Rotator Cuff Arthropathy: A Comprehensive Review

Abstract

Rotator cuff arthropathy is a spectrum of disease states secondary to full-thickness cuff tears classified by rotator cuff insufficiency and degenerative disease within the shoulder joint. Diagnosis can be made through standard physical exam and radiographic films demonstrating varying levels of weakness, along with acetabularization, femoralization, and superior migration of the humeral head. Severity of disease is classified through both the Hamada and Seebauer grading systems, which are used clinically to determine the appropriate treatment algorithm. Treatment exists along the spectrum from conservative therapy with physical therapy to a definitive treatment with total joint replacement. Depending on a patient’s progression and other comorbidities, arthroscopic treatments may additionally be used in specific circumstances as joint-sparing techniques. In recent years, reverse total shoulder arthroplasty has produced increasingly favorable outcomes with improvements in pain and function while simultaneously diminishing complication rates, making it generally accepted as standard of care. This disease limits quality of life for a large population of patients and efforts toward optimization of the treatment regimen is critical. This review provides an overview on the diagnostic criteria, classification, pathoanatomic changes, biomechanics, treatment options, outcomes, and complications of rotator cuff arthropathy. Rotator cuff arthropathy is a spectrum of disease states secondary to full-thickness cuff tears classified by rotator cuff insufficiency and degenerative disease within the shoulder joint. Diagnosis can be made through standard physical exam and radiographic films demonstrating varying levels of weakness, along with acetabularization, femoralization, and superior migration of the humeral head. Severity of disease is classified through both the Hamada and Seebauer grading systems, which are used clinically to determine the appropriate treatment algorithm. Treatment exists along the spectrum from conservative therapy with physical therapy to a definitive treatment with total joint replacement. Depending on a patient’s progression and other comorbidities, arthroscopic treatments may additionally be used in specific circumstances as joint-sparing techniques. In recent years, reverse total shoulder arthroplasty has produced increasingly favorable outcomes with improvements in pain and function while simultaneously diminishing complication rates, making it generally accepted as standard of care. This disease limits quality of life for a large population of patients and efforts toward optimization of the treatment regimen is critical. This review provides an overview on the diagnostic criteria, classification, pathoanatomic changes, biomechanics, treatment options, outcomes, and complications of rotator cuff arthropathy. Rotator cuff arthropathy (RCA) was described by Charles Neer in 1977 as a set of pathoanatomical findings secondary to chronic full-thickness rotator cuff tears. Neer postulated that erosion of the greater tuberosity of the humerus and restructuring of the coracoacromial arch allowed space for the proximal aspect of the humerus, creating the unique appearance of the joint within this subset of patients.1Neer C.S. Craig E.V. Fukuda H. Cuff-tear arthropathy.J Bone Joint Surg Am. 1983; 65: 1232-1244Google Scholar Despite his inability to discern the pathogenesis, he hypothesized that 4% of patients with massive tears progress to RCA, a process that remains poorly understood.1Neer C.S. Craig E.V. Fukuda H. Cuff-tear arthropathy.J Bone Joint Surg Am. 1983; 65: 1232-1244Google Scholar,2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar Recent diagnostic criteria state that RCA encapsulates the spectrum of pathologies defined by the presence of rotator cuff insufficiency, degenerative changes of the glenohumeral joint, and superior migration of the humeral head. Historically, nonuniform poorly defined treatment algorithms have produced mediocre outcomes for patients.2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar Currently, the treatment algorithm begins conservatively with physical therapy, with those who fail commonly receiving reverse shoulder arthroplasty (RTSA) as definitive treatment. Despite the many surgical advances over the last decade, there remains room for improved understanding of how to achieve optimal outcomes for patients with RCA. This review is intended to provide an updated overview of the diagnosis, classification, pathoanatomy, biomechanics, treatment, outcomes, and complications of rotator cuff arthropathy. The classic patient with RCA presents with progressive pain and limitation of activity, commonly in their dominant extremity.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar Although this may occur in patients of varying age groups, the majority of the patients are in their seventh decade or older.