Painful Shoulder After Surgery for Rotator Cuff Disease

Persistent shoulder pain after surgery for rotator cuff disease may be caused by conditions that are either extrinsic or intrinsic to the shoulder. Extrinsic causes of persistent shoulder pain include cervical radiculopathy, suprascapular neuropathy, abnormalities of scapular rotation (due to long-thoracic or spinalaccessory neuropathy), and adjacent or metastatic neoplasms. Causes of persistent pain that are intrinsic to the shoulder include both intra-articular conditions ( e.g., glenohumeral osteoarthritis, adhesive capsulitis, recurrent anterior subluxation, and labral and bicipital tendon abnormalities) and extra-articular conditions (e.g., persistent subacromial impingement, persistent or recurrent rotator cuff defects, acromioclavicular arthropathy, and deltoid muscle deficiency). Successful management requires an accurate diagnosis, maximal rehabilitation, judicious use of surgical intervention, and a well-motivated patient. The results of revision surgery in patients with persistent subacromial impingement, with or without an intact cuff, are inferior to reported results after primary acromioplasty or rotator cuff repair. Rotator cuff disease is a common cause of shoulder disability, particularly in patients beyond the fourth decade of life. Anterior acromioplasty, combined with rotator cuff repair when indicated, generally provides predictable pain relief and improved function.1 However, when pain continues in spite of surgery for rotator cuff disease, patient management becomes more complicated and less predictable. It is important to recognize that persistent rotator cuff disease is only one of the many potential causes for such pain (Table 1). Possible extrinsic causes include cervical radiculopathy; suprascapular, long-thoracic, or spinalaccessory neuropathy; and adjacent or metastatic neoplastic disease. Potentially causative intrinsic shoulder disorders may be intraarticular, such as osteoarthritis, adhesive capsulitis, recurrent anterior subluxation, and labral or bicipital tendon abnormalities, or extra-articular, such as subacromial impingement, persistent or recurrent rotator cuff defect, acromioclavicular joint arthropathy, and deltoid insufficiency. Successful management begins with an accurate identification of the underlying pathologic process responsible for the pain.Table 1: Causes of Persistent Shoulder Pain After Rotator Cuff Surgery