Rotator Cuff Tear Arthropathy: Pathophysiology, Imaging Characteristics, and Treatment Options

M u s c u l o s k e l e t a l I m a g i n g R ev i ew
Eajazi et al.
Rotator Cuff Tear Arthropathy
Musculoskeletal Imaging
Review
American Journal of Roentgenology 2015.205:W502-W511.
Rotator Cuff Tear Arthropathy:

Pathophysiology, Imaging
Characteristics, and
Treatment Options
Alireza Eajazi1
Steve Kussman2
Christina LeBedis1
Ali Guermazi1
Andrew Kompel1
Andrew Jawa3
Akira M. Murakami1
OBJECTIVE. The purpose of this article is to review the biomechanical properties of the
rotator cuff and glenohumeral joint and the pathophysiology, imaging characteristics, and
treatment options of rotator cuff tear arthropathy (RCTA).
CONCLUSION. Although multiple pathways have been proposed as causes of RCTA, the
exact cause remains unclear. Increasing knowledge about the clinical diagnosis, imaging features, and indicators of severity improves recognition and treatment of this pathologic condition.
Eajazi A, Kussman S, LeBedis C, et al.
he shoulder has the most mobility but the least intrinsic stability
of all joints in the human body
[1]. A complex association of
static and dynamic stabilizers balances the
joints mobility with its functional stability.
The rotator cuff tendons play a crucial role in
maintaining this dynamic stability in the naturally unstable glenohumeral joint [2, 3]. The
loss of this important stabilizer can lead to a
complex pattern of joint degeneration referred to as rotator cuff tear arthropathy
(RCTA). Understanding the role of the rotator cuff in maintaining the balance between
mobility and stability leads to an appreciation
of the progressive findings seen in RCTA and
the treatment options that are available if arthropathy progresses to joint failure.
In 1977, Charles Neer and his colleagues
invented the term cuff tear arthropathy
and eventually provided the first detailed description of RCTA in 1983 [4]. RCTA has
three major characteristics: first, massive rotator cuff tear (Fig. 1A); second, degenerative changes (i.e., glenoid erosion, loss of articular cartilage, osteoporosis of the humeral
head, and eventually humeral head collapse)
(Figs. 1B and 1C); and third, superior migration of the humerus resulting in femoralization of the humeral head (Fig. 2A) and acetabularization of the coracoacromial arch
[5] (Fig. 2B).
Understanding the imaging findings and
stages of RCTA is important in the preoperative evaluation of the patient with a symptomatic massive rotator cuff tear because
Keywords: arthropathy, biomechanics, imaging, MRI,

rotator cuff tear, shoulder
DOI:10.2214/AJR.14.13815
Received September 3, 2014; accepted after revision
April 27, 2015.
1
Department of Radiology, Boston University Medical
Center, 820 Harrison Ave, FGH Bldg, 3rd Fl, Boston, MA
02118. Address correspondence to A. Eajazi
(alireza.eajazi@gmail.com).
2
Department of Radiology, University of California, San
Diego, San Diego, CA.
3
Boston Sports and Shoulder Center, New England

Baptist Hospital, Boston, MA.
WEB
This is a web exclusive article.
AJR 2015; 205:W502W511
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American Roentgen Ray Society
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this information can be used to determine

the proper surgical treatment of end-stage
arthropathy and to provide patients with realistic expectations about the postoperative
outcome. The objectives of this article are
to review the biomechanical properties of
the rotator cuff and glenohumeral joint and
their relationship to the pathophysiology of
RCTA. We will discuss the various imaging
modalities and classification systems for the
diagnosis of RCTA and will review the current management options for treatment.
Biomechanics of Shoulder
The glenohumeral joint lacks intrinsic osseous constraints, which allows a high degree
of mobility but simultaneously creates inherent instability. This instability is compensated for by many static stabilizers, such as the
labrum, joint capsule, and glenohumeral ligaments. The dynamic stabilizers of the rotator cuffwhich consist of the supraspinatus,
infraspinatus, teres minor, and subscapularis
musclesare crucial. These muscles provide
stability through a mechanism termed concavity compression [68] (Fig. 3).
The forces acting on the shoulder can be
divided into three components: a stabilizing
compressive force, a destabilizing translational superior-inferior force, and an anteriorposterior force. Joint stability is simply a balanced ratio between the translational forces
in any direction and the compression forces
[911]. For instance, the combined force of
the subscapularis muscle anteriorly and the
infraspinatus and teres minor muscles poste-
AJR:205, November 2015
Fig. 1MRI of rotator cuff tear arthropathy.

