Shoulder Arthritis and Rotator Cuff Tears

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is a severe and complex form of shoulder arthritis in which the shoulder has lost not only the cartilage that normally covers its joint surface but also the tendons of the rotator cuff tear which help position and power the joint.

Normally the tendons of the rotator cuff (large arrows) allow smooth motion of the upper end of the arm bone (humerus) beneath the overlying bones and muscles. [Figure 1]

When the rotator cuff is degenerated chronically torn or otherwise deficient the normally smooth upper surface of the upper end of the arm bone (humeral head) is unprotected from rubbing with the undersurface of the bone and ligaments above as shown by the large arrow.[Figure 2]

In cuff tear arthropathy the upper surface of the ball of the upper arm bone (humeral head) becomes roughened as it rubs against the overlying bone (the acromion) as shown by the arrow [Figure 3]. This condition results in shoulder pain weakness stiffness and grinding on movement.

Treatment options for cuff tear arthropathy include partial joint replacement with a cuff tear arthropathy (CTA) prosthesis. If severe instability of the joint complicates cuff tear arthropathy a reversed (reverse Delta) prosthesis may be indicated.

Immediate medical attention

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is a chronic condition and rarely needs immediate attention. At times however there is a great degree of swelling around the shoulder that causes increased pain. If this swelling is associated with redness and fever the possibility of infection needs to be considered. Under these conditions a physician should examine the individual immediately.

Facts and myths

Prognosis

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is a chronic condition that does not heal or improve by itself. It is progressive in that over time the bone of the ball of the shoulder (humeral head) and the overlying structures (the acromion and the coracoacromial ligament) become progressively eroded. When severe special surgical procedures such as a prosthetic replacement with at CTA head or a reverse Delta (reversed) prosthesis may be indicated in contrast to management with a total shoulder joint replacement.

Lethality

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not a lethal condition.

Pain

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) frequently causes pain and limited use of the arm.

Debilitation

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is progressive and as the condition worsens the shoulder becomes weaker more painful and less useful.

Comfort

Most individuals with rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) have discomfort especially at night and when attempting to use the arm.

Curability

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not curable. The degeneration of the rotator cuff and joint surface cannot be reversed.

Fertility and pregnancy

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) usually occurs in individuals well past the childbearing age.

Independence

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) can severely limit the use of the arm to the point that the individual cannot use it in caring for themselves or in performing activities of daily living.

Mobility

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) reduces the individual’s ability to move the arm. It reduces the strength and the comfort of these movements.

Daily activities

Persons with rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) often have difficulty with sports housework and other activities of daily living.

Energy

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is usually accompanied by fatigue of the involved shoulder.

Diet

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is unaffected by diet.

Relationships

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) may make sleeping hugging dancing and other social activities difficult.

Other impacts

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not contagious. Swelling of the shoulder often associated with this condition may be disfiguring.

Incidence

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) most commonly affects individuals older than 65 years. It is more common in women than in men. When severe, special surgical procedures such as a prosthetic replacement with at CTA head or a reverse Delta (reversed) prosthesis may be indicated in contrast to management with a total shoulder joint replacement.

Acquisition

The cause of rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not clear. Most affected individuals have not had injuries to their shoulders. Rather that resulting from trauma their rotator cuff tears happened as a progressive degeneration of the shoulder; this same degeneration seems to affect the joint surface as well.

Genetics

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not known to be inherited although rotator cuff tears appear to be more common in individuals from families in which other members also have cuff tears.

Communicability

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not contagious.

Lifestyle risk factors

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not known to be associated with diet metabolism or lifestyle. Individuals with severe rheumatoid arthritis may develop a shoulder condition similar to rotator cuff tear arthropathy.

Injury & trauma risk factors

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) may result from rotator cuff tears following an injury or trauma but more commonly the condition arises from progressive degenerative failure of the rotator cuff.

Prevention

Anatomy

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) affects the shoulder joint surface (see single large arrow) [Figure 4] and the rotator cuff that normally overlies it (see double large arrows) [Figure 5]. When severe special surgical procedures such as a prosthetic replacement with at CTA head or a reverse Delta (reversed) prosthesis may be indicated in contrast to management with a total shoulder joint replacement.

