Early Rotator Cuff Arthropathy

This is a great example of why x-rays are always valuable. It is clear that there is not enough space between the humeral head (top of arm bone) and the shoulder blade because the rotator cuff has been worn away. This only happens in chronic cases.

Rotator cuff tendons are not always reparable, when they are they called irreparable rotator cuff tears. This can be the case with either chronic tears or massively retracted tears. A chronic tear is most commonly defined as a tear that is older than six months.Massively retracted tears are usually tears that are retracted greater than 4 cm or alternatively retracted past the glenoid. The glenoid is the cup of the shoulder, as the shoulder is a ball and socket type joint (socket being the cup of the glenoid).

 

Nonoperative treatment for irreparable rotator cuff tears is often able to control some symptoms of these chronic large massive tears. This nonoperative treatment can be a mixture of physical therapy, activity cessation or modification, rest, anti-inflammatory use, and possibly even a corticosteroid injection. A lot of people will find relief with nonoperative treatment. This is because rotator cuff tears are especially common the older we get. Greater than 50% of the general population over the age of 60 already has a rotator cuff tear (granted it might not be massive in size), so that means that it is possible to live asymptomatically with a rotator cuff tear. That is the goal of nonoperative treatment. Nonoperative treatment does not fix the tear. The goal of nonoperative treatment is to help you feel comfortable with the fact that you have a rotator cuff tear – meaning that your shoulder is able to do what it wants to do in a pain-free manner with enough range of motion and strength.

 

Of course that is not always the case. A good amount of people fail nonoperative treatment of their large rotator cuff tears, and will need surgery. I will always go out of my way to do what is in the patient’s best interest. If that is attempting a rotator cuff repair despite long odds of it healing I am always more than happy to try to do that as long as the patient understands that the success of the surgery may be limited by their own bodies capability to heal the tear. There are of course some patients that I will not offer arthroscopic surgery for to fix the rotator cuffs (in general if I’m discussing with my patients repair it is always going to be arthroscopic for rotator cuffs, I do not do open rotator cuff repairs), and these are generally patients that have signs of chronic tearing with loss of muscle mass (atrophy or shrinkage of muscles). This usually belies a deeper problem. Once there is been atrophy or loss of muscle mass, it means there’s been a type of “functional denervation” of the muscle. What that means is once a muscle is no longer attached to bone (muscle attaches to bone through a tendon, that is the purpose of the rotator cuff) it is not functioning anymore. Therefore the body starts to think that them muscle is serving no purpose anymore. Therefore the muscle starts to disappear. Once that whole cascade of events starts to occur the rotator cuff is not reparable. That leads to a discussion of the necessity of a shoulder replacement, if surgery is indicated.

 

Reverse shoulder arthroplasty (replacement)

Post-operative x-ray of a reverse shoulder replacement done on the previous x-ray of chronic rotator cuff disease.

Shoulder replacement surgery – also known as arthroplasty surgery – can be broken down into anatomic shoulder arthroplasty (a total shoulder) or reverse shoulder arthroplasty. As explained elsewhere on my website there are excellent indications for both of these surgeries. Anatomic shoulder arthroplasty is usually reserved for people with arthritis of the shoulder and an intact rotator cuff. Therefore we will not be discussing that surgery as an option for patients with a massive or chronic rotator cuff rupture. These patients with large rotator cuff tears that show signs of chronicity or irreparability in conjunction with having pain that is limiting activities of daily living or impacting their quality of life will be offered a reverse shoulder arthroplasty.

Reverse shoulder arthroplasty is essentially what it sounds like. The shoulder anatomy is reversed. The shoulder is a ball and socket type joint. The arm bone is the ball and the shoulder blade is the socket. When we reverse this the arm bone becomes a socket in the shoulder blade becomes the ball. To simplify the biomechanics of this surgery this essentially will allow your deltoid, which is the muscle on the outside of your arm, to power and move your shoulder. This can obviate the need and function of the rotator cuff. Therefore you do not need a rotator cuff to move your shoulder. Again there is an excellent page within my website further discussing this , the indications, the surgery, and what rehabilitation looks like afterwards.

 

If you are living with chronic pain in your shoulder from a large rotator cuff tear that you’ve been told is not fixable you should consider getting an opinion from me regarding the potential use of a reverse shoulder arthroplasty to help your shoulder. I can be found at my Northgate office on Mondays and Fridays, and in Ballard on Tuesdays and Thursdays. As always if you have any questions don’t hesitate to contact me.