**4. Investigations**

finding helping to predict irreparability of a tear is a static superior subluxation of a glenohumeral joint with an acromiohumeral interval of 7 mm or less. Also static anterior subluxation

As the incidence of rotator cuff tears increases with age, especially after age 60, elderly patients are the most likely group to seek help due to massive rotator cuff tears [10, 18]. Some of them might report a traumatic event and an acute loss of function, with or without previous symptoms; however, most will deny any noticeable trauma and complain of variable levels of pain [10]. It is important to ascertain that the pain reported by the patient is actually

If it is accompanied by stiffness, especially with limitation of passive external rotation and passive glenohumeral abduction, it is very likely that the pain is due to adhesive capsulitis

Acromioclavicular joint pain, though different from the usual rotator cuff pain [19] is the second most common cause of pain that is not caused by, but is occasionally [1] attributed to

Loss of function and disability are the next biggest complaint, as MRCT is always accompanied by some degree of shoulder weakness. This weakness is especially marked with the limb away from patient's body. Anterosuperior tears usually result with painful weakness of elevation. Posterosuperior tears and global tears cause weakness of elevation and external rotation [20]. This usually spans from hardly any perceived weakness to so-called pseudoparalysis of elevation and/or external rotation [1]. Pseudoparalysis of anterior elevation describes the inability to elevate the arm to 90 deg. in the presence of unrestricted passive range of glenohumeral motion and in the absence of any neurologic impairment [21]. Pseudoparalysis of external rotation describes complete loss of active external rotation power in the presence of unrestricted passive external rotation and in the absence of neurologic impairment [1]. Collin et al. demonstrated that dysfunction of the entire subscapularis and supraspinatus or three rotator cuff muscles are risk factors for pseudoparalysis [13]. There are studies suggesting that primary arthroscopic repair can lead to reversal of preoperative pseudoparalysis in 90% of patients, but this number drops to 43% in revision surgeries [22]. Examination of the patient with suspected massive or irreparable rotator cuff tear should be performed with patient's torso exposed allowing proper comparison between two shoulders. Any atrophy in the supraspinatus or infraspinatus fossa should be noted, indicating a chronic tear. If the coracoacromial arch is incompetent, the outline of humeral head might be more prominent due to anterosuperior subluxation. Visible deltoid atrophy is especially of concern in patients with previous open surgeries. The long head of the biceps tendon might be affected by massive cuff tears and is often torn resulting in a 'Popeye' deformity (a visible

observed in CT scan or MRI appears to be indicative of irreparability of the tear [1].

**3. Clinical signs and symptoms**

rather than MRCT.

102 Advances in Shoulder Surgery

rotator cuff tear.

bulge just proximal to the elbow).

caused by the massive cuff tear, and not from another source.

Plain radiographs are of a great value to the evaluation. They provide information on the glenohumeral joint, acromial morphology, and the position of the humeral head. Standard evaluation consists of anteroposterior, axillary, and an outlet or scapular Y views. Grashey view (a true anteroposterior view) is most helpful to show the status of the glenohumeral joint, whereas an outlet and scapular Y views can be useful to examine acromial pathology [10]. Plain anteroposterior views will demonstrate any upriding of the humeral head and any osteoarthritic changes. Decreased interval between the humeral head and undersurface of the acromion is often associated with massive and irreparable cuff tears. This distance, the acromiohumeral interval (AHI), measures 7–14 mm in healthy shoulders [24] and as previously mentioned if it falls below 7 mm, the probability of successful cuff repair drastically decreases [25]. Hamada et al. [26] demonstrated correlation between progression of rotator cuff tear and reduction of AHI. He developed a radiographic classification of massive rotator cuff tear arthritis which divides massive rotator cuff tears into 5 grades: in Hamada Grade 1 the AHI is maintained, and narrows in Grade 2. Acetabulization (concave deformity of the acromion undersurface) in addition to the Grade 2 narrowing is classified as Grade 3. In Grade 4, narrowing of the glenohumeral joint is added to the Grade 3 features, and Grade 5 comprises instances of humeral head collapse [26]. Walch et al. recognized a group with massive tears that demonstrated glenohumeral narrowing without acromial acetabulization. Thus, they divided Grade 4 of Hamada into two subtypes: Grade 4A, glenohumeral arthritis without subacromial arthritis (acetabulization); and Grade 4B, glenohumeral arthritis with subacromial arthritis (Grade 4 of Hamada et al.). These subtypes allowed for more specific classification of patients and almost all patients could be classified [26].

**5. Treatment options**

**5.1. Conservative treatment**

Conservative treatment is often appropriate if a tear is proven to be irreparable, or the patient does not want operative intervention. Patients without any significant symptoms of pain may benefit from the anterior and middle deltoid rehabilitation programme. This has a success rate of about 30% and is particularly useful for those patients with loss of function without a great deal of pain. In this group conservative treatment may lead to a very satisfactory clinical situation with restoration of active arm elevation but to an inevitable increase in joint degeneration [1]. Zingg et al. [34] have documented a surprisingly good clinical outcome using non-operative treatment with a substantial structural deterioration of cartilage, tendon, and muscle.

