ROTATOR CUFF ARTHROPATHY
Its description, causes, symptoms, diagnosis and treatment (operative and non-operative)
The rotator cuff is a group of 4 muscles that help move the shoulder. The muscles attach to the bones around the ball-and-socket joint by a thick, non-elastic tissue called a tendon. Tendons can tear by an acute injury or degenerate over time. Tears can occur in any of the 4 tendons. In order of commonality, the supraspinatus is most often injured, followed by the infraspinatus, subscapularis and teres minor. Rotator cuff arthropathy is defined as arthritis as the result of tearing of the rotator cuff tendons.
What are the causes?
Rotator cuff tears have multiple causes. Acute trauma, longstanding impingement syndrome (caused by abrasion on the acromion or bone spurs at the AC joint), repetitive overhead activities and degeneration in the older population are all common. When the tendons are detached from the bone, the shoulder becomes dysfunctional. Pain is associated with motion of the arm and motion eventually decreases if the tendons are not repaired back to the bone.
What are the symptoms?
Rotator cuff tears cause pain, particularly on the side of the shoulder and at night, leading the patient to believe they slept wrong on their shoulder. Subacromial bursitis typically accompanies rotator cuff tears. Depending on the severity and location of the tear, loss of motion and strength can occur in a specific plane. This may be lifting the arm to the side, overhead or behind their back. Activities of daily living like reaching up to a cupboard, reaching for a wallet in a back pocket, brushing your hair or fastening a bra may be severely impacted when a rotator cuff tear is present. A massive tear of more than one tendon may result in pseudoparalysis, an inability for the patient to move their arm away from their body. Pain may also radiate up the shoulder to the neck, as the patient attempts to move the shoulder using other muscles. If the tendons remain torn for an extended period of time, the ball does not stay centered in the joint, causing wear and tear to one or both sides of the ball-and-socket joint.
How is it diagnosed?
Your surgeon will perform a thorough history and physical exam including X-rays. Exam findings will consist of loss of active range of motion (you move your arm), preserved passive range of motion (the surgeon moves your arm), weakness and pain with muscle testing. X-rays may or may not demonstrate acromion abnormalities or AC joint bone spurs that may be causing impingement of the rotator cuff. Superior or anterior movement of the humerus (ball) on X-ray is a sign of a chronic rotator cuff tear that may not be amenable to repair (also known as superior or anterior escape). MRI is useful to quantify the size, severity and age of the tear. For patients who cannot have an MRI, CT/”CAT” scan with contrast dye may be helpful in assessing damage to the rotator cuff.
How is it treated?
Non-operative - The extent of the arthritis, long term damage to the tendons and muscles, function of the shoulder, amount of pain and patient factors (age, health issues like diabetes or seizure disorder, tobacco use and activity level) all influence the treatment of rotator cuff arthropathy. Non-operative treatment can be attempted but once the diagnosis of rotator cuff arthropathy is made, is not usually helpful. Physical therapy, anti-inflammatory medication, cryotherapy, activity modification or injections into the space just above the rotator cuff may alleviate pain and inflammation. Patients whose pain does not resolve with non-operative treatment should discuss surgical treatment options with their surgeon.
Operative - Patients who have a chronic, irreparable tear in the rotator cuff but have minimal to no arthritis, several minimally invasive arthroscopic procedures can be performed for pain relief. An arthroscopic CAM procedure, also known as a debridement or "cleanout", can remove inflammatory tissue, remove bone spurs and treat biceps tendon injury/inflammation. An arthroscopic superior capsular reconstruction (SCR) uses donor tissue to realign the ball-and-socket joint and restore some of the mechanics that are affected by chronic rotator cuff tendon tears. Both of these procedures may decrease pain, but restoration of function is patient dependent. For more advanced rotator cuff arthropathy with moderate to severe arthritis, reverse total shoulder arthroplasty (rTSA) can be performed for pain relief and restoration of some function. In rTSA, your surgeon can remove the arthritic areas of the ball-and-socket joint and replace them with metal and plastic components. In this procedure, the ball-and-socket components are switched, so that the ball becomes a socket and the socket becomes a ball, allowing the shoulder to move pain-free and using other muscles in lieu of the rotator cuff. Your surgeon will discuss all of your options based on the severity of damage in your shoulder.