A, Coronal proton densityweighted MR image of 73-year-old woman shows massive rotator cuff tear.
B, Coronal proton densityweighted MR image of 69-year-old woman shows chronic superior migration of humeral head (arrow) resulting in full-thickness chondral loss,
osteophyte formation, and subchondral cystic changes over superior humeral head and superior glenoid.
C, T2-weighted fat-suppressed MR image of right shoulder of 58-year-old woman shows chronic superior migration of humeral head resulting in degeneration and
maceration of superior labrum (arrowhead).
Fig. 2Radiography of rotator cuff tear arthropathy.

A, Frontal radiograph of right shoulder of 73-year-old woman shows femoralization of humeral head and erosion
of greater tuberosity (arrowhead).
B, Frontal radiograph of left shoulder of 87-year-old man shows acetabularization of coracoacromial arch
that is, reshaping of coracoacromial arch to create socket for superior aspect of humerus (arrow).
riorly provide antagonistic forces that compress the humeral head onto the glenoid bone
[3, 12]. This stability also depends on the effective glenoid arc and the area of the glenoids articular surface available for humeral head compression [13]. Also important is
the interplay between the deltoid muscle and
the rotator cuff. The rotator cuff provides a
net inferiorly directed and compressive force,
whereas the strong deltoid muscle provides a
superiorly directed force; these forces result
in a net force balance or force coupling of the
glenohumeral joint [14] (Fig. 4A).
Massive Rotator Cuff Tear

There is no general agreement regarding the
definition of a massive rotator cuff tear, although its prevalence has been reported in the
literature to range from 10% to 40% of all rotator cuff tears [1517]. Both functional and
anatomic characteristics have been used to
classify massive rotator cuff tears, but each
type of characteristics has some disadvantages. Cofield et al. [18] defined a massive rotator
cuff tear as a cuff tear with a diameter of 5 cm
or larger, whereas Zumstein et al. [19] defined
it as complete detachment of two or more ten-
dons. Other investigators have proposed classification systems based on the area of the defect or on indexes of tear dimensions [20].
Despite the different criteria used to define a massive rotator cuff tear, the result of
a massive rotator cuff tear is the destabilization of the glenohumeral joint and the attritional destruction of the primary static stabilizers, leading to chondral wear and
subsequent osteoarthritis [21]. It is noteworthy that massive rotator cuff tears, although
technically challenging to repair, are not
necessarily irreparable [22]. Signs of irreparability include static superior migration of
the humeral head, a narrowed or absent acromiohumeral interval (AHI), and fatty infiltration affecting 50% or more of the rotator
cuff muscles [16, 17, 23, 24].
Pathogenesis of Rotator Cuff Tear
Arthropathy
The exact cause of RCTA is unknown, although numerous pathomechanical concepts
have been hypothesized for its development.
Crystal-Mediated Theory
An association between RCTA and the
presence of calcium phosphate crystals in synovial fluid and tissue was proposed by Halverson et al. [25]. They postulated that the
calcium phosphatecontaining crystals in
synovial tissue induce an immunologic cascade that leads to the release of proteolytic
enzymes and that these proteolytic enzymes
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Eajazi et al.
the glenoid bone is often eccentric, involving the anterior-superior margin. This wear
leads to an accelerated process of further
cuff destruction and arthropathy (Fig. 4B).
Nutritional factorsThe nutritional factors associated with massive full-thickness
tears are related to the loss of motion and
periarticular damage due to disruption of the
normal joint milieu. The loss of fluid pressure and the accompanying reduction in the
quality of the chemical content of the synovial fluid lead to cartilage and bone atrophy.
Recurrent bloody effusions and the loss of
glycosaminoglycan content of the cartilage
further accelerate the destruction of both
bone and soft tissue [27].
Fig. 3Drawing shows concavity-compression mechanism (triple-headed arrow) of rotator cuff: Rotator cuff
muscles (single-headed arrows) provide joint stability and center humeral head on glenoid cavity. (Drawing by
Murakami AM)
cause the rapid degradation of the cartilage

