Shoulder symptoms and complaints accounted for more than 11 million primary care provider office visits in 2010.1 Of these visits, rotator cuff pathology was one of the most common causes of shoulder pain.2 The estimated cost per patient for surgical rotator cuff repair was $15,063 in 2013.3 Rotator cuff tears usually present with localized pain, decreased range of motion, and discernible weakness compared with the contralateral shoulder.4 The term cuff tear arthropathy covers a broad array of pathologies with three defining characteristics: rotator cuff insufficiency, glenohumeral joint degeneration, and superior migration of the humeral head. Rotator cuff injury is highly correlated with age; patients in one study had a 50% likelihood of bilateral tears after age 66 years.5 Given the high prevalence of rotator cuff tears and the high costs associated with treatment, clinicians need to be prepared to manage the condition in primary care and in orthopedic specialties. The standard of care is changing (Figure 1) because of new knowledge about the natural progression of symptomatic and asymptomatic cuff tears and their relationship to risk factors for progressing to cuff tear arthopathy.6,7 This article reviews relevant epidemiologic and etiologic features of chronic rotator cuff pathology, its relationship to cuff tear arthropathy, and diagnosis and treatment of cuff tear arthropathy, including definitive treatment with reverse shoulder arthroplasty.
McCarty theorizes that basic calcium phosphate crystal accumulation in the glenohumeral joint (shoulder) correlates with rotator cuff deficiency.5 Synovial cells phagocytize the crystals, releasing prostaglandins and proteases that destroy articular cartilage. A positive feedback cycle accelerates degeneration of the rotator cuff and biceps tendon, leading to glenohumeral joint degradation.
A second theory, by Neer, proposes that after a large tear, the glenohumeral joint loses integrity, leading to extravasation of synovial fluid.8 This is thought to lead to impaired delivery of nutrients to the articular surface. As a consequence of pain, the patient uses the affected shoulder less and the injured glenohumeral joint becomes inactive, leading to disuse osteoporosis and collapse of the subchondral bone to the humeral head. Loss of joint dynamic stabilization can lead to proximal migration of the humeral head.9 Proximal migration of the humeral head results in its physical wear, erosion of the glenoid fossa and the acromion, and erosion of the acromioclavicular joint and the coracoid.10,11
- Female sex. Cuff tear arthropathy appears to be more common in women: McCarty reported data from five studies with a female prevalence range of 77% to 100%.8 However, this high prevalence may be due to women living longer, on average, than men.
- Massive rotator cuff tear. An unrepaired or asymptomatic tear may progress to a massive tear.7,12,13 As proposed by Nam and colleagues, a massive tear leads to cuff tear arthropathy because the rotator cuff loses concavity compression.14 Dynamic force stabilization is lost between the rotator cuff and the deltoid, and the humeral head migrates proximally.10,14
- Advanced age. Increasing age is known to increase risk for rotator cuff pathology. In a recent study, 664 patients were screened for rotator cuff tears, and 22% had full-thickness tears with the following age prevalence: 0% in patients ages 20 to 49 years; 10.7% in patients ages 50 to 59 years; 15.2% in patients ages 60 to 69 years; 26.5% in patients ages 70 to 79 years, and 36.6% in patients ages 80 to 89 years.15
- High shoulder activity. Occupations associated with a high volume of upper body exertion are correlated with development of shoulder pathology that may lead to rotator cuff tears. A cross-sectional study by Svedsen and colleagues evaluated 1,866 men in occupations associated with overhead exertion: machinists, auto mechanics, and house painters.16 Moderate shoulder pain with discomfort was detected in 15.6%, 16.8%, and 31.8% of the study subjects, respectively.16 These findings suggest that workers in occupations with frequent overhead exertion are predisposed to rotator cuff tears.
- Shoulder trauma. The energy associated with traumatic shoulder injury can precipitate injury to rotator cuff tendons, as illustrated in a recent case report.17 Turman and colleagues describe a 16-year-old who sustained a shoulder injury in a football game and was unable to continue game play. Orthopedic evaluation 4 days postinjury revealed diffuse shoulder tenderness, limited active range of motion, and weakness in the supraspinatus, infraspinatus, and subscapularis muscles. An MRI revealed posterior subluxation of the long head biceps tendon, and full-thickness tears of the supraspinatus, infraspinatus, and subscapularis tendons with a probable full-thickness tear of the teres minor tendon. The patient underwent arthroscopic and deltopectoral open repairs. The case report authors note that traumatic full-thickness tears in young athletes often are misdiagnosed; rotator cuff conditions may not be repairable if diagnosed too late. This is in contrast to the prevalence of traumatic shoulder injury and dislocation in patients over age 40 years, in whom full-thickness tears are expected.
- Smoking. Patients who smoke may be predisposed to cuff tear arthropathy, according to a cadaver study that found advanced rotator cuff pathology was more than twice as likely in patients who had a history of smoking.18
Cuff tear arthropathy is clinically defined by three features:
- rotator cuff insufficiency
- degenerative glenohumeral joint changes
- superior migration of the humeral head.14
For patients of advanced age with progressive shoulder pain, limited range of motion, and stiffness, a comprehensive approach to physical examination includes:
- global inspection of the glenohumeral joint, including assessment for anterosuperior escape of the humeral head from the glenoid fossa, which indicates deficiency in the subscapularis and supraspinatus tendons
- examining the patient for shoulder edema, which indicates subacromial bursa fluid pressure
- examining the cervical spine to rule out a cervical spine disorder that could refer pain to the shoulder
- assessing passive and active glenohumeral range of motion.14 A patient with cuff tear arthropathy may present varying results if the glenohumeral fulcrum is stable and well compensated by a preserved deltoid muscle, or the patient may display pseudoparalysis in abduction and forward flexion.
