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

Rotator Cuff Tear Arthropathy:

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Pathophysiology, Imaging
Characteristics, and
Treatment Options
Alireza Eajazi1 OBJECTIVE. The purpose of this article is to review the biomechanical properties of the
Steve Kussman2 rotator cuff and glenohumeral joint and the pathophysiology, imaging characteristics, and
Christina LeBedis1 treatment options of rotator cuff tear arthropathy (RCTA).
Ali Guermazi1 CONCLUSION. Although multiple pathways have been proposed as causes of RCTA, the
Andrew Kompel1 exact cause remains unclear. Increasing knowledge about the clinical diagnosis, imaging fea-
tures, and indicators of severity improves recognition and treatment of this pathologic condition.
Andrew Jawa3
Akira M. Murakami1

T
Eajazi A, Kussman S, LeBedis C, et al. he shoulder has the most mobili-
ty but the least intrinsic stability
of all joints in the human body
[1]. A complex association of
static and dynamic stabilizers balances the
joint’s mobility with its functional stability.
The rotator cuff tendons play a crucial role in
maintaining this dynamic stability in the nat-
urally unstable glenohumeral joint [2, 3]. The
loss of this important stabilizer can lead to a
complex pattern of joint degeneration re-
ferred to as rotator cuff tear arthropathy
(RCTA). Understanding the role of the rota-
tor cuff in maintaining the balance between
Keywords: arthropathy, biomechanics, imaging, MRI, mobility and stability leads to an appreciation
rotator cuff tear, shoulder
of the progressive findings seen in RCTA and
DOI:10.2214/AJR.14.13815 the treatment options that are available if ar-
thropathy progresses to joint failure.
Received September 3, 2014; accepted after revision In 1977, Charles Neer and his colleagues
April 27, 2015.
invented the term “cuff tear arthropathy”
1
Department of Radiology, Boston University Medical and eventually provided the first detailed de-
Center, 820 Harrison Ave, FGH Bldg, 3rd Fl, Boston, MA scription of RCTA in 1983 [4]. RCTA has
02118. Address correspondence to A. Eajazi three major characteristics: first, massive ro-
(alireza.eajazi@gmail.com). tator cuff tear (Fig. 1A); second, degenera-
2
Department of Radiology, University of California, San
tive changes (i.e., glenoid erosion, loss of ar-
Diego, San Diego, CA.  ticular cartilage, osteoporosis of the humeral
head, and eventually humeral head collapse)
3
Boston Sports and Shoulder Center, New England (Figs. 1B and 1C); and third, superior migra-
Baptist Hospital, Boston, MA. 
tion of the humerus resulting in “femoraliza-
WEB tion” of the humeral head (Fig. 2A) and “ac-
This is a web exclusive article. etabularization” of the coracoacromial arch
[5] (Fig. 2B).
AJR 2015; 205:W502–W511
Understanding the imaging findings and
0361–803X/15/2055–W502 stages of RCTA is important in the preop-
erative evaluation of the patient with a symp-
© American Roentgen Ray Society tomatic massive rotator cuff tear because
this information can be used to determine
the proper surgical treatment of end-stage
arthropathy and to provide patients with re-
alistic 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 cur-
rent management options for treatment.
Biomechanics of Shoulder
The glenohumeral joint lacks intrinsic os-
seous constraints, which allows a high degree
of mobility but simultaneously creates inher-
ent instability. This instability is compensat-
ed for by many static stabilizers, such as the
labrum, joint capsule, and glenohumeral liga-
ments. The dynamic stabilizers of the rota-
tor cuff—which consist of the supraspinatus,
infraspinatus, teres minor, and subscapularis
muscles—are crucial. These muscles provide
stability through a mechanism termed “con-
cavity compression” [6–8] (Fig. 3).
The forces acting on the shoulder can be
divided into three components: a stabilizing
compressive force, a destabilizing transla-
tional superior-inferior force, and an anterior-
posterior force. Joint stability is simply a bal-
anced ratio between the translational forces
in any direction and the compression forces
[9–11]. For instance, the combined force of
the subscapularis muscle anteriorly and the
infraspinatus and teres minor muscles poste-

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 Rotator Cuff Tear Arthropathy
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A B C
Fig. 1—MRI of rotator cuff tear arthropathy.
A, Coronal proton density–weighted MR image of 73-year-old woman shows massive rotator cuff tear.
B, Coronal proton density–weighted 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).

