attempt is made to repair the rotator cuff. Surgery is considered when:
Shoulder replacement surgery for cuff tear arthropathy is an elective procedure scheduled when circumstances are optimal for the patient. It is not an urgent procedure. The patient has plenty of time to become informed about the process of surgery and recovery.
Factors that the patient should consider in choosing the optimal time include the following:
This operation is intended for patients who have developed instability and/or severe shoulder dysfunction from cuff tear arthropathy where attempts to elevate the arm results in dislocation of the ball from the socket or the arm cannot be lifted away from the body at all. Reverse total shoulder arthroplasty is an excellent treatment option for patients with pseudoparalysis of the shoulder who have poorly compensated function.
Click here to see a patient in action who has had reverse total shoulder arthroplasty surgery.
As the name describes, an artificial ball is placed against the socket in this operation, and an artificial socket is used to replace the ball. This constrains the ball and socket so that dislocation does not occur. By reversing this relationship, the deltoid muscle can elevate the arm in the absence of a rotator cuff. This operation requires that the socket has sufficient bone to place the prosthetic ball. This is frequently determined with a preoperative CT scan.
Recovery from this operation also involves immediate range of motion exercises and early strengthening of the deltoid muscle. Continuous passive motion is not used in these cases. Rather patients are started in early outpatient therapy for range of motion and strengthening exercises or do gentle exercises independently.
Dr. Jurek trained specifically in her shoulder fellowship to perform this procedure and performs a high number of reverse total shoulder replacement surgeries every year.
A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles — not the rotator cuff — to move the arm.
This operation is considered in patients with an irreparable rotator cuff tear in whom significant erosion of the upper socket has not yet occurred. These patients tend to be earlier in the course of the disease and have substantial loss of shoulder function and pain without significant arthritis.
The goal of treatment is to clear away any remaining inflamed tendon tissue that causes mechanical abrasion and release any scar tissue that prevents a full range of motion. In addition, any rough areas of bone on the humeral head are contoured and rounded off so that the ball glides smoothly beneath the acromion bone. This operation can be done arthroscopically through very small incisions. It does not violate any muscle attachments so that recovery is accelerated.
Postoperatively, patients are permitted immediate full use of the arm. Post-operative physical therapy aims to preserve range of motion and strengthen the shoulder girdle muscles that compensate for the torn rotator cuff. Outpatient physical therapy is frequently helpful in optimizing recovery after this procedure.
This operation is geared toward patients with an irreparable rotator cuff who have disabling pain from abrasion of the humeral head against the arthritic socket and acromion bone. Unlike the Smooth and Move Operation, this surgery addresses arthritis that has developed between the ball and upper socket. Through an incision on the front of the shoulder, an artificial ball with a smooth round metal head is inserted onto a metal stem that fits in the canal of the humerus bone. This ball reduces the friction and abrasion against the arthritic socket and acromion from bone-on-bone contact. Unlike a total shoulder replacement, the socket is not replaced in a hemiarthroplasty procedure to treat cuff tear arthropathy because of a high risk of socket loosening. There are certain conditions that make this surgery an excellent choice for certain patients, but frequently, reverse total shoulder arthroplasty is the treatment of choice when it comes to a replacement shoulder surgery to treat rotator cuff tear arthropathy.
Postoperatively, patients are started on immediate gentle range of motion exercises. This operation effectively diminishes pain from arthritis but does not guarantee any improvement in shoulder strength or the ability to lift the arm (the reverse total shoulder arthroplasty is much more reliable in achieving progress in shoulder strength and the ability to lift the arm).
Early motion after shoulder replacement surgery helps achieve the best possible shoulder function. Early motion is facilitated by the complete surgical release of the tight tissues. After surgery, the patient has only to maintain the range of motion achieved at the operation. However, scar tissue will tend to develop and limit movement after surgery unless motion is started immediately. Early motion also stimulates the recovery of muscle function. During the hospitalization, the patient learns a simple rehabilitation program that will be used for maintaining the range of motion after discharge.
Once the shoulder has recovered enough from the surgery, formal physical therapy is usually initiated. This is typically started at 4 to 6 weeks after surgery. Sometimes physical therapy is not needed; this will be discussed with Dr. Jurek at your clinic follow-up visit.