Rotator cuff tear arthropathy is what can happen when a very large rotator cuff tear is left for years. Without the cuff holding it down, the ball of the shoulder rides UP, wears against the bone above it, and the joint slowly turns arthritic.
It usually affects people in their seventies and beyond. The typical picture is a painful shoulder you can’t lift yourself, even though someone else can lift it for you.
There are two main paths: a specific strengthening program for the front of the shoulder, or a reverse shoulder replacement. Which one fits depends mostly on how high you can still lift your arm.
Why you can’t lift the arm
- Normally, the rotator cuff holds the ball in the socket while the big deltoid muscle lifts the arm
- With most of the cuff gone, the deltoid just pulls the ball upward instead of lifting the arm
- It’s not a nerve problem, and it’s not only pain. If the shoulder is numbed and the arm still won’t lift, the problem is mechanical
- Doctors call it “pseudoparalysis” when you can lift less than about 45 degrees, and “pseudoparesis” between about 45 and 90 degrees
The arm isn’t paralyzed. The muscles that hold it in place have gone.
What the X-ray shows
- A narrow gap between the ball and the bone above it. Under about 6 mm usually means a long-standing tear at the back of the cuff
- The bone above reshaping into a socket where the ball has been pressing on it
- Arthritis in the joint, and in the latest stage, collapse of the ball itself
- Doctors grade it from 1 to 5 (the Hamada grades). Different doctors reading the same X-ray don’t always agree, so treat your grade as approximate
How fast it progresses isn’t known. Anyone quoting you a number of years is guessing.
Option 1: retraining the front of the shoulder
- The idea: train the front part of the deltoid, with help from the chest and back muscles, to take over the lifting the cuff used to do
- Usually done lying down first, then gradually more upright as control improves
- Realistic success: about 4 in 10 overall, when success is measured strictly
- It costs nothing but time, and doesn’t close the door on surgery later
The 50-degree test
- If you can still lift your arm above about 50 degrees (roughly halfway to shoulder height), the program has a genuine chance
- If the tear is only at the back of the cuff, success was about 9 in 10 in one study
- If the tendon at the FRONT (subscapularis) is fully torn, success dropped to about 3 in 10
- If three or more tendons are gone, a bit under half
- Below 50 degrees, the odds are against it, and it’s time to talk about surgery
Option 2: reverse shoulder replacement
- The main surgical answer for this condition
- It swaps the ball and socket around, so the deltoid can lift the arm on its own without a rotator cuff
- Lifting and pain usually improve a lot. Turning the arm OUTWARD usually doesn’t come back much
- It does less well in people under 60
Full details in reverse shoulder replacement: what to expect.
Other options you may hear about
- Graft to rebuild the top of the joint (superior capsular reconstruction): can work well for shoulders WITHOUT arthritis yet, but the graft fails to heal in about 1 in 4. Not an option once the joint is arthritic
- Tendon transfer: moves a working muscle to do a failed one’s job. Early results look promising, but the evidence is thin
- Balloon spacer: a trial found patients did WORSE with the balloon than without it. If it’s offered, ask about that trial
Get seen urgently if
- You suddenly can’t lift the arm after a fall or strain, with a known cuff tear
- A new bump appears at the front and top of the shoulder when you try to lift
- The shoulder is hot and swollen and you feel unwell
- After a reverse replacement, the shoulder suddenly pops, gives way or becomes hot and painful
Get it reviewed if
- Your lifting drops below about 50 degrees
- Pain is stopping you sleeping despite treatment
- You’ve done three months of the deltoid program with no gain
For the tear itself, see rotator cuff tear.
Above 50 degrees, train the deltoid first. Below it, the reverse replacement is the stronger bet.