matrix components and the destruction of
periarticular and articular structures [26].
Rotator Cuff Tear Theory
Neer et al. [21] hypothesized that massive
rotator cuff tears lead to the degeneration of
the shoulder joint through two mechanisms:
a mechanical pathway and a nutritional pathway. This concept is based on clinical observations and pathologic observations made at
surgery and on review of histologic samples.
Mechanical factorsThe mechanical factors associated with massive rotator cuff tears
lead to unbalanced muscle forces. These factors are anteroposterior instability of the humeral head, resulting from massive cuff tears
and rupture or dislocation of the long head
of the biceps tendon, which leads to superior
migration of the humeral head and acromial
impingement. Shoulder joint wear occurs as
a result of repetitive trauma from the altered
biomechanics associated with the loss of primary and secondary stabilizers. The wear on
Force Couple Theory

The deltoid and rotator cuff muscles work
cooperatively to preserve a balanced force
couple for the glenohumeral joint in both the
coronal and transverse planes. The muscles inferior to the humeral head equator maintain a
balanced coronal force, whereas the subscapularis and infraspinatusteres minor complex
balance each other in the transverse plane. In
this capacity, the rotator cuff muscles function
as primary dynamic stabilizers to maintain a
concentric reduction during rotation of the humeral head on the glenoid bone [2831]. A
massive rotator cuff tear can disrupt this force
couple, as shown fluoroscopically by Burkhart et al. [14] in comparisons of the kine-
Fig. 4Rotator cuff. (Drawings by Murakami AM)

