Several years after a rotator‑cuff repair I now have shoulder swelling and pain; what are the likely etiologies and recommended work‑up and management?

Shoulder Pain and Swelling Years After Rotator Cuff Repair

The most likely etiology is a recurrent rotator cuff tear, which occurs in approximately 25% of patients post-repair, and you should obtain MRI, MR arthrography, or ultrasound as first-line imaging to confirm the diagnosis. 1, 2

Differential Diagnosis: Likely Etiologies

Primary Considerations (Intrinsic to Shoulder)

Recurrent/Re-tear of Rotator Cuff (Most Common)

• Occurs in up to 25% of patients after surgical repair, with most re-tears happening within the first three months but can occur years later 2, 3
• Presents with pain, weakness, and may have visible swelling from fluid accumulation or muscle atrophy 3
• Degenerative tears are more common than acute re-injury, especially given the time interval 1

Adhesive Capsulitis (Frozen Shoulder)

• Common complication after rotator cuff surgery, particularly in younger patients (<60 years) and females 3, 4
• Presents with progressive stiffness and pain, incidence of post-operative shoulder stiffness is 8.64% 4

Glenohumeral Osteoarthritis

• Can develop as secondary consequence of chronic rotator cuff pathology 3, 5
• Progressive cartilage and bone changes occur after rotator cuff tears affecting joint stability 5

Subacromial Impingement (Persistent or Recurrent)

• May persist despite initial surgical intervention 3
• Results from incomplete decompression or scar tissue formation 3

Secondary Considerations (Extrinsic to Shoulder)

Cervical Radiculopathy

• Can mimic shoulder pathology with referred pain and swelling perception 3
• Must be excluded in differential diagnosis 1

Infection (Low probability but high consequence)

• Rare but serious complication presenting with pain, swelling, warmth 1
• More common in diabetic patients, though evidence is inconclusive 1

Recommended Work-Up

Imaging Protocol (First-Line)

Three equivalent first-line options (all rated 9/9 by ACR): 1

1. MRI shoulder without contrast - Excellent for detecting re-tears, muscle atrophy, fatty infiltration 1, 2
2. MR arthrography - Superior for distinguishing full-thickness from partial-thickness tears 1, 2
3. Ultrasound - May be preferred as first-line given easy availability, lower cost, dynamic evaluation capability, and superior detection of smaller early re-tears with fewer post-surgical artifacts than MRI 1, 2

Key imaging findings to assess:

• Tendon retraction, muscle atrophy, and fatty infiltration (correlate with worse outcomes and healing) 1
• Hardware integrity and position 1
• Signs of infection (though rare) 2

Clinical Examination Specifics

Document these specific findings:

• Active and passive range of motion in all planes (forward elevation, external rotation, internal rotation) 3
• Strength testing with empty can test and external rotation resistance 6
• Presence of muscle atrophy (supraspinatus, infraspinatus) - visible and palpable 1
• Impingement signs (Neer, Hawkins-Kennedy) 3
• Acromioclavicular joint tenderness 3

Exclude extrinsic causes:

• Cervical spine examination with Spurling's test for radiculopathy 3
• Neurologic examination for suprascapular or long thoracic neuropathy 3

Laboratory Studies (If Infection Suspected)

• ESR, CRP, CBC if systemic symptoms present (fever, constitutional symptoms) 6
• Joint aspiration if effusion present with concern for septic arthritis 6

Management Algorithm

If Re-tear Confirmed on Imaging

Conservative Management (Initial approach for most):

• NSAIDs or COX-2 inhibitors for pain control 1
• Paracetamol 650-1000mg every 6 hours (maximum 4g daily) 1, 6
• Structured physical therapy focusing on range of motion and strengthening 1
• Opioids reserved for rescue analgesia only 1

Surgical Revision Considerations:

• Results of revision surgery are inferior to primary repair 3
• Consider if: large tear with significant functional limitation, failed conservative management (typically 3-6 months), absence of severe fatty infiltration or muscle atrophy (poor prognostic indicators) 1
• Critical caveat: Preoperative infraspinatus fatty degeneration and muscle atrophy correlate with worse outcomes and healing 1

If Adhesive Capsulitis Confirmed

• Aggressive physical therapy with emphasis on capsular stretching 3
• Consider manipulation under anesthesia or arthroscopic capsular release if refractory 3
• Higher risk in patients <60 years who had partial tear completion during initial surgery 4

If Persistent Impingement Without Re-tear

• Trial of conservative management with physical therapy and anti-inflammatory medications 3
• Revision acromioplasty has inferior results compared to primary procedures 3

Critical Pitfalls to Avoid

Do not assume musculoskeletal etiology without excluding cardiac causes - bilateral shoulder pain with systemic symptoms (nausea) requires ECG and cardiac biomarkers first 6

Do not delay imaging - clinical examination alone cannot reliably distinguish between re-tear, stiffness, and other pathology 1, 2

Do not proceed with revision surgery without assessing muscle quality - fatty infiltration and atrophy predict poor surgical outcomes 1

Do not overlook extrinsic causes - cervical radiculopathy and neuropathies can masquerade as shoulder pathology 3

Avoid prolonged NSAID use - particularly in elderly patients given cardiovascular, renal, and gastrointestinal risks 6