What is the treatment for a rotator cuff tear with moderate glenohumeral chondrosis and labral degeneration?

Treatment of Rotator Cuff Tear with Moderate Glenohumeral Chondrosis and Labral Degeneration

The presence of moderate glenohumeral chondrosis alongside a rotator cuff tear significantly alters the treatment paradigm and should prompt consideration of reverse shoulder arthroplasty rather than standard rotator cuff repair, as the combination of rotator cuff pathology and glenohumeral arthritis constitutes rotator cuff tear arthropathy—a specific indication for reverse arthroplasty. 1

Initial Assessment and Treatment Decision Algorithm

Key Clinical Factors to Evaluate

Symptom severity and functional impairment are the primary drivers of treatment decisions, not tear size alone. 2

• If the patient has pseudoparalysis (inability to actively elevate the arm) with massive, unrepairable tear: Reverse shoulder arthroplasty is indicated after failed conservative treatment 1
• If the patient has moderate to severe glenohumeral arthritis visible on imaging with rotator cuff tear: This represents rotator cuff tear arthropathy, and reverse shoulder arthroplasty should be strongly considered 1
• If symptoms are mild to moderate without pseudoparalysis: Initial conservative management is appropriate 2, 3

Conservative Management Protocol (First-Line for Symptomatic Patients)

Start immediately with supervised physical therapy, as strong evidence demonstrates improved patient-reported outcomes in symptomatic full-thickness rotator cuff tears. 2, 3

• Supervised physical therapy is superior to home exercises alone and should include stretching and strengthening exercises 3, 4
• Add a single corticosteroid injection with local anesthetic for short-term pain and function improvement (moderate evidence supports this) 2, 3
• Combine with NSAIDs for multimodal pain control 3
• Avoid multiple corticosteroid injections, as they may compromise rotator cuff integrity and affect subsequent repair attempts 3

Critical Caveat: The Chondrosis Changes Everything

The moderate glenohumeral chondrosis you describe is a game-changer. Standard rotator cuff repair requires intact articular cartilage to function properly. 1 When significant chondrosis is present:

• Standard rotator cuff repair outcomes are compromised because the glenohumeral joint surface is already degenerating
• The combination of rotator cuff tear + glenohumeral arthritis = rotator cuff tear arthropathy, which is a specific indication for reverse shoulder arthroplasty 1
• Regular total shoulder arthroplasty requires an intact rotator cuff for stabilization, making it inappropriate here 1

Surgical Decision-Making

If conservative treatment fails after 3-6 months OR if there is pseudoparalysis with massive tear:

For Younger Patients (<60 years) with Moderate Chondrosis:

• Consider arthroscopic debridement of labral degeneration with rotator cuff repair if the chondrosis is truly only "moderate" and not advanced 2
• Warn patients that older age is associated with higher failure rates and poorer outcomes after rotator cuff repair (strong evidence) 2
• Comorbidities (especially diabetes) predict poorer outcomes and higher retear rates 2

For Older Patients (>60-65 years) OR Advanced Chondrosis:

• Reverse shoulder arthroplasty is the definitive treatment for rotator cuff tear arthropathy 1
• This inverts the normal anatomy, placing a metal ball on the glenoid and cup on the humerus, allowing the deltoid to compensate for the deficient rotator cuff 1
• Ensure deltoid function is intact, as severely impaired deltoid is an absolute contraindication 1

Monitoring During Conservative Treatment

Tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management alone. 2, 3

• Obtain MRI or ultrasound at baseline and 6-12 months to monitor progression 2, 3
• Timing to end conservative treatment is indicated when the patient demonstrates increased weakness and loss of function not recoverable by physiotherapy 4

Common Pitfalls to Avoid

• Do not perform standard rotator cuff repair when significant glenohumeral arthritis is present—this will fail because the joint surface is already compromised 1
• Do not delay imaging when clinical suspicion is high, as early diagnosis guides appropriate treatment timing 3
• Do not assume the labral degeneration requires separate surgical attention—in the context of rotator cuff tear arthropathy, it is part of the overall degenerative process 3
• Do not use multiple corticosteroid injections, as they compromise tissue integrity 3

Prognostic Factors That Worsen Outcomes

Strong evidence shows older age predicts higher failure rates and poorer outcomes after any rotator cuff repair. 2 Additional negative prognostic factors include:

• Diabetes: Higher retear rates and poorer quality of life scores 2
• Other comorbidities: Associated with poorer patient-reported outcomes 2
• Larger tear size: May benefit from marrow stimulation to decrease retear rates, though this doesn't improve patient-reported outcomes 2

Bottom Line Treatment Algorithm

1. If symptomatic: Start supervised PT + single corticosteroid injection + NSAIDs 2, 3
2. If conservative treatment fails after 3-6 months AND chondrosis is mild-moderate in younger patient: Consider rotator cuff repair with labral debridement 2
3. If chondrosis is moderate-severe OR patient >60-65 years OR pseudoparalysis present: Proceed directly to reverse shoulder arthroplasty 1
4. If asymptomatic: Do not operate 2