By Dr. Michael DeFranco
STATEN ISLAND, N.Y. — The shoulder joint primarily consists of two bones: the head of the humerus and the glenoid. Together these two bones function similar to a ball (humeral head) moving inside a cup (glenoid). The bones of the shoulder joint are covered with cartilage, which helps to create smooth motion during activities.
Arthritis develops when the cartilage wears away. This process occurs primarily with age, but also develops secondary to injury or systemic disease. Among the various types of arthritis, osteoarthritis, also known as degenerative joint disease, is the most common. The main characteristic of osteoarthritis is focal loss of cartilage, which is irreversible and slowly progressive.
Osteoarthritis of the shoulder joint is less common compared to the hip or knee. Women and people age 60 and older are most likely to develop shoulder arthritis. Although age is the greatest risk factor for the development of shoulder osteoarthritis, other factors may also play a role including gender, nutrition, race, ethnicity, previous injury to the shoulder joint, muscle weakness, and bone density. The rotator cuff, which is a family of muscles that surrounds the shoulder joint and provides the force for it to move, may be torn in addition to having shoulder arthritis, but this is rarely the case.
The development of osteoarthritis in the shoulder changes the shape of the joint. When arthritis develops, the surfaces of the joint become distorted. As a result, the joint moves more like a square in a hole rather than a ball in a cup. The transformation creates pain and limits range of motion. The impact on daily life can be significant by restricting not only daily activities, but also athletic activities and sleep.
TYPES OF TREATMENT
Treatment for shoulder arthritis is divided generally into nonoperative and operative management. Decisions on which option to choose are based on the patient’s age, severity of symptoms (pain, dysfunction), X-ray findings, and medical problems.
Nonoperative care includes the use of physical therapy, medications, and injections (e.g., cortisone, viscosupplementation). Physical therapy includes techniques such as massage, joint mobilization, gentle strengthening exercises, ultrasound, acupuncture and electric stimulation. Medications used to help control the pain associated with arthritis include nonsteroidal anti-inflammatory medications (NSAID, e.g. ibuprofen, acetaminophen), and over-the-counter supplements (e.g. vitamin B, vitamin C, chondroitin sulfate, herbal therapy).
Two types of injections placed inside the shoulder joint to treat arthritis are corticosteroid and viscosupplementation. Corticosteroids are powerful medications used to reduce the inflammation that develops within the joint in response to arthritis. Pain relief is achieved by reducing inflammation with corticosteroids.
Viscosupplementation is a gel-like preparation of hyaluronic acid that helps to lubricate the joint and reduce pain. Hyaluronic acid is a naturally occurring substance within the fluid of the shoulder joint. Typically injections are used in combination with an oral medication to relieve pain. Although each of these options are the first line in the treatment of shoulder arthritis, insufficient evidence exists among research studies to predict the efficacy of them in terms of pain relief and better function.
If nonoperative treatment fails to provide adequate pain relief and better function, then surgery becomes an option. Surgical treatment includes arthroscopic surgery, biologic reconstruction of the joint, partial shoulder replacement, total shoulder replacement, and reverse shoulder replacement.
Arthroscopic surgery is usually reserved for patients with mild arthritis. At the time of surgery the arthritic areas of the joint are debrided and the soft tissues surrounding the shoulder joint may be released to help improve range of motion. Shoulder arthroscopy does not cure arthritis.
The only cure for arthritis is a shoulder replacement. Biologic reconstruction of the shoulder joint consists of using tissue from the patient or a tissue bank to cover or replace areas of the shoulder joint worn away by arthritis. These procedures are typically reserved for patients under age 40, where the potential for healing is the best.
When the degree of shoulder arthritis is advanced or in older patients who are not candidates for biologic reconstruction, partial or total shoulder replacement of the shoulder joint becomes an option. Reverse shoulder replacement is most commonly used in patients with the combination of severe shoulder arthritis and an irreparable rotator cuff tear.
The shoulder is the third most common joint to require surgical replacement for osteoarthritis. More than 25,000 shoulder replacements are performed in the United States each year. The goals of a shoulder replacement are to relieve pain and to improve range of motion. Achieving these goals allow the patient to return to an active life style and to enjoy an improved quality of life.
In general, the procedure involves removing the arthritis from the shoulder and replacing it with a metal and plastic prosthesis. After surgery, patients typically spend two days in the hospital. Patients wear a sling for about one month to protect the shoulder while it heals. Over the course of several months, the patient works with a physical therapist to improve range of motion and strength.
About 2 percent of patients undergoing shoulder replacement will experience complications. Every patient should discuss the risk of complications with their surgeon before proceeding with surgery. Patients considering a shoulder replacement should consult an orthopaedic surgeon who is well-trained and experienced in shoulder replacement surgery.
Additional information about shoulder arthritis and treatment can be obtained at the website for the American Academy of Orthopaedic Surgeons.
*This column is provided by the Richmond County Medical Society. Dr. Michael DeFranco is a member of the Society, and specializes in sports medicine and shoulder reconstruction. He maintains a practice in Westerleigh.