Shoulder Arthritis Pain
Arthritis means “inflamed joint,” and refers to any condition of the joint in which there is damage to the smooth cartilage covering a moving surface of a joint (called the articular cartilage). Progression of arthritis eventually leads to cartilage loss and “bone on bone” of the joint surfaces. Cartilage damage and loss can cause pain.
After the hip and knee, the shoulder is the third most common large joint affected by arthritis. The loss of cartilage with shoulder arthritis is frequently a source of severe pain, limited function, joint stiffness, and significant diminished of quality of life. While there is currently no cure for advanced arthritis, there are many treatments, both non-surgical and surgical, that enable the symptoms to be well treated and for patients to maintain active lifestyles.
Types of shoulder arthritis
Osteoarthritis: A “wear and tear” type of arthritis, and usually occurs as a combination of use, genetics, micro trauma, and increased forces across the joint. The cartilage becomes frayed and worn, and eventually disappears; without this protective covering, the underlying bones grind against one another, causing pain.
Cuff Tear Arthropathy: This is the end stage of very large tears of the rotator cuff tendon. The rotator cuff consists of four muscles which stabilize and are the primary movers of the shoulder joint. While large tears of the rotator cuff tendon, are less uncommon, patients with untreated rotator cuff tears can develop cuff tear arthropathy. Treatment of shoulder arthritis caused by cuff tear arthropathy can be particularly difficult challenging, since it results from damage to both soft tissue support of the joint as well as the joint surface.
Osteonecrosis: Osteonecrosis is also known as avascular necrosis and is a condition in which the blood supply to the bone forming the ball of the shoulder is interrupted, leading to the death and collapse of a segment of the bone. With loss of the bone support, the overlying cartilage is subject to forces which cause the cartilage to become damaged as well.
Inflammatory Arthritis: Inflammatory arthritis is caused by inflammation of the joint and joint lining, ultimately wearing away the cartilage surfaces. In conditions such as rheumatoid arthritis and psoriatic arthritis are examples.
Post-Traumatic Arthritis: This can result from a fracture of the ball or of the socket. If the cartilage surface is damaged at the time of the bone fracture, this damage can cause the cartilage surface to wear out and disappear.
Symptoms and Signs of Shoulder Arthritis
The most common symptom of shoulder arthritis is pain with activity. Pain can occur at rest, and may even interrupt sleep as the condition progresses. As the cartilage wears away, the joint becomes stiff, reducing range of motion, and limiting activity. The pain is frequently centered around the shoulder, but commonly is felt further down the the arm. The most frustrating symptom for most people is the loss of sleep, as it frequently becomes difficult to find a comfortable position either on the affected or unaffected side.
Motion is often affected, and may be accompanied by cracking, grinding, or catching as the ball/socket bones rub against one another.
Usually an x-ray will be taken to show the amount of lost joint space that indicates cartilage loss. Often bone spurs will form on either side of the joint and the bones can gradually change from their normal shape. Occasionally a CT scan or MRI will be required for further evaluation of the bone or soft tissues.
Treatment of Shoulder Arthritis
The initial treatment of shoulder arthritis is usually non surgical and includes activity modifications, ice/heat, medications, therapy, and injections. Often a combination of treatments is used to get optimum effect. Sometimes avoiding the activities which put the most stress on the arms can let some of the pain abate so that patients can gradually resume activities. Ice and heat can also help reduce inflammation after periods of particularly stressful activities. Physical therapy often plays a role in maintaining or improving range of motion and strength, but may in some circumstances aggravate the pain from arthritis – so its role should be reevaluated if it is a source of aggravation of pain.
Medications for Shoulder Arthritis
Medications are often helpful in the treatment of arthritis. NSAIDs (Non-steroidal anti-inflammatory drugs) such as naproxen, ibuprofen, meloxicam, or aspirin can be very effective. However, as with any drugs they can sometimes cause issues with side effects such as the stomach or gastro-intestinal tract and are usually taken with food. The decision to use NSAIDs or other pain relievers like acetaminophen (Tylenol) should be made with your doctor. Dietary Supplements, such as glucosamine or chondroitin sulfate are used by some patients to find relief. There is little scientific evidence of the role or value of dietary supplements in arthritis treatment. In addition, the FDA does not regulate these supplements, and there may be interactions with other medications you are taking. Consultation with your physician is recommended before taking dietary supplements.