A, Rotator cuff biomechanics. Drawing shows that net inferior and compressive force vector (double-headed arrow) of rotator cuff is balanced by net superiorly directed
force vector of deltoid muscle (single-headed arrow).
B, Rotator cuff insufficiency. Drawing shows superior migration of humeral head and degenerative changes of glenohumeral joint (arrow) that are suggestive of rotator
cuff insufficiency.
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matic patterns of massive rotator cuff tears. As
a result, the uncoupled or unopposed deltoid
muscle leads to superior migration of the humeral head, which in turn results in the distinctive degenerative wear pattern on the acromion and coracoid process. Additionally,
the uncoupling leads to instability and reduced
motion, which lead to chondral loss.
Fatty degeneration of the rotator cuff muscles, which occurs after a rotator cuff tear, is
characterized by atrophy of the muscle fibers,
fibrosis, and fatty accumulation within and
around the muscles [32, 33]. It is frequently
associated with an aging-related reduction of
the regenerative potential of the rotator cuff
tendons [34]. Studies have shown that lowgrade preoperative fatty degeneration may
predict a better clinical outcome [32, 33],
whereas high-grade infiltration is associated with a worse clinical outcome [35, 36]. A
delayed diagnosis of a rotator cuff tear also
worsens the prognosis because both the tendon and muscle belly undergo atrophy and
degeneration [37]. Fatty infiltration and muscle atrophy have also been shown to not improve after successful structural repair of the
rotator cuff, and their presence is associated
with poor functional results [32, 3840]. The
risk of irreversible fatty infiltration of the rotator cuff muscles may limit future treatment
options and must be considered when counseling patients. This event has a negative influence on both functional and radiographic
outcomes [41].
Diagnostic Imaging
Radiography
A few classification systems based on radiography have been developed to define
the bone changes that occur in RCTA. Although the characteristics of these systems
overlap, each system focuses on a different
set of findings associated with the disorder.
These systems include the Seebauer system
[27] and the Hamada system [42].
The Seebauer classification system separates RCTA into four distinct types: IA, IB,
IIA, and IIB [27]. Each type is characterized
by a massive rotator cuff tear, a distinctive
level of joint instability, humeral head translation, and articular surface erosion [27].
This classification system is a biomechanical description of RCTA, in which each type
is distinguished on the basis of the degree of
superior migration of the humeral head from
the center of rotation and the amount of instability [27]. The extent of decentralization
seen on radiographs depends on the size of
the rotator cuff tear, the integrity of the coracoacromial arch, and the degree and direction of glenoid bone erosion [27] (Fig. 5).
The Hamada classification system describes structural changes within the coracoacromial arch and changes in the acromiohumeral interval (AHI) on anteroposterior
radiographs as the bases for classification
[43]. This system divides massive rotator
cuff tears into five radiographic stages, with
consecutive stages indicating disease progression [42]. Table 1 shows the characteristics of each of the stages in this system.
MRI
The multiplanar imaging capabilities of
MRI combined with its excellent soft-tissue
contrast make it ideally suited for imaging
the rotator cuff. Although a massive rotator
cuff tear can often be diagnosed on the basis of physical examination and advanced radiographic findings as detailed earlier, MRI
can be used to evaluate the integrity of the
cuff overall or to determine whether an existing tear is repairable when other findings
are ambiguous. Additionally, MRI can assist
in the characterization of chondral loss that
can be typical of RCTA.
CT
The primary use of CT in patients with
advanced osteoarthritis of the glenohumeral
joint has been in the assessment of the glenoid bone. In particular, advanced osteoarthritis can be associated with posterior glenoid bone loss, which can inevitably lead to
posterior subluxation of the humeral head.
These findings are associated with a poor
clinical outcome after total shoulder arthroplasty (TSA) [44]. Accurate assessment of
the glenoid bone stock is also important in
surgical planning because a small volume of
bone may require bone grafting to accommodate the glenoid prosthesis [45]. CT has been
shown to be more effective than radiography
in this assessment and in the measurement of
glenoid version [46]. Glenoid version is defined by Friedman et al. [47] as the angle between a line drawn from the medial border of
the scapula to the center of the glenoid bone
and the line perpendicular to the face of the
glenoid bone on the axial 2D CT slice at or
just below the tip of the coracoid process.
Both CT and MRI can be used to assess
the degree of fatty infiltration according to
the classification system proposed by Goutallier et al. [33]. They first described a classification system based on the presence of fatty streaks within the muscle belly on CT, but
the grading criteria have since been applied to
MRI [37, 48]. The classification system that
Goutallier et al. [33] described in their original article in 1994 is composed of five stages
of fatty infiltration (Fig. 6 and Table 2).
Sonography
Sonography is an alternative modality for
evaluating the rotator cuff that is capable of
providing images with high image contrast
but without the use of ionizing radiation. The
diagnostic accuracy of shoulder sonography
for rotator cuff tears can reach as high as
91% and 100% for partial- and full-thickness
tears, respectively [4951]. Although the accuracy of sonography hinges on the skill and
experience of the operator performing the
examination [52], sonography is a suitable
alternative modality in patients who are not
able to undergo MRI because it is contraindicated or cannot be tolerated.
Management
Patients presenting with RCTA present with
pain, disability, or both. Numerous treatment
TABLE 1: Classification System for Assessing Rotator Cuff Tear Arthropathy

