Assessment and Management of the Painful Reverse Total Shoulder Arthroplasty

» Reverse total shoulder arthroplasty (rTSA) has become the standard surgical treatment for rotator cuff arthropathy, offering reliable improvements in function and pain relief. However, postoperative shoulder pain remains a complex and clinically significant challenge.» The differential diagnosis of a painful rTSA includes infectious, mechanical, and neurological or immunological complications. Key etiologies include periprosthetic joint infection (0.5%-6.7% incidence, 13.8% of all complications), instability, aseptic loosening (glenoid loosening 2.3%, humeral loosening 1.4%), polyethylene wear, scapular notching (reported as high as 96%), postoperative fractures, neurologic injury (up to 3.6%), and metal hypersensitivity (prevalence of 10%-15% in the general population).» Diagnostic workup requires a structured approach combining clinical examination, radiographic analysis, serologic markers, advanced imaging, and intraoperative assessment when necessary. Several etiologies, particularly infection, metal allergy, and polyethylene wear, may present with overlapping symptoms, necessitating a systematic evaluation.» Management of the painful rTSA is diagnosis-specific and ranges from nonoperative interventions (physical therapy, benign neglect, nonsteroidal anti-inflammatory drugs, corticosteroids, or bracing) to surgical revision procedures such as debridement, component exchange, fracture fixation, or tendon lengthening.» Understanding the biomechanical principles of rTSA design, implant positioning, and soft tissue balance is critical for both prevention and treatment of postoperative pain. While biomechanical innovations have improved joint stability and the efficiency of surrounding soft tissue, the expanding use of rTSA continues to pose challenges for complication rates and long-term outcomes, necessitating clinical vigilance and individualized patient management strategies.