dons. Other investigators have proposed clas-

sification systems based on the area of the de-
fect or on indexes of tear dimensions [20].
Despite the different criteria used to de-
fine a massive rotator cuff tear, the result of
a massive rotator cuff tear is the destabili-
zation of the glenohumeral joint and the at-
tritional destruction of the primary stat-
ic stabilizers, leading to chondral wear and
subsequent osteoarthritis [21]. It is notewor-
thy that massive rotator cuff tears, although
technically challenging to repair, are not
necessarily irreparable [22]. Signs of irrepa-
rability include static superior migration of
the humeral head, a narrowed or absent ac-
A B romiohumeral interval (AHI), and fatty infil-
Fig. 2—Radiography of rotator cuff tear arthropathy. tration affecting 50% or more of the rotator
A, Frontal radiograph of right shoulder of 73-year-old woman shows femoralization of humeral head and erosion cuff muscles [16, 17, 23, 24].
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). Pathogenesis of Rotator Cuff Tear
Arthropathy
riorly provide antagonistic forces that com- Massive Rotator Cuff Tear The exact cause of RCTA is unknown, al-
press the humeral head onto the glenoid bone There is no general agreement regarding the though numerous pathomechanical concepts
[3, 12]. This stability also depends on the ef- definition of a “massive” rotator cuff tear, al- have been hypothesized for its development.
fective glenoid arc and the area of the gle- though its prevalence has been reported in the
noid’s articular surface available for humer- literature to range from 10% to 40% of all ro- Crystal-Mediated Theory
al head compression [13]. Also important is tator cuff tears [15–17]. Both functional and An association between RCTA and the
the interplay between the deltoid muscle and anatomic characteristics have been used to presence of calcium phosphate crystals in sy-
the rotator cuff. The rotator cuff provides a classify massive rotator cuff tears, but each novial fluid and tissue was proposed by Hal-
net inferiorly directed and compressive force, type of characteristics has some disadvantag- verson et al. [25]. They postulated that the
whereas the strong deltoid muscle provides a es. Cofield et al. [18] defined a massive rotator calcium phosphate–containing crystals in
superiorly directed force; these forces result cuff tear as a cuff tear with a diameter of 5 cm synovial tissue induce an immunologic cas-
in a net force balance or force coupling of the or larger, whereas Zumstein et al. [19] defined cade that leads to the release of proteolytic
glenohumeral joint [14] (Fig. 4A). it as complete detachment of two or more ten- enzymes and that these proteolytic enzymes

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 Eajazi et al.

the glenoid bone is often eccentric, involv-

ing the anterior-superior margin. This wear
leads to an accelerated process of further
cuff destruction and arthropathy (Fig. 4B).
Nutritional factors—The nutritional fac-
tors associated with massive full-thickness
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tears are related to the loss of motion and

periarticular damage due to disruption of the
normal joint milieu. The loss of fluid pres-
sure and the accompanying reduction in the
quality of the chemical content of the syno-
vial 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].

Force Couple Theory

Fig. 3—Drawing shows concavity-compression mechanism (triple-headed arrow) of rotator cuff: Rotator cuff The deltoid and rotator cuff muscles work
muscles (single-headed arrows) provide joint stability and center humeral head on glenoid cavity. (Drawing by
Murakami AM) cooperatively to preserve a balanced force
couple for the glenohumeral joint in both the
cause the rapid degradation of the cartilage Mechanical factors—The mechanical fac- coronal and transverse planes. The muscles in-
matrix components and the destruction of tors associated with massive rotator cuff tears ferior to the humeral head equator maintain a
periarticular and articular structures [26]. lead to unbalanced muscle forces. These fac- balanced coronal force, whereas the subscap-
tors are anteroposterior instability of the hu- ularis and infraspinatus–teres minor complex
Rotator Cuff Tear Theory meral head, resulting from massive cuff tears balance each other in the transverse plane. In
Neer et al. [21] hypothesized that massive and rupture or dislocation of the long head this capacity, the rotator cuff muscles function
rotator cuff tears lead to the degeneration of of the biceps tendon, which leads to superior as primary dynamic stabilizers to maintain a
the shoulder joint through two mechanisms: migration of the humeral head and acromial concentric reduction during rotation of the hu-
a mechanical pathway and a nutritional path- impingement. Shoulder joint wear occurs as meral head on the glenoid bone [28–31]. A
way. This concept is based on clinical obser- a result of repetitive trauma from the altered massive rotator cuff tear can disrupt this force
vations and pathologic observations made at biomechanics associated with the loss of pri- couple, as shown fluoroscopically by Bur-
surgery and on review of histologic samples. mary and secondary stabilizers. The wear on khart et al. [14] in comparisons of the kine-

