Rotator Cuff Arthropathy
Symptoms
Rotator cuff arthropathy, or shoulder arthritis with a chronic rotator cuff tear, causes pain and lack of function typically in people over the age of 60. The hallmark is pain and reduced overhead function. Typically, passive motion is preserved but active overhead motion is limited. If motion is not limited, weakness is present. This results is difficultly sleeping and difficulty with overhead activities from combing one’s hair to sports such as tennis or golf. The diagnosis is typically obvious on X-rays which show a reduced joint space and superior migration of the humeral head.
causes & Anatomy
The shoulder is the most mobile joint in the body. Normally, the rotator cuff keeps the humeral head or ball centered within the joint by pulling the ball into the socket through a mechanism referred to a concavity compression.
When the rotator cuff tear is chronically torn it enlarges to become a massive tear. This disrupts the stability of the joint. The loss of rotator cuff function allows the deltoid to pull the humeral head superiorly. This then results in arthritis over time as the humeral head hits the acromion. The humeral head then develops “adaptive” changes or rounds off.
Treatment
In the case of mild rotator cuff arthropathy conservative treatment should be attempted. Severe rotator cuff arthropathy may require surgery if someone is in good health and has limitation in quality of life. Deciding to perform surgery is based on quality of life rather than X-rays. For the most part, rotator cuff tears and arthritis progresses slowly over years. Age is also a factor in treatment, but in today’s world health is more important than age. Because the diagnosis is obvious on X-rays, an MRI or CT scan is only needed if surgery is being considered.
Treatment options include:
Medications: Anti-inflammatories such as ibuprofen (Motrin or Advil) and naproxen (Aleve) are used to reduce pain and inflammation. The max does for ibuprofen is 800 mg three times per day. The max does for naproxen is 500 mg twice daily. Prolonged usage should be avoided and these should be taken with food since they can affect the stomach lining. If one experiences an upset stomach these should be stopped.
Injection: An injection of steroid (cortisone) into the shoulder is one of the most common means to provide pain relief. One of the keys is the location of the injection. I perform shoulder injections with an ultrasound machine. This allows direct visualization of the joint and improved accuracy of the injection. Up to 3 injections over a 2 year period are allowed. Beyond this there are typically diminishing returns and excessive injections may be detrimental to the tissue. Additionally, injection within 3 months of surgery raises the risk of infection so they should be limited if someone is seriously considering surgery.
Alternative injections include Toradol (an anti-inflammatory agent similar to ibuprofen), prolotherapy, or platelet-rich plasma (PRP). I use Toradol in people who do not tolerate steroids. Prolotherapy involves injecting a substance such as sugar into tissue to “stimulate a healing response.” I do not perform prolotherapy as it has not been shown to improve symptoms in shoulder arthritis.
PRP involves taking a small amount of blood from a patient, spinning in a centrifuge to separate the growth factors from the red blood cells, and then injecting the growth factors back into the shoulder to potentially decrease pain. This is done in the clinic and takes about 15-20 mins to perform. PRP is believed to have anti-inflammatory properties and the injection is a safe, low-risk procedure. However, this is mostly commonly used for arthritis without a rotator cuff tear
Stretching: Physical therapy with strengthening is one of the mainstays of treatment of rotator cuff tears and rotator cuff arthropathy. Although therapy does not heal the rotator cuff, therapy can lead to substantial improvements in function with good patient satisfaction. The core exercises in strengthening the rotator cuff are provided at the end of this handout. These exercises can be performed twice per day, 5 days a week.
Surgery: In the event that symptoms do not improve with conservative care, surgery is an option. In most cases the most reliable option is a reverse shoulder replacement. Many people have heard of a hip or knee replacement but don’t know about shoulder replacement. While less common than hip or knee replacement, the surgery is very effective and has a lower risk of complication than hip or knee replacement. This procedure requires general anesthesia with an incision in front of the shoulder and takes about 1 hour to perform. The ball and the socket joint are resurfaced with a metal and high-strength plastic prosthetic implant in order to remove pain and improve range of motion. The reverse shoulder stabilizes the joint by placing a ball on the socket and a cup on the arm bone side to restore stability to the joint. This allows the deltoid and remaining shoulder muscles to work effectively and restore function in addition to providing pain relief.
This is an outpatient procedure, meaning that people go home the day of surgery. A sling is worn for 4 weeks after surgery with use of the elbow, wrist, and hand only for general activities. The success rate is over 90%. Range of motion improvement can be substantial and pain relief can be complete since the arthritis is removed. Risks include infection (less than 1% in my patients), and component loosening over time (90% of the implants are still in 10 years after surgery and 70-80% are in 20 years after surgery).
