Ortho Dx: Shoulder Pain Without Arthritis - Clinical Advisor

Ortho Dx: Shoulder Pain Without Arthritis

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  • Figure 1. Anteroposterior radiograph of the right shoulder.

  • Figure 2. Sagittal plane magnetic resonance imaging of the right shoulder.

A 66-year-old man presents with pain in his right shoulder. The patient has experienced weakness in the shoulder for several years, but did not experience pain until 6 months ago. Conservative treatments, including oral anti-inflammatory medication and corticosteroid injections into his shoulder, have not provided relief from the discomfort. Physical examination reveals significant weakness with forward flexion of the arm in the scapular plane. Anteroposterior radiograph (Figure 1) shows a decreased glenohumeral interval without evidence of shoulder arthritis. Sagittal plane magnetic resonance imaging (Figure 2) shows a massive, irreparable rotator cuff tear with significant retraction involving the supraspinatus and infraspinatus muscles.

The rotator cuff functions to keep the humeral head centered on the glenoid cavity during shoulder motion. As the deltoid muscle contracts to lift the arm, the rotator cuff resists superior migration of the humeral head.1 Massive chronic tears of...

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The rotator cuff functions to keep the humeral head centered on the glenoid cavity during shoulder motion. As the deltoid muscle contracts to lift the arm, the rotator cuff resists superior migration of the humeral head.1 Massive chronic tears of the rotator cuff may result in the humeral head migrating superiorly, as seen as a decreased acromiohumeral interval on the anteroposterior radiograph of this patient. Rotator cuff arthropathy is the condition in which the rotator cuff is torn, retracted, and no longer functional.1

The treatment of rotator cuff arthropathy is very challenging, particularly in younger, more active adults. The treatment of choice for most patients with severe rotator cuff arthropathy and glenohumeral arthritis who have failed conservative treatments is a reverse total shoulder replacement.2

A superior capsular reconstruction (SCR) is a procedure that is utilized for patients with mild rotator cuff arthropathy and no glenohumeral arthritis.1,2 The SCR technique involves placing suture anchors in the superior glenoid to tie an acellular dermal graft down to the glenoid. Suture anchors are then placed in the rotator cuff footprint to tie the other side of the graft down on the proximal humerus.2 The purpose of the graft is to resist superior migration of the humeral head.1

Some early studies have indicated that SCR may provide relief of pain and improve shoulder function in the short term (the first 2-3 years postoperatively); however, long-term studies do not demonstrate these findings as the procedure is relatively new.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.

References

1. Rachel FM, Cvetanovich G, Savin D, Romeo AA. Superior capsular reconstruction: indications, techniques, and clinical outcomes.  JBJS Rev. 2018;6(7):e10.  

2. Adams CR, Denard PJ, Brady PC, Hartzler RU, Burkhart SS.  The arthroscopic superior capsular reconstruction. Am J Orthop. 2016;45(5):320-324.

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