Rotator Cuff Arthropathy
What is Rotator Cuff Arthropathy?
The rotator cuff is a network of 4 muscles and 4 tendons that hold the humeral head (upper arm bone) in place and allow it to rotate within the shoulder joint. The muscles that form the tendons are the supraspinatus, infraspinatus, teres minor, and subscapularis. When the rotator cuff muscles contract they pull the head of the humerus into the socket of the shoulder—stabilizing the shoulder and allowing the shoulder to rotate out/in and to help lift the arm.
Acute rotator cuff tears are common due to trauma, a fall on an outstretched hand, heavy lifting, or forcibly pulling. Injury to the rotator cuff is more likely in patients over the age of 40, and in people whose job or hobbies require repetitive overhead activities (such as painting, plastering, or weightlifting.)
If the rotator cuff is torn and never repaired, arthritis may develop over time due to continual wear and tear on the shoulder. As arthritis develops, the shoulder may become unbalanced and unable to support the weight of the arm for lifting. This compound degenerative condition of the shoulder is called rotator cuff arthropathy (Figure 1). By the time rotator cuff arthropathy develops, the shoulder has usually lost not only the cartilage that normally covers its joint surface but also lost the tendons of the rotator cuff that allow smooth motion of the humerus and help position and power the joint. Thus, the humeral head is left unprotected, allowing rubbing between the humeral head and the acromion resulting in a roughened surface with cartilage loss, and progressively eroded structures.
Signs and Symptoms:
Weakness, stiffness, and pain when lifting or rotating the arm, as well as a grinding sensation at the shoulder joint, may be indications of rotator cuff arthropathy. Pain may be worse at night, and with time, range of motion may decrease.
Rotator cuff arthropathy is a chronic condition that does not heal by itself; however, conservative treatment may help to reduce symptoms. The goals of conservative treatment are to reduce pain, and to increase range of motion and function. Conservative options include rest, ice, anti-inflammatory medications, and steroid injections to temporarily reduce pain. Range of motion and strengthening exercises may also help lessen symptoms.
If conservative treatment is not effective in reducing symptoms, surgery may be recommended. In some cases, just debridement of the joint and rotator cuff may improve symptoms. Provided that the patient has the necessary stability, a partial joint replacement with a CTA (Cuff Tear Arthropathy) prosthesis may be considered (Figure 2). A CTA prosthesis is designed to replace the ball portion of the shoulder joint called the humeral head. The prosthesis has a more extended articular surface than a traditional shoulder replacement, which allows for a more natural fit and a greater range of motion (because the implant surface remains in contact with the socket longer). Another type of prosthesis, called a Resurfacing prosthesis, may also be use (see Humeral Head Resurfacing Arthroplasty under “Shoulder Arthritis”). The CTA prosthesis is anchored in place by a short stem that is secured into the shaft of the humerus. While many patients with rotator cuff arthropathy are good candidates for a CTA prosthesis, patients with severe instability may require a reverse shoulder replacement instead.
Post Operative Rehabilitation:
- Expect a surgical bulky dressing for 3-4 days and arm immobilizer to be worn for comfort.
- Use cryocuff or ice shoulder 3-5 times per day for 15 minute intervals until your next clinic visit.
- Maintaining upright shoulder positioning may be more comfortable. (You may sleep in a recliner chair at night if it is more comfortable, but this is not required.)
- After pain catheter is removed after 3 days, may shower with a plastic bag covering the area and seal with tape. No covering is needed after wound is sealed and dry between 5-7 days post op.
- Take your pain medicine as needed and as prescribed. Call if any problems or questions arise.
- Watch for signs of infection and call immediately if these signs develop:
- Fever higher than 102°F, shortness of breath, or have nausea and vomiting that does not improve with anti-nausea meds.
- Warmth, redness, and/or increased drainage coming from your incision site.
- Watch for signs of blood clots and go to the ER immediately if these signs develop:
- Excessive increase in swelling, hardness, pain, or redness in forearm or calf.
- No hot tub or Jacuzzi for at least two weeks or until all wounds are healed and sutures are out.
- Do not elevate surgical arm above 70° (with your own muscle power) for the first 8 weeks.
- Do not lift any objects > than a coffee mug for at least 8 weeks post op.
- Avoid external rotation past neutral until 8 weeks post op.
- No active range of motion with shoulder for at least 8 weeks – only passive motion. (Pendulums, stick, and pulleys etc…)
3-5 Days Post Op:
- Block catheter will be removed and dressing will be changed.
- May shower w/o plastic covering once block has been removed and wound is sealed w/o bloody drainage.
- Once block has worn off, begin pendulum/codmans exercises (gentle circular swing of arm from standing position while flexed at hips 90°) 2 to 3 times each day.
- Begin passive Range of Motion (ROM) flexion and external rotation exercises 3-4 times per day as instructed by therapist.
- Use hand in activities of daily living such as eating, drinking, brushing teeth, etc.
10-14 Days Post Op (at therapy):
- Sutures will be removed; initiate assisted forward flexion to tolerance, using opposite hand (supine position w/hand on head, use neck to add stretch).
- Begin assisted external rotation to neutral (straight ahead—no further until 8 weeks) and passive internal rotation with arm abducted to 90 degrees (in supine position).
- Start scapular stabilization isometrics—avoiding affected musculature.
4-6 Weeks Post Op:
- Follow up appointment in clinic with P.A. or M.D. to check progress with ROM.
- Depending on progress, begin wall climbs and overhead stretching with pulleys.
- Continue to use arm for progressive daily activities.
8 Weeks Post Op:
- Follow up appointment in clinic with P.A. or M.D.
- Continue stretching exercises of shoulder 3-4 times per day.
- Initiate both active and active-assisted shoulder ROM with terminal stretch.
- Begin gentle isometric exercises within pain tolerance.
- Add pulleys and add further forward flexion toward normal, with pulley, stick, and wall walking.
- Gently increase active external rotation stretch toward full range (infraspinatus).
- Active resisted forward flexion (for anterior deltoid).
- Rockwood V Theraband; Hughstons and Rilvald scap stab strengthening exercises now added.
- When sufficient passive ROM has been achieved (between 120-140° flexion and 20-40° external rotation), may begin strengthening exercises of the deltoid and rotator cuff muscles with Therabands, and gradually increase weight.
- Begin shoulder shrug exercises with weights to strengthen the scapular stabilizer muscles.
12-14 Weeks Post Op:
- Follow up appointment in clinic with P.A. or M.D.
- Continue stretching and strengthening 2-3 times per week.
- May return to medium level activities at 4 months and unrestricted heavy activities at 6 months.
- May continue to improve for up to 1 ½ years after surgery.
Note: These instructions are to serve as guidelines and are subject to Physician discretion. Actual progress may be faster or slower depending on the individual.