A B
Fig. 4—Rotator 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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 Rotator Cuff Tear Arthropathy

matic patterns of massive rotator cuff tears. As
a result, the uncoupled or unopposed deltoid
muscle leads to superior migration of the hu-
meral head, which in turn results in the dis-
tinctive degenerative wear pattern on the ac-
romion and coracoid process. Additionally,
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the rotator cuff tear, the integrity of the cor-
acoacromial arch, and the degree and direc-
tion of glenoid bone erosion [27] (Fig. 5).
The Hamada classification system de-
scribes structural changes within the cora-
coacromial arch and changes in the acromio-
bone may require bone grafting to accommo-
date 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 de-
fined by Friedman et al. [47] as the angle be-

the uncoupling leads to instability and reduced
motion, which lead to chondral loss.
Fatty degeneration of the rotator cuff mus-
cles, 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 low-
grade preoperative fatty degeneration may
predict a better clinical outcome [32, 33],
whereas high-grade infiltration is associat-
ed with a worse clinical outcome [35, 36]. A
delayed diagnosis of a rotator cuff tear also
worsens the prognosis because both the ten-
don and muscle belly undergo atrophy and
degeneration [37]. Fatty infiltration and mus-
cle atrophy have also been shown to not im-
prove after successful structural repair of the
rotator cuff, and their presence is associated
with poor functional results [32, 38–40]. The
risk of irreversible fatty infiltration of the ro-
tator cuff muscles may limit future treatment
options and must be considered when coun-
seling patients. This event has a negative in-
fluence on both functional and radiographic
outcomes [41].
Diagnostic Imaging
Radiography
A few classification systems based on ra-
diography have been developed to define
the bone changes that occur in RCTA. Al-
though 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 sepa-
rates 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 trans-
lation, and articular surface erosion [27].
This classification system is a biomechani-
cal 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 in-
stability [27]. The extent of decentralization
seen on radiographs depends on the size of
humeral interval (AHI) on anteroposterior tween a line drawn from the medial border of
radiographs as the bases for classification the scapula to the center of the glenoid bone
[43]. This system divides massive rotator and the line perpendicular to the face of the
cuff tears into five radiographic stages, with glenoid bone on the axial 2D CT slice at or
consecutive stages indicating disease pro- just below the tip of the coracoid process.
gression [42]. Table 1 shows the characteris- Both CT and MRI can be used to assess
tics of each of the stages in this system. the degree of fatty infiltration according to
the classification system proposed by Goutal-
MRI lier et al. [33]. They first described a classi-
The multiplanar imaging capabilities of fication system based on the presence of fat-
MRI combined with its excellent soft-tissue ty streaks within the muscle belly on CT, but
contrast make it ideally suited for imaging the grading criteria have since been applied to
the rotator cuff. Although a massive rotator MRI [37, 48]. The classification system that
cuff tear can often be diagnosed on the ba- Goutallier et al. [33] described in their origi-
sis of physical examination and advanced ra- nal article in 1994 is composed of five stages
diographic findings as detailed earlier, MRI of fatty infiltration (Fig. 6 and Table 2).
can be used to evaluate the integrity of the
cuff overall or to determine whether an ex- Sonography
isting tear is repairable when other findings Sonography is an alternative modality for
are ambiguous. Additionally, MRI can assist evaluating the rotator cuff that is capable of
in the characterization of chondral loss that providing images with high image contrast
can be typical of RCTA. but without the use of ionizing radiation. The
diagnostic accuracy of shoulder sonography
CT for rotator cuff tears can reach as high as
The primary use of CT in patients with 91% and 100% for partial- and full-thickness
advanced osteoarthritis of the glenohumeral tears, respectively [49–51]. Although the ac-
joint has been in the assessment of the gle- curacy of sonography hinges on the skill and
noid bone. In particular, advanced osteo- experience of the operator performing the
arthritis can be associated with posterior gle- examination [52], sonography is a suitable
noid bone loss, which can inevitably lead to alternative modality in patients who are not
posterior subluxation of the humeral head. able to undergo MRI because it is contrain-
These findings are associated with a poor dicated or cannot be tolerated.
clinical outcome after total shoulder arthro-
plasty (TSA) [44]. Accurate assessment of Management
the glenoid bone stock is also important in Patients presenting with RCTA present with
surgical planning because a small volume of 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
1 AHI is ≥ 6 mm
2 AHI is ≤ 5 mm
3 AHI is ≤ 5 mm and there is acetabularization of the
coracoacromial arch
4 Glenohumeral joint is narrowed
4a Without acetabularization
4b With acetabularization
5 Humeral head osteonecrosis is present and eventually results
in humeral head collapse
Note—AHI = acromiohumeral interval.