Initial symptoms

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) may initially give symptoms of shoulder weakness swelling and grinding on motion.

Symptoms

Individuals with rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) usually have weakness of the shoulder especially on overhead use of the arm stiffness grinding on use of the shoulder and occasionally swelling of the upper arm.

Progression

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is a progressive condition with increasing weakness stiffness grinding and swelling over time.

Secondary effects

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) can lead to progressive destruction of the bone of the arm bone (humeral head) and the socket of the shoulder blade (glenoid part of the scapula).

Conditions with similar symptoms

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) produces symptoms that are similar to those of other forms of shoulder arthritis such as rheumatoid arthritis and degenerative joint disease.

Causes

The cause of rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is not known. We suspect that it is a result of the simultaneous degeneration of the rotator cuff and the surface of the ball of the shoulder (the humeral head). When severe special surgical procedures such as a prosthetic replacement with at CTA head or a reverse Delta (reversed) prosthesis may be indicated in contrast to management with a total shoulder joint replacement.

Effects

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is associate d with the progressive loss of the cartilage and bone of the humeral head (ball of the shoulder) and the rotator cuff.

Diagnosis

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is diagnosed by a history of progressive loss of shoulder function usually without an injury along with a physical examination showing weakness and grinding on movement and a typical appearance on X-ray. In these films the humeral head can be seen contacting the undersurface of the coracoacromial arch (see arrows). [Figure 6]

Diagnostic tests

The most important test for cuff tear arthropathy is the x-ray characteristically showing rounding off of the humeral head as it contacts with the undersurface of the coracoacromial arch. [Figure 7]

Effects

There is usually no significant discomfort during the diagnosis of rotator cuff tear arthropathy.

Health care team

Rotator cuff tear arthropathy (arthritis of the shoulder associated with a massive cuff tear) is best diagnosed by an orthopedic surgeon with experience in shoulder disorders.

Finding a doctor

Treatment

An orthopedic surgeon with experience with many similar cases can provide a balanced perspective to individuals with rotator cuff tear arthropathy.

If the symptoms of rotator cuff tear arthropathy (shoulder arthritis with a massive rotator cuff tear) are mild the condition may be treated with gentle motion exercises and exercises to strengthen the deltoid and other muscles around the shoulder that remain intact. and

If exercises do not improve the comfort and function of the shoulder surgery may be necessary to create a smooth gliding surface on the humeral head (ball of the arm bone). This surgery may consist of rounding off any rough edges on the joint surface and removing interfering soft tissue as was performed for the individual whose shoulder is shown in the x-ray. [Figure 8].

Alternatively the situation may require replacing the joint surface with a smooth metal prosthesis with a stem that is fixed by a press fit in the shaft of the bone as is shown in the diagram. [Figure 9].

In cases where rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects) is associated with instability of the joint a reversed or reverse Delta prosthesis may be needed to fix the fulcrum of shoulder movement. [Figure 10]

Self-management

The individual with cuff tear arthropathy may self-manage the condition with gentle range of motion exercises to enhance the smoothness of the joint and its flexibility followed by strengthening exercise once the shoulder is comfortable to enhance its function.

Health care team

Rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects) can best be managed by a shoulder specialist who sees many such cases per year. Such surgeons may be found in the Shoulder Section in major schools of medicine.

You can also call 206-598-0312 to make an appointment.

Pain and fatigue

The pain and fatigue caused by rotator cuff tear arthropathy shoulder arthritis associated with massive rotator cuff defects) may be managed by first range of motion exercises and then by strengthening exercises.

Diet

Diet has not proven to be a useful method for managing rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects).

Exercise and therapy

Exercises can help the range of motion and the strength in some cases of rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects).

Medications

Medications other than mild analgesics and anti-inflammatory medications have not been shown to be helpful in the management of rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects).

Surgery

Surgery can be helpful in the management of rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects). The surgical procedures can range from a simple smoothing of the roughened bone [Figure 11] to a resurfacing of the humeral head with a smooth prosthesis such as a CTA head fixed to the shaft of the arm bone (humerus) [Figure 12]. If the joint is unstable a reversed prosthesis such as the reverse Delta [Figure 13] may be needed.

