Understanding shoulder pseudoparalysis. Part II: Treatment

Key points

• Treatment decisions for pseudoparalytic shoulders are complex and require a high level of experience in shoulder surgery; management depends on clinical findings, tear and tissue quality, and patient and surgeon criteria.
• Non-operative treatment is the first option for patients with a higher risk profile for reconstruction or arthroplasty, but its value needs better evidence.
• Partial cuff repair with or without superior capsular reconstruction (SCR) is an option for loss of active forward elevation (AFE); tendon transfers are used for irreparable loss of rotation.
• For combined loss of elevation and external rotation (CLEER), options include lateralised reverse shoulder arthroplasty (RSA) alone or RSA combined with a tendon transfer.
• RSA with loss of active external rotation (AER) can be revised by adding a tendon transfer.

Overview

This second part of a two-part review describes the management options for shoulder pseudoparesis and pseudoparalysis and assesses the evidence for each. Most evidence concerns AFE pseudoparesis, with far fewer studies on true AFE pseudoparalysis or loss of active external or internal rotation, so the authors' treatment algorithm is intended for pseudoparesis.

Non-operative treatment

Evidence on non-operative treatment of true pseudoparesis or pseudoparalysis is limited, and the rehabilitation studies reviewed mostly lacked control groups. A systematic review by Shepet et al. quoted an overall success rate of 32–96% and proposed a protocol based on supervised therapy, two to three sessions per week, progression from range of motion to strengthening and then scapular stabilisation and proprioception, with subacromial corticosteroid injection and NSAIDs as allowed adjuncts. In younger patients with repairable tears, proceeding directly to repair may be advisable.

Cuff repair and superior capsular reconstruction

Repairability depends on retraction, fatty infiltration and muscle atrophy, chronicity and tear location. Tears with Goutallier grade 3 or higher were traditionally considered irreparable, but there is evidence that repair may be reasonable with up to 75% fatty infiltration. Arthroscopic or open repair is recommended for pseudoparesis in certain circumstances with careful patient selection, but cannot be recommended for patients with 0° of AFE. SCR may reverse pseudoparesis, and perhaps pseudoparalysis, in massive tears without glenohumeral arthritis, although long-term data are scarce.

Biceps procedures and tendon transfers

Isolated biceps tenotomy is likely of little benefit in true pseudoparesis or pseudoparalysis. The evidence suggests latissimus dorsi transfer is not a good option for AFE pseudoparalysis; lower trapezius transfer may help but needs further evaluation. Pectoralis major or minor and latissimus dorsi transfers showed favourable results for irreparable anterior cuff tears, aimed mainly at internal rotation.

Arthroplasty

Hemiarthroplasty gave poor results compared with RSA, and most surgeons have moved to RSA when arthroplasty is indicated. The studies reviewed support RSA for pseudoparesis and pseudoparalysis, although concerns about prosthesis longevity have traditionally reserved it for older patients. The authors recommend RSA with a lateralised glenoid for CLEER-1, adding latissimus dorsi ± teres major transfer for CLEER-2, and a staged transfer if postoperative AER is unsatisfactory.

Frequently asked questions

Can pseudoparalysis be treated without surgery?

Non-operative programmes are the first option for patients at higher risk from reconstruction or arthroplasty, but the evidence is insufficient, particularly for reversing pseudoparesis or pseudoparalysis.

When is reverse shoulder arthroplasty favoured?

The main factors are glenohumeral arthritis, shoulder instability and an irreparable tear. In pseudoparalysis the authors advise caution with joint-preserving procedures and a lower threshold to proceed to RSA.

Should a tendon transfer be added to RSA?

For CLEER-1 the authors recommend RSA with a lateralised glenoid; for CLEER-2 they recommend adding a latissimus dorsi ± teres major (L'Episcopo) transfer.

Source

Coward JC, Bauer S, Babic SM, Coron C, Okamoto T, Blakeney WG. Understanding shoulder pseudoparalysis. Part II: Treatment. EFORT Open Reviews 2022;7(3):227-239. https://doi.org/10.1530/EOR-21-0070. Licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or medical advice.