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 Eajazi et al.

TABLE 2: Classification System for Assessing Fatty Infiltration of advanced degenerative osteoarthritis in pa-
Rotator Cuff Muscles on Imaginga According to Goutallier et al. [33] tients older than 60 years [54]. Other indica-
tions include inflammatory arthritis, humer-
Stage of Fatty Infiltration Characteristics
al head avascular necrosis with secondary
0 Normal muscles, no fatty streaks glenohumeral arthritis, postinfectious arthri-
1 Some fatty streaks tis, and Charcot arthropathy [54, 55].
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2 Fatty infiltration is present but there is more muscle than fat Unconstrained TSA prostheses were used
by Neer et al. [4, 21] to treat 26 shoulders
3 Moderate fatty infiltration is present in which there is as much
fat as muscle with RCTA and yielded poor functional out-
comes. The poor outcomes were thought to
4 Severe fatty infiltration is present in which there is more fat
than muscle
be related to the superior migration of the
aCT or MRI.
humeral head seen with a defective rotator
cuff, which resulted in eccentric loading of
the superior aspect of the glenoid compo-
options are available, and the treatment of physical therapy for patients who are unable nent. Over time, this eccentric loading re-
choice varies according to the patient’s circum- or unwilling to undergo surgical interven- sulted in loosening of the glenoid compo-
stances, surgeon’s preferences, and resources. tion. Intraarticular corticosteroid injections nent, a complication that Franklin et al. [56]
may be useful at first, but multiple injections termed the “rocking horse glenoid.”
Initial Management are not recommended because of decreasing Constrained and semiconstrained TSA
The initial management of RCTA should utility and the possibility of increasing the prostheses were used with the hope of pre-
begin with conservative measures includ- risk of infection [53]. Although the initial venting superior humeral head migration
ing activity modification, oral analgesics management of RCTA should begin with and thus the eccentric loading of the supe-
including nonsteroidal antiinflammatory conservative measures, surgical interven- rior aspect of the glenoid component. Never-
drugs or cyclooxygenase inhibitors, physi- tion is often required. theless, these prostheses still caused stresses
cal therapy, fluid aspiration, and intraar- at the superior interface of the glenoid com-
ticular injections of corticosteroid and hy- Surgical Options ponent and therefore were also associated
aluronans. Aspiration and corticosteroid Total shoulder arthroplasty—TSA is most with high rates of glenoid component loos-
administration may be a useful adjunct to commonly performed for the treatment of ening [57, 58].

A B C

Fig. 5—Radiographs 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.
D

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A B
D E
Humeral hemiarthroplasty—Humeral
hemiarthroplasty is now a current treatment
option for patients with symptomatic RCTA
and modest functional goals [53, 59–62].
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 loosen-
ing. Humeral hemiarthroplasty also avoids
the problem of the rocking horse glenoid.
The results from several studies have shown
no pain or mild pain in 47–86% of shoulders
with glenohumeral arthritis and a deficient
rotator cuff treated with humeral hemiar-
throplasty [53, 59–61]. Active forward eleva-
tion of the glenohumeral joint was also found
to increase by an average of 17–50° after hu-
meral hemiarthroplasty [53, 59–61]. 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 signifi-
cant number of patients are left with painful
and unsatisfactory shoulders after humeral
AJR:205, November 2015 W507
Rotator Cuff Tear Arthropathy
hemiarthroplasty, even though this surgical
option helped many patients and was prefer-
able to TSA [53, 61, 63].
Reverse total shoulder arthroplasty—
RCTA is currently the primary indication for
reverse TSA, as this group has reported pre-
dictable outcomes [64]. The ideal candidate
for reverse TSA is an older patient with de-
creased 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 expe-
rience with reverse TSA, the indications have
been expanded to include revision arthroplas-
ty, inflammatory arthropathy with a massive
rotator cuff tear, painful and irreparable rota-
tor cuff tear, proximal humeral nonunion or
malunion, acute fractures, tumor, and chron-
ic pseudoparalysis without arthritis [65–75].
A reverse TSA is essentially a reversal of
the normal shoulder ball-and-socket anato-
my. In this design, the concave component
replaces the humeral head, and the con-
vex 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
C
Fig. 6—Stages 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 direct-
ly contacts the glenoid bone (Fig. 7).
This design results in a semiconstrained
prosthesis that stabilizes the glenohumer-
al center of rotation like a functioning rota-
tor cuff [76]. This design avoids the superi-
or migration of the humerus on the glenoid
bone, thereby restoring the deltoid muscle’s
anatomic resting length. The deltoid muscle
now can compensate for the rotator cuff de-
ficiency. By replacing both sides of the joint,
reverse TSA offers more reliable pain relief
than humeral hemiarthroplasty [59]. Mul-
tiple series of patients with RCTA that was
treated using reverse TSA have shown sub-
stantial 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 post-
operative period [82]. Several clinical stud-
ies have also reported noticeable improve-
ments in activity and quality of life after a
successful reverse TSA [65, 78, 81, 83, 84].
 Eajazi et al.
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A B C
Fig. 7—Reverse 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.

