- What it is
- Massive cuff tear + secondary arthritis
- Classic feature
- Loss of active elevation (pseudoparalysis)
- Imaging
- Plain X-ray (Hamada classification)
- Surgical answer
- Reverse total shoulder replacement
What cuff tear arthropathy is.
Cuff tear arthropathy is the end-stage condition that develops when a massive rotator cuff tear is left in place for many years. The mechanism is mechanical: the cuff is what holds the humeral head centred on the glenoid socket. Without a functional cuff, the head migrates upward (proximal migration), abutting the underside of the acromion. Over time, the cartilage of the glenohumeral joint is lost and the bone of the humeral head changes shape. The condition is named for both its mechanical and its arthritic components.
How it is recognised.
The classical patient is in their 70s, often female, with a history of years of shoulder pain and progressive loss of function. The cardinal feature is loss of active elevation — the patient cannot lift the arm above shoulder height, even though passive movement (where the examiner lifts the arm) is preserved. This pattern is sometimes called pseudoparalysis.
Plain radiographs are highly characteristic: proximal migration of the humeral head, narrowing or loss of the acromiohumeral interval, rounding of the greater tuberosity, and erosion of the undersurface of the acromion. The radiological severity is graded with the Hamada classification.
Treatment.
Non-operative
- Activity modification, analgesia, physiotherapy focused on what motion remains.
- Image-guided intra-articular corticosteroid injection for symptom flares.
- Conservative management is appropriate for patients who are not surgical candidates, or whose symptoms remain manageable.
Surgical
The contemporary surgical answer is the reverse total shoulder replacement. This implant was specifically designed to solve the problem of cuff-deficient arthritis: by reversing the ball-and-socket geometry, it allows the deltoid muscle to elevate the arm without the help of the cuff. Reliable pain relief is achieved in the majority of patients, and meaningful restoration of active forward elevation is the typical functional outcome. Australian registry data show implant survivorship of greater than 95% at 10 years.1
Frequently asked questions.
Can I just repair the cuff?
By the time cuff tear arthropathy is established, the cuff is irreparable — the tendons have retracted, the muscles have atrophied, and the bone has changed shape. Cuff repair is not an option at this stage.
What can a reverse shoulder replacement do for me?
Reverse total shoulder replacement reliably relieves pain and meaningfully restores active forward elevation in well-selected patients. It allows you to lift the arm to shoulder height or above for daily activities — reaching, dressing, grooming. It is less reliable at restoring active external rotation.
How long do reverse replacements last?
Australian National Joint Replacement Registry data show implant survivorship of greater than 95% at 10 years. Modern designs are expected to last considerably longer.
Is the operation safe in my 70s or 80s?
Yes, in patients medically fit for major surgery. The procedure is well-tolerated and is routinely performed in older patients. The anaesthetic and medical risks are assessed at pre-admission.
What if I do nothing?
The condition is unlikely to improve. Pain and stiffness tend to worsen over years. Some patients live within the limitations and manage well; others find the loss of overhead function intolerable and proceed to surgery.
References.
- Australian Orthopaedic Association National Joint Replacement Registry. Shoulder Arthroplasty Annual Report. Adelaide: AOA; 2024.
- Hamada K, et al. Roentgenographic findings in massive rotator cuff tears: a long-term observation. Clin Orthop Relat Res. 1990;254:92–96.
- Bacle G, et al. Long-term outcomes of reverse total shoulder arthroplasty. J Bone Joint Surg Am. 2017;99(6):454–461.