(RCTA) on Radiography According to Hamada et al. [42]
Stage of RCTA
Characteristics
AHI is6 mm
AHI is5 mm
AHI is5 mm and there is acetabularization of the

coracoacromial arch
Glenohumeral joint is narrowed

4a
Without acetabularization
4b
With acetabularization
Humeral head osteonecrosis is present and eventually results

in humeral head collapse
NoteAHI= acromiohumeral interval.
Eajazi et al.
TABLE 2: Classification System for Assessing Fatty Infiltration of
Rotator Cuff Muscles on Imaginga According to Goutallier et al. [33]
Surgical Options
Total shoulder arthroplastyTSA is most
commonly performed for the treatment of
advanced degenerative osteoarthritis in patients older than 60 years [54]. Other indications include inflammatory arthritis, humeral head avascular necrosis with secondary
glenohumeral arthritis, postinfectious arthritis, and Charcot arthropathy [54, 55].
Unconstrained TSA prostheses were used
by Neer et al. [4, 21] to treat 26 shoulders
with RCTA and yielded poor functional outcomes. The poor outcomes were thought to
be related to the superior migration of the
humeral head seen with a defective rotator
cuff, which resulted in eccentric loading of
the superior aspect of the glenoid component. Over time, this eccentric loading resulted in loosening of the glenoid component, a complication that Franklin et al. [56]
termed the rocking horse glenoid.
Constrained and semiconstrained TSA
prostheses were used with the hope of preventing superior humeral head migration
and thus the eccentric loading of the superior aspect of the glenoid component. Nevertheless, these prostheses still caused stresses
at the superior interface of the glenoid component and therefore were also associated
with high rates of glenoid component loosening [57, 58].
Stage of Fatty Infiltration
Characteristics
Normal muscles, no fatty streaks
Some fatty streaks
Fatty infiltration is present but there is more muscle than fat
Moderate fatty infiltration is present in which there is as much

fat as muscle
Severe fatty infiltration is present in which there is more fat

than muscle
aCT or MRI.
options are available, and the treatment of

choice varies according to the patients circumstances, surgeons preferences, and resources.
Initial Management
The initial management of RCTA should
begin with conservative measures including activity modification, oral analgesics
including nonsteroidal antiinflammatory
drugs or cyclooxygenase inhibitors, physical therapy, fluid aspiration, and intraarticular injections of corticosteroid and hyaluronans. Aspiration and corticosteroid
administration may be a useful adjunct to
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physical therapy for patients who are unable

or unwilling to undergo surgical intervention. Intraarticular corticosteroid injections
may be useful at first, but multiple injections
are not recommended because of decreasing
utility and the possibility of increasing the
risk of infection [53]. Although the initial
management of RCTA should begin with
conservative measures, surgical intervention is often required.
Fig. 5Radiographs show examples of types of rotator cuff tear arthropathy (RCTA) according to Seebauer
classification system [27].
A, 58-year-old man with type IA RCTA. Type IA is characterized as centered and stable. Imaging findings are intact
anterior restraints, minimal superior migration, femoralization, and acetabularization.
B, 74-year-old woman with type IB RCTA. Type IB is characterized as centered and medialized. Imaging findings are
intact anterior restraints, minimal superior migration, and medial erosion of glenoid bone.
C, 87-year-old man with type IIA RCTA. Type IIA is characterized as decentered, limited, and stable. Imaging findings
are compromised anterior restraints, superior translation, minimal stabilization by coracoacromial arch, and superior
and medial erosions of glenoid bone.
D, 68-year-old man with type IIB RCTA. Type IIB is characterized as decentered and unstable. Imaging findings are
incompetent anterior structures, anterior-superior escape, and no stabilization by coracoacromial arch.
Humeral
hemiarthroplastyHumeral
hemiarthroplasty is now a current treatment
option for patients with symptomatic RCTA
and modest functional goals [53, 5962].
The benefits of humeral hemiarthroplasty
are a shorter and technically easier surgery:
Repair of the rotator cuff is easier because
of less humeral lateralization [58], and the
lack of a glenoid component eliminates the
potential complication of component loosening. Humeral hemiarthroplasty also avoids
the problem of the rocking horse glenoid.
The results from several studies have shown
no pain or mild pain in 4786% of shoulders
with glenohumeral arthritis and a deficient
rotator cuff treated with humeral hemiarthroplasty [53, 5961]. Active forward elevation of the glenohumeral joint was also found
to increase by an average of 1750 after humeral hemiarthroplasty [53, 5961]. Based
on the limited-goals criterion proposed by
Neer et al. [4, 21], between 63% and 86% of
humeral hemiarthroplasties were considered
to have successful outcomes [53, 59, 61].
However, studies have shown that a significant number of patients are left with painful
and unsatisfactory shoulders after humeral
hemiarthroplasty, even though this surgical