Injections for Shoulder Arthritis
Injection of corticosteroids or viscosupplemenation may help to treat the inflammation inside the joint. While there is often little risk associated with a joint injection of cortisone, its effects, if positive, may not be long lasting. In addition, patients who have diabetes may see a rise in blood sugar for a variable period of time after a cortisone injections. Viscosupplementation is a synthetic compound such as hyaluronic acid and derivatives are similar in structure to normal joint fluid. They are injected into the joint in an effort to increase lubrication of the joint.
Surgical treatment of Shoulder Arthritis
If non operative treatment is not effective, your doctor may discuss surgical options:
rthroscopy is a minimally invasive operation requiring anesthesia, in which a small camera is placed inside the joint through a small incision. Through another incision, small instruments can be brought inside the joint to manipulate tissue. Arthroscopy of the shoulder to remove loose fragments of cartilage and bone in the joint (debridement) may play a role in early arthritis when there is little damage to the joint surface. This does not eliminate arthritis, but can be helpful in removing loose pieces of tissue which are irritants. However, the results are unpredictable and the benefits may be minimal, subjecting the patient to an operation and anesthesia, with essentially no role in effectively treating the symptoms when arthritis is advanced.
Shoulder replacement is an operation in which implants made of plastic and metal are placed to create new joint surfaces. During this operation, the arthritic ball and socket are removed and replaced by a metal ball and a smooth plastic socket, called a prosthesis. It is the smooth metal ball moving on the smooth plastic socket that relieves pain. There are several types of shoulder replacement operations.
- Total Shoulder Replacement: both the arthritic ball and the arthritic socket are given new surfaces. This prosthesis is sometimes called an anatomic total shoulder. This prosthesis requires functioning rotator cuff musculature and is dependent on the patient’s own muscles and tendons for motion and stability.
- Hemiarthroplasty: the ball is replaced but not the socket. This has its greatest use in the situations where the articular cartilage of the socket is either normal or shows minimal damage. It is sometimes used in the setting of fractures of the proximal humerus.
- Reverse Total Shoulder Replacement: This procedure is used when the patient’s rotator cuff tissues are not healthy enough to move the joint replacement or keep it stable. It has its greatest use in the types of arthritis in which both the rotator cuff tissue is severely damaged or absent and the joint is severely affected by arthritis. In this procedure the metal ball is placed on the patient’s socket, and the plastic cup is placed on top of the upper humerus.
Rehabilitation for Shoulder Arthritis and Shoulder Replacement
Shoulder will be immobilized with a sling after shoulder replacement for several weeks. Depending on the conditions of the bone and soft tissues at surgery depends on the length of time of immobilization. Therapy usually starts in the first couple of weeks after surgery with passive range of motion. Active range of motion begins when adequate time is given for healing of the soft tissues and is progressed on an individualized basis.
An arthritic shoulder is often very tight to begin with, however if post-operative stiffness is a problem in a shoulder in which motion was restored during surgery, the stiffness is usually a result of incomplete rehabilitation. Continued rehabilitative efforts are usually effective in restoring shoulder motion and strength.
The most common complications involved in TSA, which occur only rarely, include shoulder stiffness, instability (the ball slipping out of the socket), infection, nerve damage, and glenoid loosening.
Final thought of Shoulder Arthritis and Replacement
While less common than hip or knee arthritis, shoulder joint arthritis can be equally disabling and have a significant impact on quality of life. Non-surgical management is the mainstay of treatment initially. When that fails, surgery is an option.
Shoulder replacement is a procedure intended to reduce pain and restore mobility in patients with end stage shoulder arthritis, and occasionally after certain severe shoulder fractures. It is important to understand that proper and extensive post-operative rehabilitation is a key factor in achieving the maximum benefit of shoulder replacement surgery.
Shoulder replacement surgery is not to be undertaken lightly; however, if performed for the right reasons it can result in significant pain relief and an increased quality of life. If you have any further questions about shoulder pain or arthritis please don’t hesitate to schedule an appointment with Dr. Mazoch.