History and Physical Examination

Evaluation of the patient with RA and severe arthritis of the shoulder starts with taking a thorough history. It is critically important to understand the severity of patients’ symptoms and their ability to comply with postoperative rehabilitation and restrictions. The severity of pain at rest and at night and alleviating and aggravating factors should be determined.

Care should be taken to examine the patient’s current medical treatment regimens to ensure that maximal medical management has been attempted. Although operative treatment may be necessary, patients are best managed with a team approach with a consulting rheumatologist. Every attempt should be made to maximize medical management oral medications and injection therapy in order to avoid operative intervention in this patient population, which may be predisposed to infection and often have associated medical comorbidities. This nonoperative approach includes oral and injectable medications and intra-articular injections.

Only rarely do patients with rheumatologic disease present with shoulder pain as the initial complaint. Often patients are seen in referral for shoulder pain that has been resistant to nonoperative interventions, including changes in oral medications and failed trials of therapy. Patients may complain about pain (at rest, at night, and with activities) and loss of strength and motion. Physical examination often demonstrates shoulder swelling with effusion in the subacromial or and subdeltoid space. There may be significant crepitance with gentle motion. Limitations in all planes of active and passive motion, including elevation, external, and internal rotation, are common due to underlying arthrofibrosis. Motion may be painful, which may lead to deficits in strength despite structurally intact rotator cuff tendons.

Other considerations include careful examination of the acromioclavicular joint and biceps tendon. Provocative maneuvers should be performed to assess for pathology in these commonly involved structures. Rheumatoid patients who are considered to be operative candidates should also be evaluated for neck pain and neurologic or radicular symptoms.

In this population, underlying cervical pathology is often associated with shoulder pain and may be an exacerbating pain generator. Furthermore, there is a high incidence of underlying cervical instability due to rheumatoid-induced ligamentous laxity. Radiographs of the neck, including flexion and extension views, should be obtained prior to consideration for operative intervention to assess for cervical subluxation.

Radiographic Studies

Radiographs of the affected shoulder typically include four views: 40 degree posterior oblique views with internal and external rotation, axillary view, and lateral scapula or Y view. Acromiohumeral distance also should be assessed to evaluate proximal humeral migration on the anteroposterior view of the proximal humerus from the midportion of the acromion to the highest portion of the humeral head. Although less than 6 mm of acromiohumeral distance is associated with rotator cuff tearing, diminished acromiohumeral distance in patients with rheumatoid arthritis does necessarily indicate complete rotator cuff tearing.

Advanced imaging with magnetic resonance imaging (MRI) can be helpful for assessment of underlying soft tissue changes such as rotator cuff and biceps tendon abnormalities. Patients with underlying synovitis often demonstrate thinning or full-thickness tearing of the rotator cuff tendons and inflammation, fraying, or tearing of the biceps tendon. MRI can also demonstrate the extent of the intra-articular synovitis and subacromial bursitis.

Computed tomography (CT) scans are an invaluable tool to assess the shoulder prior to shoulder arthroplasty. Specifically, in the setting of significant glenoid erosion, CT scans provide significant information concerning glenoid version and the amount of bone loss. Recently, in complex settings, we have started to use three-dimensional (3D) CT to evaluate the humerus and glenoid in order to obtain a more complete understanding of the glenohumeral morphology.