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar Hallmark findings of loss of motion coupled with significant weakness are easily attributable to damage of rotator cuff tendons; however, given that RCA encompasses a spectrum of disease states, it is better identified through a thorough physical exam and radiologic assessment. Physical examination classically demonstrates weakness in supraspinatus and infraspinatus musculature with subcutaneous effusion, secondary to increased fluid pressure on the subacromial bursa, also occasionally seen.2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar Special tests are used to further characterize strength of rotator cuff musculature, such as the lift-off test for subscapularis isolation and the Hornblower’s test for involvement of the teres minor.2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar Passive and active range of motion (ROM) of the glenohumeral joint are commonly diminished because of weakness, pain, and/or stiffness. Specifically, presence or absence of an intact subscapularis may impact ROM due to changes within the force coupling and the anterior and posterior-superior rotator cuff muscles.4Halder A.M. Itoi E. An K.N. Anatomy and biomechanics of the should.Orthop Clin North Am. 2000; 31: 159-176Google Scholar This diminished ROM exists on a spectrum. Some develop compensatory strength in the deltoid, whereas others progress to pseudoparalysis in abduction and forward flexion.2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar Anterosuperior escape of the humeral head may also be identified on exam with increased severity of disease. Radiographic changes may additionally aid in diagnosis. The initial radiographic change seen for the acromion is sclerosis of the inferior aspect referred to as a sourcil sign. This is followed by acetabularization or thinning of the coracoacromial arch with destruction of the superior glenoid.2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar,3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar Additionally, femoralization, defined as erosion of the greater tuberosity of the humerus, secondary to contact with the acromion, may be noted. Progressive superior migration of the humeral head seen as narrowing of the acromio-humeral distance, may also assist in identifying this pathology radiographically.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar Lastly, peripheral osteophyte formation is occasionally seen.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar Although plain radiographic film is typically sufficient with physical exam to diagnose RCA, computed tomography and magnetic resonance imaging may be beneficial for surgical planning to evaluate abnormal patterns of wear on the glenoid, and determine the integrity of specific tendons and quality of bone stock.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar Two classification schemes exist for RCA: the Seebauer system and the Hamada system. The Seebauer system (Table 1) uses biomechanical metrics to delineate four grades of RCA based on the degree of superior migration from the center of rotation and the amount of instability around this point. Hamada’s system (Table 2) provides a mechanistic understanding of the radiographic changes seen in massive rotator cuff tears. This system is based upon the notion that all massive tears temporally progress to RCA through identifiable radiographic features. Grades of 1 through 5 are assigned based upon this progression in the size of the acromiohumeral interval and glenohumeral joint space.5Hamada K. Yamanaka K. Uchiyama Y. Mikasa T. Mikasa M. A radiographic classification of massive rotator cuff tear arthritis.Clin Orthop. 2011; 469: 2452-2460Google Scholar Both classification systems are useful clinically, providing similar inter- and intraobserver reliability and allowing communication regarding the severity of disease to dictate the type of treatment chosen by physicians.Table 1The Seebauer SystemSeebauer SystemType ICenteredIaDynamic joint stability + minimal superior migrationIbCompromised stability + minimal superior migrationType IIDecenteredIIaInsufficient stabilization + superior translationIIBAbsent stabilization + anteriosuperior escape Open table in a new tab Table 2The Hamada SystemHamada SystemGrade 1Acromiohumeral interval ≥6 mmGrade 2Acromiohumeral interval ≤5 mmGrade 3Acromiohumeral interval ≤5 mm + acetabularizationGrade 4aGlenohumeral join narrowing without acetabularizationGrade 4bGlenohumeral join narrowing with acetabularizationGrade 5Bony destruction of the humeral head + collapse Open table in a new tab RCA was first described as severe disorganization of the glenohumeral joint and collapse of the humeral head following massive rotator cuff tears.1Neer C.S. Craig E.V. Fukuda H. Cuff-tear arthropathy.J Bone Joint Surg Am. 1983; 65: 1232-1244Google Scholar Erosion of the glenoid, acromion, clavicle, and acromioclavicular joint were additionally noted at varying degrees. Evidence of repair and collapse of the subchondral bone, hypervascular oestoporotic spongiosa, osteoarthritis at points of fixed contact, and atrophic cartiladge covering the humeral head were also correlated with this pathology.1Neer C.S. Craig E.V. Fukuda H. Cuff-tear arthropathy.J Bone Joint Surg Am. 1983; 65: 1232-1244Google Scholar Now, the two key pathoanatomic sequela of RCA are femoralization and acetabularization. Femoralization is erosion of the glenoid and coracoid leaving the humerus rounded off and diminishing coverage from the rotator cuff, thus resembling the femoral head.1Neer C.S. Craig E.V. Fukuda H. Cuff-tear arthropathy.J Bone Joint Surg Am. 1983; 65: 1232-1244Google Scholar Acetabularization is thinning of the coracoacromial arch with destruction of the superior glenoid. This is defined clinically as acetabular arthritis and radiographically by a concave deformity of the acetabular surface or coracoacromial arch.5Hamada K. Yamanaka K. Uchiyama Y. Mikasa T. Mikasa M. A radiographic classification of massive rotator cuff tear arthritis.Clin Orthop. 2011; 469: 2452-2460Google Scholar This concavity is classically accompanied by recession of the greater tuberosity and occasionally by excessive spur formation across the coracoacromial ligament.5Hamada K. Yamanaka K. Uchiyama Y. Mikasa T. Mikasa M. A radiographic classification of massive rotator cuff tear arthritis.Clin Orthop. 