option helped many patients and was preferable to TSA [53, 61, 63].
Reverse total shoulder arthroplasty
RCTA is currently the primary indication for
reverse TSA, as this group has reported predictable outcomes [64]. The ideal candidate
for reverse TSA is an older patient with decreased functional demand, a preoperative
active forward elevation of the glenohumeral
joint of less than 90, and an intact deltoid
muscle. As surgeons have gained more experience with reverse TSA, the indications have
been expanded to include revision arthroplasty, inflammatory arthropathy with a massive
rotator cuff tear, painful and irreparable rotator cuff tear, proximal humeral nonunion or
malunion, acute fractures, tumor, and chronic pseudoparalysis without arthritis [6575].
A reverse TSA is essentially a reversal of
the normal shoulder ball-and-socket anatomy. In this design, the concave component
replaces the humeral head, and the convex component is fixed to the glenoid bone,
which results in a humerosocket and a
glenosphere. It is composed of three main
components: the baseplate (metaglene), the
Fig. 6Stages of fatty infiltration of rotator cuff

muscles according to classification system proposed
by Goutallier et al. [33].
A, MR image of 33-year-old woman shows stage 0
fatty infiltration.
B, MR image of 74-year-old man shows stage 1 fatty
infiltration.
C, MR image of 58-year-old woman shows stage 2
fatty infiltration.
D, MR image of 73-year-old woman shows stage 3
fatty infiltration.
E, MR image of 58-year-old man shows stage 4 fatty
infiltration.
glenosphere, and the humeral socket. The

baseplate is a metal-backed plate that directly contacts the glenoid bone (Fig. 7).
This design results in a semiconstrained
prosthesis that stabilizes the glenohumeral center of rotation like a functioning rotator cuff [76]. This design avoids the superior migration of the humerus on the glenoid
bone, thereby restoring the deltoid muscles
anatomic resting length. The deltoid muscle
now can compensate for the rotator cuff deficiency. By replacing both sides of the joint,
reverse TSA offers more reliable pain relief
than humeral hemiarthroplasty [59]. Multiple series of patients with RCTA that was
treated using reverse TSA have shown substantial improvements in Constant-Murley
scores, an average active forward elevation
of the glenohumeral joint of greater than
110, and good long-term joint stability [77
81]. Furthermore, a faster recovery may be
achieved because the rotator cuff does not
need to be protected during the early postoperative period [82]. Several clinical studies have also reported noticeable improvements in activity and quality of life after a
successful reverse TSA [65, 78, 81, 83, 84].
Eajazi et al.
Fig. 7Reverse total shoulder arthroplasty (TSA).

A, Drawing shows anatomy after reverse TSA: Ball is at glenoid, and socket is on humeral head. Axis is moved medially and distally to allow control by deltoid
muscle. Arrow shows restored center of rotation. (Drawing by Murakami AM)
B, Radiograph of 74-year-old woman who underwent reverse TSA of right shoulder shows prosthesis.
C, Photograph shows reverse TSA prosthesis.
ArthrodesisAnother surgical option

is glenohumeral arthrodesis, which has the
goal of relieving pain by eliminating motion.
The most noticeable disadvantage of this
procedure is the total loss of glenohumeral
joint motion. Additionally, the compensatory
scapulothoracic motion may expose the acromioclavicular joint to excessive motion and
result in further pain [91, 92]. Despite these
drawbacks, some patients may benefit from
glenohumeral arthrodesis. Patients with multiple failed previous operations, a history of
infection, or a deficient anterior deltoid muscle may have the best outcomes with glenohumeral arthrodesis [93].
Although abundant long-term data are not