Options Before Reverse Total Shoulder Replacement http://dx.doi.org/10.5772/intechopen.70795 105

In general, in irreparable cuff tears non-operative management is attempted for 6 months before considering surgery [9]. Typical treatment includes physiotherapy, anti-inflammatory and analgesic drugs, re-education, acupuncture and judicious use of subacromial (which in case of MRCT are also intraarticular) injections. Injections of either corticosteroids or hyaluronic acid are used. While repeated intraarticular steroid injections are discouraged by some authors as being largely ineffective [35, 36], others pointed out on a good and comparable therapeutic effect of both dexamethasone and sodium hyaluronate [37]. Hyaluronans are meant to act by blocking pain receptors, stimulating endogenous hyaluronan production and have a direct anti-inflammatory effect by inhibiting leukocyte action [38]. These injections have been shown to be of benefit for early and late osteoarthritis of the shoulder [39, 40]. A series of infiltrations with hyaluronic acid (once a week for 3 weeks) followed by rehabilitative treatment yielded significant pain reduction, improvement of range of motion, and autonomy in daily life activities [41] in a cohort of 22 patients (mean age 78y) with rotator cuff tears.

Conservative treatment does not substantially alter the course of the natural history of massive tears and as such can only be advised for patients whose cuff tears are already irreparable

Somewhere in between conservative and surgical treatment is a place for supra scapular nerve block and ablation. This salvage procedure can be used for pain relief where this is the major symptom, after initial conservative therapies have been exhausted [42] and the patient is not fit for major surgery, or does not want an operation. The suprascapular nerve is derived from the upper trunk of the brachial plexus (C5, C6) and is a mixed motor and sensory nerve. It provides the main sensory innervation to the posterior shoulder joint capsule, acromioclavicular joint, subacromial bursa, coracoclavicular and coracohumeral ligament [43] and motor branches to both supra and infraspinatus muscles. Blockade of the suprascapular nerve has been shown to improve chronic pain in numerous studies [44]. Among different techniques described are supra scapular nerve blocks (SSNB) [42], percutaneous SSN pulsed radiofrequency and arthroscopic SSN neurectomy [45]. Pulsed radiofrequency (PRF) works by delivering an electrical field to neural tissue rather than thermal coagulation and affects the smaller pain fibres more than the larger motor fibres, thus preserving any residual motor function [45]. There is morphologic evidence that PRF is less neurodestructive than CRF (continuous radiofrequency)

and who for various reasons would not be suitable for operative treatment [1].

CT scan was the original investigation described by Goutallier in assessment of fatty atrophy, and can still be used for patients where any bony changes need to be more accurately determined and the state of muscle wasting and atrophy. Goutallier et al. classified muscle quality by the amount of fatty infiltration in the rotator cuff muscle as identified on CT in the axial plane, with a thorough analysis of the whole muscle belly [16]. They graded muscular fatty degeneration into 5 stages: Stage 0 is a normal muscle with no fatty infiltration and stage 1 is a muscle in which some fatty streaks can be seen on CT. Stage 2 is a muscle with substantial fatty atrophy but still affecting less than 50% of visible muscle. In stages 3 and 4 fatty atrophy affects 50% and over 50% of muscle respectively [16]. According to various authors fatty muscle infiltration beyond Goutallier stage 2 represents a non-functional muscle belly making a successful repair of its tendon virtually impossible [1, 16].

One of the most common imaging modalities for assessing the rotator cuff is magnetic resonance imaging (MRI). It can reliably identify and characterize the rotator cuff tendon tears [27]. MRI scan is easier to read in assessing the size of any rotator cuff tear and both muscle wasting and fatty atrophy, but patients with sore shoulders may struggle to stay still for the duration of the scan which may take 45 min. With the growing popularity of magnetic resonance imaging Goutallier classification was adapted to MRI. Some authors correlated it with surgical outcomes and retear rates [10] and found that like for CT the advanced degree of fatty infiltration (over 2 Goutallier) on preoperative MRI was a strong predictive factor of cuff repair failure [10].

It is worth remembering that for MRI, the Goutallier scoring uses a different plane compared to CT. It is no longer the axial plane but the most lateral parasagittal image on which the scapular spine is still in contact with the scapular body (Y view) [28]. This makes the method prone to false interpretation in cases of massive cuff tears, because severe muscle-tendon retraction can cause bunching of the muscle that may actually create an illusion of a larger muscle belly than in reality [10]. Some authors reported the use of so-called 'tangent sign' [29] as an indicator of advanced fatty infiltration [30] and as a predictor of whether a rotator cuff tear will be reparable [31]. A tangent sign is positive when atrophied supraspinatus muscle falls below a tangent line drawn between superior border of coracoid process and superior margin of scapular spine. This is assessed, just like Goutallier score, on the most lateral MRI image on which both coracoid process and scapular spine are still in contact with scapular body [32]. However a recent study by Kim et al. showed that tangent sign alone was not a good predictive indicator of outcome of massive cuff repair. According to authors the single most predictive factor of successful repair in MRCT remains infraspinatus fatty infiltration <3 according to Goutallier [32].

Another important diagnostic modality is a ultrasound scan, which has become a popular modality for evaluating rotator cuff pathology because of its low cost and reliability in identifying the presence of a tear and its size even during the postoperative period [10]. Unfortunately ultrasound cannot penetrate through bone and may not provide accurate information about large rotator cuff tears where the tendon edges have retracted medial to the lateral acromial border [33]. Its optimal use is also notoriously dependent on the technician's experience.