You can also call 206-598-0312 to make an appointment.

Joint aspiration

Joint aspiration (removing fluid from the joint) can be helpful for relieving the fluid that tends to collect in shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear). However the fluid tends to recollect rapidly and repeated injections may risk infection. Joint aspiration may be needed to examine the joint fluid for the possibility of infection.

Splints or braces

Splints or braces have not proven useful for shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear).

Alternative remedies

Alternative remedies have not proven useful for shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear).

Social impacts

Adverse social impacts have not been noted from the treatment of shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear).

Long-term management

Strategies for coping

Individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear) may be able to cope with their condition by reducing their activity expectations. They may arrange their kitchen so that frequently used items are placed in lower shelves that are easier to access. They may purchase goods in smaller packages so that the packages are easier to lift. They may prefer a car that has controls in easier to reach positions. And they may find that sleeping in a recliner is more comfortable that sleeping flat in a bed.

Asking for help

Individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear) should seek help from a specialist with experience in evaluating and managing this condition. Such individuals may be found in the shoulder services of major schools of medicine.

You can also call 206-598-0312 to make an appointment.

Work

Individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear) are often retired from work. However for those who are still vocationally active accommodations may be helpful. Placing files at levels that are easy to reach minimizing the lifting expectations and facilitating driving by selecting a vehicle that places minimal demands on the shoulder may all be helpful.

Family and friends

Families of individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear) can be of major help by assisting with tasks that require shoulder range of motion and strength as well as by arranging the home and the workplace in a shoulder-convenient manner.

Adaptive aids

Adaptive aids may be of assistance to individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear). A sling may support the arm when it becomes fatigued. Tools with extended handle may increase the reach of the individual.

Stress

Individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear) can reduce stress by making sure that they have put in place accommodations for their limited function.

Resources

Condition research

At the University of Washington surgeons are conducting research to find better ways to manage shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear). Part of our work is focused on stimulating the body's ability to regenerate a smooth joint surface.

Pharmaceutical research

At present pharmaceutical research does not hold out substantial promise for individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear).

Non-surgical research

We are exploring various exercise regimes to determine which are the most effective in managing shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear) both before and after reconstructive surgery.

Surgical research

Most of our research regarding individuals with shoulders afflicted with rotator cuff tear arthropathy (shoulder arthritis with a massive cuff tear) concerns surgical procedures. We are investigating three separate approaches depending on the severity of the disease. The first involves smoothing the humeral head (the ball at the upper end of the arm bone) and removing any thickened bursa or other tissue that is interfering with the smooth motion of the shoulder. This is the procedure that has been performed on the shoulder shown in the X-ray. [Figure 14]. The second involves replacement of the ball of the upper end of the arm bone (humeral head) using a special cuff tear arthropathy (CTA) humeral head prosthesis fixed the arm bone with a stem that goes inside it. [Figure 15]. The third used when the shoulder joint is unstable involves an implant in which the ball and socket are reversed (reverse Delta shoulder prosthesis) [Figure 16].

Cellular genetics or tissue research

One of our primary areas of research interest at the University of Washington concerns regenerative orthopedics that is stimulating the body’s own cells to re-grow lost tendon bone and cartilage. While in its early stages we have obtained some encouraging initial results and are eagerly pursing this new scientific direction.

Summary of rotator cuff tear arthropathy

The most important facts about cuff tear arthropathy (shoulder arthritis with a massive rotator cuff defect) are

(1) It is a chronic degenerative condition of the shoulder with loss of the rotator cuff and loss of the cartilage and bone of the joint surfaces . (2) It is not preventable nor is it treatable with non-operative means. (3) Simple range of motion and strengthening exercises may help lessen the symptoms. (4) Surgical smoothing or replacement of the joint using a CTA prosthesis offers the best opportunity for functional improvement in individuals with severe functional problems from rotator cuff tear arthropathy. (5) If severe instability complicates cuff tear arthropathy a reversed (reverse Delta) prosthesis may be considered.

You can also call 206-598-0312 to make an appointment.