available, short- to intermediate-term outcome studies suggest that survivorship of
the reverse TSA is comparable with humeral hemiarthroplasty and TSA [78, 81,
8590].
Fig. 8Complications of reverse total shoulder arthroplasty (TSA): dislocation and stress fracture.
A, Frontal radiograph of left shoulder of 69-year-old woman shows dislocation of components of reverse TSA
prosthesis.
B, Frontal radiograph of left shoulder of 73-year-old man shows acromial stress fracture (arrowhead) due to
reverse TSA prosthesis.
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Complications
Despite favorable short- and medium-term
clinical results, the overall complication rate
of reverse TSA is high, ranging between 19%
and 68% depending on what is considered to be
a complication [94]. Wall et al. [79] reviewed
the results of reverse TSA according to cause
and reported a 19% complication rate in 186
patients, with the most common complications
being dislocation (7.5%) (Fig. 8A) and infection (4%). Glenoid fractures, humeral fractures,
pain, radial nerve palsy, and loosening of the
glenosphere or baseplate were among the least
commonly reported complications. It is impor-
Fig. 9Complication of reverse total shoulder arthroplasty (TSA): scapular notching.

A, Drawing shows Nerot-Sirveaux grading system (grades 14) for characterizing postoperative scapular
notching after reverse TSA. (Drawing by Murakami AM)
B, Radiograph of left shoulder of 69-year-old woman who underwent reverse TSA shows grade 4 scapular notching.
tant to understand that the risk of complications

in the revision surgeries was more than double
that observed with primary surgeries (37% and
13%, respectively) [79]. Instability is one of the
other complications that may be related to undertensioning of the deltoid muscle, deltoid insufficiency or detachment, or medial impingement of the humeral component on the scapular
neck [79]. Overtensioning of the deltoid muscle, however, can lead to fracture of the acromion, especially in elderly patients with osteoporosis [95] (Fig. 8B). Given the dead space
surrounding the prosthesis, there is a substantial
risk of postoperative hematoma formation and
deep infection [78].
Another common complication is scapular
notching, which is due to the impingement of
the medial aspect of the humeral cup on the
scapular neck during adduction [96100]. The
incidence of scapular notching has been reported to be as high as 96% [78]. A classification
system proposed by Sirveaux et al. [43] in 2004
to grade scapular notching is illustrated in Figure 9. In grade 1 of this classification, notching
involves only scapular bone. Grade 2 notching contacts the inferior screw of the baseplate.
Grade 3 notching extends to the superior aspect
of the inferior screw of the baseplate, and grade
4 notching extends past the superior aspect of
the inferior screw of the baseplate to include
the area under the baseplate.
The clinical relevance of scapular notching is controversial. In some studies, significant scapular notching was associated
with worse clinical outcomes and premature
baseplate failure [66, 100]. Both the prevalence and severity of scapular notching are
noted to increase over time [98]. Other studies have found no relation between notch-
ing and a lower Constant-Murley score, decreased range of motion, pain, or glenoid
component loosening [98]. The incidence of
scapular notching has been shown to depend
on several factors, including the position or
offset of the glenosphere. For example, the
use of laterally offset glenospheres in different styles of prostheses has reduced the incidence of scapular notching to between 0%
and 13% [81, 94].
Conclusion
RCTA is an uncommon and challenging to treat condition. Increased knowledge
about the clinical diagnosis, imaging features, and imaging and clinical indicators of
severity improves recognition of this pathologic condition. Multiple pathways have been
proposed as the cause of RCTA, but the exact
cause remains unclear. The initial management of RCTA should begin with conservative measures, but surgical intervention is often required. The current surgical treatments
of RCTA are TSA, humeral hemiarthroplasty, and reverse TSA, with reverse TSA being the most recent advancement. In patients
with advanced RCTA, painful pseudoparalysis, or both, reverse TSA can provide predictable pain relief and return of function but is
associated with a relatively high risk of complications. The significant complication rate
underscores the importance of strict patient
selection and careful operative technique
and the need for design modifications to the
existing arthroplasty prostheses.
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Rotator Cuff Tear Arthropathy: Pathophysiology, Imaging Characteristics, and Treatment Options

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American Journal of Roentgenology 2015.205:W502-W511.