Arthrodesis—Another 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 acro-
mioclavicular joint to excessive motion and
result in further pain [91, 92]. Despite these
drawbacks, some patients may benefit from
glenohumeral arthrodesis. Patients with mul-
tiple failed previous operations, a history of
infection, or a deficient anterior deltoid mus-
cle may have the best outcomes with gleno-
humeral arthrodesis [93].

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
A B
Fig. 8—Complications of reverse total shoulder arthroplasty (TSA): dislocation and stress fracture. the results of reverse TSA according to cause
A, Frontal radiograph of left shoulder of 69-year-old woman shows dislocation of components of reverse TSA and reported a 19% complication rate in 186
prosthesis.
B, Frontal radiograph of left shoulder of 73-year-old man shows acromial stress fracture (arrowhead) due to
patients, with the most common complications
reverse TSA prosthesis. being dislocation (7.5%) (Fig. 8A) and infec-
tion (4%). Glenoid fractures, humeral fractures,
Although abundant long-term data are not the reverse TSA is comparable with hu- pain, radial nerve palsy, and loosening of the
available, short- to intermediate-term out- meral hemiarthroplasty and TSA [78, 81, glenosphere or baseplate were among the least
come studies suggest that survivorship of 85–90]. commonly reported complications. It is impor-

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A B
Fig. 9—Complication of reverse total shoulder arthroplasty (TSA): scapular notching.
A, Drawing shows Nerot-Sirveaux grading system (grades 1–4) 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 un-
dertensioning of the deltoid muscle, deltoid in-
sufficiency or detachment, or medial impinge-
ment of the humeral component on the scapular
neck [79]. Overtensioning of the deltoid mus-
cle, however, can lead to fracture of the acro-
mion, especially in elderly patients with osteo-
porosis [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 [96–100]. The
incidence of scapular notching has been report-
ed 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 Fig-
ure 9. In grade 1 of this classification, notching
involves only scapular bone. Grade 2 notch-
ing 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 notch-
ing is controversial. In some studies, sig-
nificant scapular notching was associated
with worse clinical outcomes and premature
baseplate failure [66, 100]. Both the preva-
lence and severity of scapular notching are
noted to increase over time [98]. Other stud-
ies have found no relation between notch-
AJR:205, November 2015 W509
Rotator Cuff Tear Arthropathy
ing and a lower Constant-Murley score, de-
creased 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 differ-
ent styles of prostheses has reduced the inci-
dence of scapular notching to between 0%
and 13% [81, 94].
Conclusion
RCTA is an uncommon and challeng-
ing to treat condition. Increased knowledge
about the clinical diagnosis, imaging fea-
tures, and imaging and clinical indicators of
severity improves recognition of this patho-
logic condition. Multiple pathways have been
proposed as the cause of RCTA, but the exact
cause remains unclear. The initial manage-
ment of RCTA should begin with conserva-
tive measures, but surgical intervention is of-
ten required. The current surgical treatments
of RCTA are TSA, humeral hemiarthroplas-
ty, and reverse TSA, with reverse TSA be-
ing the most recent advancement. In patients
with advanced RCTA, painful pseudoparaly-
sis, or both, reverse TSA can provide predict-
able pain relief and return of function but is
associated with a relatively high risk of com-
plications. 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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