- assessing rotator cuff strength with one of the strength tests described in Table 1. Remember that patients with cuff tear arthropathy likely will have severe pain and weakness during strength testing.
Standard radiographs in the anteroposterior, scapular, and axillary views (Figure 2) can be used to diagnose cuff tear arthropathy.19 However, more than the anteroposterior radiograph is needed, because this view does not provide predictive information on the patient's clinical status.20 The main focus of radiographs in patients with suspected cuff tear arthropathy should be to assess medialization (wear erosion) of the glenohumeral center of rotation and the thickness of the glenoid fossa.14 Radiographic findings for cuff tear arthropathy are summarized in Table 2.
Rotator cuff pathology can be classified in three groups based on severity.13Table 3 outlines the groups, characteristics, and recommended treatments.
Activity modification, analgesia, anti-inflammatory medications, physical therapy, and subacromial injections of a local anesthetic and/or corticosteroid are nonsurgical options that can reduce shoulder pain and weakness and improve range of motion.6,14 These interventions are appropriate for patients with a suitable range of motion that can meet activities of daily living.14 Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac may be appropriate for patients who do not tolerate oral NSAIDs.21 Subacromial bursae injections of sodium hyaluronate with corticosteroid have resulted in greater functional improvement than corticosteroid injections alone for patients with rotator cuff tears.22 A study of patients with partial rotator cuff tears found a significant improvement in shoulder function at 6 weeks after hyaluronate administration.23
However, prolonged conservative treatment of patients in group 2 may lead to irreversible changes of the rotator cuff and progression to cuff tear arthropathy.12,13
Surgery is the appropriate treatment for cuff tear arthropathy that limits activities of daily living or symptomatic rotator cuff tears.
Clinical management of patients in group 2 (those under age 65 years with symptomatic full-thickness tears) is challenging and presents significant risk. Surgery may provide improved function and offset the risk of progression to irreparable tears and cuff tear arthropathy. A study by Berth and colleagues found no predictive evidence to connect the progression of chronic rotator cuff tears to the development of cuff tear arthropathy.24 The authors found that complete rotator cuff repair is the preferred treatment for chronic rotator cuff tears because patients had significantly improved shoulder function compared with alternative interventions such as partial repair and arthroscopic debridement. A double-row suture repair appears to reduce the rate of postrepair rupture.6
Group 3 patients have irreversible changes to the glenohumeral joint. If conservative treatment does not relieve pain or improve functionality, reverse shoulder arthroplasty may be considered (Figure 3).25 Reverse shoulder arthroplasty prosthetics change the center of rotation of the glenohumeral joint medially and lengthen the humerus 0 to 2 cm to allow reverse articulation. (Humeral lengthening of more than 2 cm poses the risk of postoperative neurologic impairment.)26 In the absence of a functional rotator cuff, the deltoid muscle elevates the arm and stabilizes the articulation of the prosthetic joint. Patients must have good deltoid muscle integrity to be candidates for this procedure. However, because of the alteration of shoulder mechanics, loss of deltoid contour and a small operative risk of rare iatrogenic humeral lengthening may contribute to low postoperative satisfaction in some patients. Table 4 lists complications of reverse shoulder arthroplasty. Despite the high risk of complications and need for careful patient selection, current studies of reverse shoulder arthroplasty show promising results with increased patient function, pain relief, and high patient satisfaction.14,25
Patients can reduce their risk for cuff tear arthropathy by:
- limiting or eliminating overuse of glenohumeral joints (for example, transitioning from a high volume of heavy upper body weight training to light, moderate weight training and predominantly cardiovascular workouts).
- smoking cessation and avoiding exposure to secondhand tobacco smoke.
- consulting an orthopedic surgeon if shoulder pain or weakness develops. After an evaluation to identify the source of the pain or weakness, the surgeon and patient can develop a plan to monitor and control the progression of a potential rotator cuff tear.
- participating in moderate structured exercise to improve and maintain shoulder strength.
Cuff tear arthropathy and associated rotator cuff degeneration are often painful, debilitating conditions that disrupt patients' quality of life. Providers can improve patient outcomes and reduce the risk of cuff tear arthropathy by accurately diagnosing, classifying, and treating rotator cuff tears before they progress. Assess patients' baseline risk for rotator cuff disease and implement risk-reduction lifestyle interventions and physical therapy to reduce the need for surgery. Balance a nonoperative approach with careful monitoring for progression of any rotator cuff tear. If a rotator cuff tear is diagnosed early and surgical intervention is warranted, arthroscopic repair is the standard of practice. For late-diagnosed rotator cuff injuries that meet the criteria for cuff tear arthropathy and warrant surgical intervention, reverse shoulder arthroplasty has been shown to reduce pain, increase function, and yield high patient satisfaction.
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