How should I evaluate and manage a patient with polyarthritis who previously had a rotator cuff repair?

Evaluation and Management of Polyarthritis in a Patient with Prior Rotator Cuff Repair

In a patient with polyarthritis and prior rotator cuff repair, focus your evaluation on distinguishing inflammatory from noninflammatory arthritis while recognizing that the previous shoulder surgery does not preclude excellent outcomes if revision surgery or systemic treatment becomes necessary.

Initial Evaluation Strategy

History Taking

• Document joint inflammation markers: Ask specifically about joint redness, warmth, or swelling, which indicate synovitis and inflammatory arthritis rather than mechanical problems 1
• Assess the pattern: Determine if five or more joints are involved (defining polyarthritis), duration of symptoms, and presence of systemic features like fever, weight loss, or fatigue 1
• Shoulder-specific inquiry: Evaluate current shoulder function, pain levels, and any limitations compared to post-repair baseline
• Exposure history: Screen for infectious triggers that could cause polyarticular arthritis 1

Physical Examination

• Systematic joint assessment: Examine all joints for synovitis patterns, not just the previously repaired shoulder 1
• Shoulder evaluation: Compare active range of motion and strength to the contralateral side; assess for signs of repair failure versus new inflammatory involvement

Laboratory Workup

• Rheumatoid factor and anti-CCP antibodies: Order these when rheumatoid arthritis is suspected, as RA affects at least 0.25% of adults and is a leading cause of chronic polyarthritis 1
• Inflammatory markers: ESR and CRP to assess systemic inflammation
• Joint aspiration if indicated: Perform if septic arthritis or crystal disease is in the differential 1

Imaging Approach

• Conventional radiography first: Obtain plain films of affected joints as the standard initial imaging for suspected inflammatory arthritis 1
• Shoulder-specific imaging: Consider MRI if there is concern for repair failure, though MRI is highly sensitive for erosive changes and inflammation in any joint 1
• Point-of-care ultrasound: Use musculoskeletal ultrasound to detect synovitis and support inflammatory arthritis diagnosis if available 1

Management Considerations

If Polyarthritis is Inflammatory (e.g., Rheumatoid Arthritis)

The prior rotator cuff repair does not adversely affect outcomes if systemic disease management or revision surgery becomes necessary. Patients with previous rotator cuff repair who later require reverse shoulder arthroplasty show significant ASES score improvements (from 43.1 to 76.6 at two years) with no significant outcome differences compared to those without prior repair 2.

• Initiate disease-modifying therapy: Start DMARDs or biologics as indicated for the underlying inflammatory condition
• Avoid multiple corticosteroid injections: While single subacromial corticosteroid injections are safe for short-term pain relief 3, multiple injections may compromise rotator cuff integrity and affect subsequent repair 4
• Monitor shoulder function: Serial examinations to detect early repair failure in the setting of systemic inflammation

If Revision Rotator Cuff Surgery is Needed

Arthroscopic revision is feasible even in complex scenarios, though complication rates are approximately twice those of primary repair (20.2% overall). 5

• Surgical technique: Perform arthroscopic debridement of scar tissue, mobilize retracted tendon edges, and use standard anchor techniques for tendon-to-bone repair 4
• Skip routine acromioplasty: Moderate evidence shows no benefit to routine acromioplasty during revision repair 6, 4
• Consider biological augmentation selectively: Limited evidence supports dermal allografts for large/massive tears and marrow stimulation to decrease retear rates in larger tears, though neither improves patient-reported outcomes 4
• Optimize metabolic control: Ensure diabetes and other comorbidities are well-controlled, as poor metabolic control increases retear rates and worsens outcomes 4

Rehabilitation Protocol

• Early mobilization is safe: Strong evidence shows similar outcomes between early mobilization and delayed mobilization up to 8 weeks for small-to-medium tears 4
• Supervised physical therapy: Recommend supervised therapy over unsupervised home exercise 4
• Multimodal pain management: Use non-opioid modalities for postoperative pain control 4

Critical Pitfalls to Avoid

• Do not assume shoulder pain is solely mechanical: In polyarthritis, the shoulder may be involved in the systemic inflammatory process rather than representing isolated repair failure 1
• Do not delay DMARD therapy: If inflammatory polyarthritis is confirmed, systemic treatment takes priority over local shoulder interventions
• Recognize escalating revision risk: Complication rates increase with each subsequent revision (14% after first revision, 17.4% after second, 33% after third) 5
• Consider infection in the differential: Though rare (2.1% in revision series), deep infection after rotator cuff repair can occur; however, successful revision repair is possible after thorough debridement 7, 5
• Account for higher baseline function: Patients with prior rotator cuff repair typically have higher baseline ASES scores than those without prior surgery, which may affect interpretation of treatment response 2