Rotator Cuff Tear Arthropathy

Rotator cuff tear arthropathy is a chronic degenerative condition that arises in a shoulder which has two conditions affecting the shoulder joint; a massive irreparable tear of the rotator cuff tendons and osteoarthritis of the shoulder joint. The loss of the rotator cuff muscles destabilises the shoulder joint such the humeral head (ball) moves and rubs inappropriately against the glenoid (socket) thereby resulting in the degenerative osteoarthritic change.

Symptoms

The symptoms associated with the condition include;

• Pain at rest and on attempted shoulder movement
• Night pain
• Poor shoulder movement
• Muscle wasting
• Restricted shoulder movement
• Shoulder instability

Causes & Risk factors

Cuff tear anthropathy usually develops as a result of long standing rotator cuff disease. Risk factors therefore include;

• Pre-existing rotator cuff disease
• Massive irreparable rotator cuff tears
• Failed rotator cuff disease
• Rheumatoid arthritis

Diagnosis

The diagnosis of cuff tear arthropathy is largely made following a history and clinical examination however it is confirmed by x-rays which reveal irregular joint surfaces, osteophytes and a humeral head that has migrated upwards, secondary to the loss of the rotator cuff. In order to gain clarification about the quality of the surrounding rotator cuff tendons an Ultrasound or MRI scan may also be organised and if there is evidence of significant bone loss secondary to the arthritis, a CT scan may also be requested.

Treatment

The treatment for cuff tear arthropathy is always tailored to each patient.

1. Rest, activity modification, pain relief and physiotherapy can prove helpful. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibruprofen can help control the pain but should only be used regularly under the guidance of your General Practitioner.
2. Physiotherapy can prove beneficial in maintaining motion by strengthening the deltoid muscle, which is not affected by the rotator cuff disease. However, its success can be mixed secondary to the instability of the humeral head and any pain that is present secondary to the degenerative disease.
3. Injection treatments can occasionally have a role. Corticosteroid injections directly into the glenohumeral joint can improve pain however the affect is always temporary and multiple injections can have a deleterious affect on the shoulder. It can have a role if other treatment options are not possible due to co-morbidities. In such circumstances a suprascapular nerve block can also be undertaken in an attempt to ease any cuff related pain.
4. Arthroscopic debridement; this is a keyhole surgical procedure in which the severity of the cartilage damage can be assessed and if appropriate, any loose cartilage can be removed which might otherwise be aggravating the joint. A subacromial decompression and tuberoplasty can also be undertaken. In such a procedure, more space is created to cater for the instability of the humeral head thereby reducing any impingement type pain. Outcomes can however be unpredictable. When the disease is too advanced, a reverse shoulder replacement will be necessary.
5. Reverse shoulder replacement;This is a shoulder replacement in which the ball is placed on the socket side of the joint and the socket is placed on the ball side of the joint. The benefit of this reverse configuration is that the humeral head, which is usually unstable in cuff tear arthropathy, is stabilised. In the absence of a viable rotator cuff, this then allows the deltoid muscle function to be optimised, such that both pain and function are improved. In cases where there has been significant bone loss, in addition to the loss of the rotator cuff, computer aided joint replacement may be recommended. In such circumstances, a CT scan is used to plan your operation and make Patient Specific Instrumentation (PSI) or CAD CAM Implants, to optimise your outcome.