Pseudoparalysis in massive irreparable rotator cuff tears: what is it and why is it so important?

Patients with massive irreparable rotator cuff tears have widely varying abilities to actively raise their arm. 

Some have quite functional active forward elevation. 

Others have pseudoparalysis, a condition in which the arm can only be passively elevated with assistance from the other arm.

but the arm cannot be actively raised by the patient above the horizontal without assistance.

Patients with massive irreparable rotator cuff tears and pseudoparalysis (as shown in the movie above) may consider reverse total shoulder arthroplasty.

On the other hand, patients without pseudoparalysis may consider simpler, less costly and safer procedures, such as a smooth and move if the shoulder is not arthritic (see this link) and a cuff tear arthropathy hemiarthroplasty if the shoulder is arthritic (see this link and this link).

Because of the clinical importance of pseudoparalysis, the question naturally arises, "are many patients on the borderline of being able to actively elevate their shoulders above the horizontal?", in other words is there a substantial percentage of patients with massive irreparable cuff tears who are "almost pseudoparalytic" or "just barely pseudoparalytic"?

This question can be addressed by data from Pseudoparesis and Pseudoparalysis in the Setting of Massive Irreparable Rotator Cuff Tear: Demographic, Anatomic, and Radiographic Risk Factors. The authors of this paper identified two groups of patients with massive irreparable rotator cuff tears:

The pseudoparalytic group: 79 patients having active forward elevation (AFE) <90 degrees with maintained passive range of motion. The mean (± standard deviation) active forward elevation for this group was 59± 26 degrees.

The non pseudoparalytic group: 50 patients with massive irreparable rotator cuff tears having active forward elevation (AFE) ≥90 degrees. The mean (± standard deviation) active forward elevation for this group was 151± 20 degrees. (p<0.001).

From these means and standard deviations the probable distributions of active forward flexion for the two groups can be determined. The important result is that there was very little overlap between the two groups (see chart below). In other words, most patients with massive irreparable rotator cuff tears were either obviously pseudoparalytic or obviously non pseudoparalytic.   

This bimodal result can be compared to the chart comparing the acromiohumeral distance for pseudoparalytic (4.8±2.7) and non pseudoparalytic (7.6±2.6, p<0.001) shoulders using data from the same study (see below). 

The minimal overlap in active flexion between the pseudoparalytic and non pseudoparalytic groups is striking by comparison to the overlap in acromiohumeral distance. 

  

Comment: This analysis points out that the clinical differentiation of pseudoparalytic and non pseudoparalytic shoulders is usually straightforward, simplifying decision making about the need for a reverse total shoulder arthroplasty (see for example, Reverse total shoulder for everything? How about for cuff tear arthropathy?).

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).