2011; 469: 2452-2460Google Scholar The two broad underlying theories of arthritic development are nutritional and mechanical. Nutritional theory suggests that the articular cartilage degradation is due to escape of nourishing factors secondary to the tear. This produces a reduction in pressure from joint fluid and thus a lack of sufficient nutrients to support the articular cartilage.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar The mechanical theory however suggests that deterioration of this articular cartilage is a product of abnormal physical stresses from the upward migration of the humeral head.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar This migration causes impingement and erosion with repetitive trauma of the articular surface leading to destruction of the cartilage. Others have suggested that the underlying pathophysiology is likely a combination; the humeral head impact produces cartilage fragmentation and debris, which incite an enzymatic response further damaging the cartilage.3Feeley B.T. Gallo R.A. Craig E.V. Cuff tear arthropathy: Current trends in diagnosis and surgical management.J Shoulder Elbow Surg. 2009; 18: 484-494Google Scholar The healthy glenohumeral joint relies heavily on the rotator cuff musculature for both stabilization and ROM. To foster stability in the absence of osseous restraints, the rotator cuff maintains a centralized position for the humeral head within the glenoid fossa.2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar For this stability to be attained, the forces exerted on the healthy joint must be balanced. When considering the vertical axis, the rotator cuff provides a net inferior force and a compressive vector, and the deltoid muscle produces a superior force within the shoulder joint. Through compression of the convex humeral head into the concave surface of the glenoid and labrum, the cuff therefore allows for concentric rotation of the head. These coupled forces are referred to as concavity-compression, and when disrupted, lead to imbalance across the joint.2Nam D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar,6Ecklund K.J. Lee T.Q. Tibone J. Gupta R. Rotator cuff tear arthropathy.J Am Acad Orthop Surg. 2007; 15: 340-349Google Scholar Maintenance of horizonal balance across the joint is additionally critical. As the only anterior cuff muscle, the subscapularis is responsible for resisting anterior-inferior translation and is balanced by the infraspinatus and teres minor musculature posteriorly to provide a balanced set of forces.4Halder A.M. Itoi E. An K.N. Anatomy and biomechanics of the should.Orthop Clin North Am. 2000; 31: 159-176Google Scholar Massive rotator cuff tears and degeneration inherently of This loss of integrity in upward migration of the humeral head erosion of the superior glenoid and acromion and an of D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google J. The biomechanics of the rotator cuff in and disease A Clin Orthop 18: Scholar the spectrum of disease there exist many treatment as conservative treatment, arthroscopic and Currently, the treatments subacromial and physical therapy with and rotator cuff D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google the impact of factors and disease severity on making in cuff tear arthropathy: a 15: Scholar Although may be in pain, is due to diminishing D. Maak T.G. Raphael B.S. Kepler C.K. Cross M.B. Warren R.F. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS Exhibit Selection.J Bone Jt Surg. 2012; 94: e34Google Scholar Physical therapy however has in the treatment of RCA along the spectrum of M. rotator cuff repair or A review of Surg Scholar is typically at the anterior deltoid with on and musculature to glenohumeral Gallo R.A. Craig E.V. B.T. The and of cuff tear arthropathy.J Shoulder Elbow Surg. Scholar Although this treatment has for has to be correlated to patients at tears or anterior cuff M. rotator cuff repair or A review of Surg Scholar In surgical may be secondary to humeral head and loss of force M. rotator cuff repair or A review of Surg Gallo R.A. Craig E.V. B.T. The and of cuff tear arthropathy.J Shoulder Elbow Surg. Scholar A of arthroscopic treatments are as joint-sparing surgical for patients with RCA. The of arthroscopic rotator cuff repair is and the is in the absence of arthritis to further degeneration and progression of RCA. many tears are to repair or are at of making of this and Gallo R.A. Craig E.V. B.T. The and of cuff tear arthropathy.J Shoulder Elbow Surg. Scholar or are also used as in the radiographic of RCA however there remains on and the impact of factors and disease severity on making in cuff tear arthropathy: a 15: Gallo R.A. Craig E.V. B.T. The and of cuff tear arthropathy.J Shoulder Elbow Surg. Scholar may for severe of RCA, however, further is to better which patients may and how to their superior with a is to deltoid function by superior migration of the humeral pain, and motion of the glenohumeral Gallo R.A. Craig E.V. B.T. The and of cuff tear arthropathy.J Shoulder Elbow Surg. for the rotator cuff outcomes Surg. Scholar for of this have The initial for was patients with intact infraspinatus and or for however, recent have this may similar outcomes in patients along the spectrum of disease when glenohumeral joint space is Gallo R.A. Craig E.V. B.T. The and of cuff tear arthropathy.J Shoulder Elbow Surg. for the rotator cuff outcomes Surg. for the rotator cuff outcomes Surg. Scholar These and with and of significant improvements through for the rotator cuff outcomes Surg. 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