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related talks: rotator cuff arthritis; AC joint arthritis; rotator cuff tear; biceps tendon tear; adhesive capsulitis;
What is Shoulder Arthritis?
The shoulder joint, also known as the glenohumeral joint, can become painful over time as the cartilage wears thin. This is called arthritis.
There are many underlying causes of arthritis, but the three most common are:
1) general wear and tear (known as osteoarthritis),
2) inflammatory conditions (for example rheumatoid arthritis), and
3) the lasting damage of a prior traumatic injury (post-traumatic arthritis).
Arthritis can also develop after a rotator cuff tear goes untreated for a long time, but this type has a whole different treatment approach, and is examined in a separate talk (see talk).
How is Shoulder Arthritis diagnosed?
A person with shoulder arthritis will report progressively worsening shoulder pain, accompanied by increased stiffness. They often say that the pain is worse at night, or with activity.
Remember that arthritis develops over a long time, so if someone says they fell down and now their shoulder hurts, we are more concerned for causes of acute pain like a broken bone.
Its rare to get shoulder arthritis under 60 years old (and when this does occur, there is usually a history of traumatic injury to the shoulder). Even significant overuse of the shoulder in sports, or in athletes with untreated rotator cuff tears or recurrent shoulder instability there isnt a notable increase in arthritis (on average) until people are in their 70s.
In arthritis, we describe the severity in terms of stages, which is determined by x-ray. So doctors should get x-rays of the shoulder if arthritis is suspected. Initially the arm bone (humeral head) is centered in the joint, and only minor central erosion of the cartilage occurs, the humeral head remains centered. However with time, the humeral head moves backward and sclerosis (abnormally hard bone) and osteophytes (accumulation of bone debris, like stalagties in a cave) develop. This is asymmetric wear, and it indicates worse arthritis.
The shoulder will appear flat compared to a normal shoulder because the arm has shifted backward (posterior) due to the worn out joint. The growth of bone spurs at the bottom of the joint, instability in the back of the joint (posterior subluxation) and erosion of the back of the joint all limit external rotation.
How is Shoulder Arthritis treated?
Treatment of arthritis always starts with conservative treatment and progresses to more invasive techniques if the pain persists.
Initial physical therapy (strengthening of the scapula and rotator cuff) and anti-inflammatory medication (like motrin) are often helpful at the earliest stages. However, over time stronger medication is often required to treat the pain. Steroid injections into the subacromial space can minimize the pain for a few days to a few weeks, and can be given a couple of times a year if they successfully provide relief.
If conservative measures fail, then ultimately surgery can provide relief. A Shoulder Replacement is often a successful procedure (as long as the rotator cuff is intact). It removes the painful joint and replaces it with metal and plastic components which glide smoothly and allow good function.
In young patients with arthritis, try to hold off joint replacement until all options have run out, until then use NSAIDs, steroids, and viscosupplements, also debridement of joint (clean up fraying of cuff, removing osteophytes). If continues to be problematic then perform a total shoulder arthroplasty, if <40 yo can consider resurfacing surgery or hemi.
What is the long term outcome?
The problem with arthritis is that its a slow and progressive disease. Doctors can offer treatment to alleviate pain, and slow the progressive of arthritis, but they cannot cure the issue. The ultimate treatment is to replace the joint with a metal replica.
3. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review. Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. J Bone Joint Surg Am. 2005 Sep;87(9):1947-56.