Understanding shoulder pseudoparalysis: Part I: Definition to diagnosis

Abstract

Variable definitions of pseudoparalysis have been used in the literature. Recent systematic reviews and biomechanical studies call for a grading of loss of force couple balance and the use of the terms ‘pseudoparesis’ and ‘pseudoparalysis’. Pain should be excluded as the cause of loss of active function. Key players for loss of force couple balance seem to be the lower subscapularis as an anterior inferior checkrein and the teres minor as a posterior inferior fulcrum. Loss of three out of five muscle–tendon units counting upper and lower subscapularis separately is predictive of pseudoparalysis. Shoulder equator concept: loss of all three posterior, or all three superior, or all three anterior muscle–tendon units is predictive of pseudoparalysis (loss of fulcrum for deltoid force). Every effort should be made to prevent propagation of rotator cuff tears into the subscapularis and posterior rotator cuff (infraspinatus and teres minor) to maintain force couple balance (value of partial cuff repair). Clinical assessment of active forward elevation, active external rotation, and active internal rotation is important to define and grade the severity of loss of force couple balance. Additional features such as patient age, traumatic aetiology, chronicity, fatty infiltration, and stage of cuff tear arthropathy are useful for a specific diagnosis with implications for treatment.

Latissimus Dorsi Transfer Combined with Subacromial Balloon Spacer for Bidirectional Rotator Cuff Deficiency

“…Isolated tendon transfer appears not sufficiently robust to restore active external rotation in patients with CLEER, 6 especially in grade 2 cases. 2 In conjunction with RSA, the L’Episcopo procedure 7 has demonstrated a substantial improvement in active external rotation. 8 However, RSA is associated with consistently high rates of complications in patients under 60 years of age.…”

“…Patients with massive, irreparable rotator cuff tears (MIRCTs) can present in many ways, from lack of symptoms to considerable functional loss. The combined loss of active elevation and external rotation (CLEER) refers to patients with vertical and horizontal shoulder imbalance 1 , 2 and consequently bidirectional pseudoparesis or pseudoparalysis. 2 Patients with active external rotation pseudoparalysis may benefit from reverse shoulder arthroplasty (RSA) with latissimus dorsi and teres major tendon transfer.…”

“…The combined loss of active elevation and external rotation (CLEER) refers to patients with vertical and horizontal shoulder imbalance 1 , 2 and consequently bidirectional pseudoparesis or pseudoparalysis. 2 Patients with active external rotation pseudoparalysis may benefit from reverse shoulder arthroplasty (RSA) with latissimus dorsi and teres major tendon transfer. 2 , 3 However, in young, relatively active patients with nonarthritic joints and no anterosuperior humeral escape, alternative surgical procedures may be considered based on physical examination, radiography, and chronicity.…”

“… 2 Patients with active external rotation pseudoparalysis may benefit from reverse shoulder arthroplasty (RSA) with latissimus dorsi and teres major tendon transfer. 2 , 3 However, in young, relatively active patients with nonarthritic joints and no anterosuperior humeral escape, alternative surgical procedures may be considered based on physical examination, radiography, and chronicity. 4…”

Understanding shoulder pseudoparalysis. Part II: Treatment

“…The studies included in this paper often use varying definitions of pseudoparesis or pseudoparalysis or alternately, phrase clinical findings entirely as a specific loss of function as opposed to using either of these terms. This paper maintains the definitions of pseudoparesis and pseudoparalysis used in part 1 to ensure consistency of comparison when assessing the relevant literature ( 1 ).…”