For more information see the handout on the list of commonly asked questions after shoulder replacement. see some of our patient outcomes follow us on Instagram below. It is always good to have information about how our patients are doing:
Symptoms
Rotator cuff tears are one of the most common causes of shoulder pain. Pain typically occurs in the front or side of the shoulder. The pain may radiate to the elbow. Symptoms are worse with overhead activity and often cause difficulty sleeping which can significantly affect quality of life. Most people have full range of motion if examined, but the motion may be limited by pain (the arm can be lifted by the examiner). Weakness is common, particularly with activities above shoulder level.
Anatomy
The rotator cuff is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor). The rotator cuff surrounds the ball and socket joint (glenohumeral joint) and provides stability to the joint as well as movement. Because the shoulder is a shallow joint and the most mobile joint in the body, it requires the rotator cuff for stability. If left untreated, tears can lead to arthritis of the shoulder (rotator cuff arthropathy). This doesn’t mean that good function can’t be maintained with a tear. In fact, many people are able to maintain function despite a tear because the shoulder remains balanced with the remaining rotator cuff and other muscles that control shoulder movement.
Muscle inserts into bone via tendon. In the vast majority of cases, when a tear occurs the tendon pulls away from the bone. Broadly speaking, tears are classified as partial or full-thickness. Partial tears go part way through the tendon, while full-thickness tears represent complete detachment. Frequently, an MRI will report “partial-tearing.” Most partial tears are not a problem. In fact, most people over the age of 40 to 50 have some changes within the rotator cuff or partial tears. The distinction with partial tears is when the tears are considered “high-grade,” meaning that they go almost all the way through the tendon.
Causes
Rotator cuff tears may occur after an injury or repetitive activity over time, but most cases occur without an injury. As we age the rotator cuff tendon degenerates. Age and genetics are the greatest risk factors for a tear. Studies show that about 50% of people over the age of 65 have a full-thickness rotator cuff tears. Most of these people don’t even know they have a tear!
Treatment
Treatment for rotator cuff tears is based on age, health, and response to conservative treatment. The rotator cuff tendon is not capable of repairing itself. Rather, the tear will stay the same size or enlarge over time. In people under the age of 60, the risk of progression is about 50% in a two-year period. The ability to get healing with a surgical repair depends upon age, the tear size, muscle atrophy, associated arthritis, and health (smoking and diabetes for instance). One must also consider timing of repair. Traumatic tears have a better outcome if fixed within 3 months of injury. Additionally, after about six months of symptoms atrophy may occur. Unfortunately, atrophy of the rotator cuff is not considered reversible. Based on this, if someone desires repair, I typically recommend performing this within six months of beginning treatment for a degenerative (chronic) tear and 3 months for a traumatic (acute) tear.
Guidelines for surgery are general and must be individualized as noted above. Long-term studies show that surgical repair leads to greater improvement in function compared to physical therapy. This is because physical therapy does not heal a tear and it may sometimes progress in size. However, one must consider their activity level and length of recovery. As a general guideline, I recommend repair for all full-thickness tears in people under the age of 65 given the risk of increase in tear size. For people between the ages of 65 and 70, treatment is based on the above factors with health and activity expectations being the most important factors. For people over the age of 70, I nearly always recommend an attempt at conservative treatment. Surgery is considered if one does not respond to conservative treatment or if the tear is from a recent trauma.
For partial tears, conservative treatment should almost always be attempted first since these tears progress slowly or may not progress at all. Then, surgery is considered if one does not respond to 4 to 6 months of conservative treatment.
Most tears, regardless of size can be repaired. We perform all rotator cuff repairs arthroscopically. This is less invasive and therefore less painful than an open incision. It also allows a better view of the rotator cuff. This procedure requires general anesthesia, takes 45 to 60 minutes to perform, and patients go home the same day. Small incisions are made in the shoulder, a scope is inserted, and the rotator cuff is repaired with anchors. Anchors are essentially headless screws or soft material which are placed flush with the bone. These anchors have sutures that are used to bring the tendon done to the bone so that the tendon can heal to the bone. The long-term outcome of this procedure is very good (>90% success in most cases) and the risk of complication is very low (1/5000 chance of infection). However, repair requires a long recovery. The tendon takes about 12 weeks to heal into the bone. Therefore, a sling is worn for 4 to 6 weeks after surgery depending on the tear size. Specific motion exercises afterwards are tailored to the tear pattern (patient-specific). The sling is removed at 4 to 6 weeks and motion is progressed. Strengthening is allowed at 12 weeks, followed by gym activities at 4 months. Full recovery takes 6 months for small tears and 12 months for large or massive tears.
