Shoulder arthritis is one of the most frequent causes of shoulder pain that we see at OrthoTexas. Although there are multiple cause of shoulder arthritis, “wear-and-tear” over time is by far the most common reason for shoulder arthritis. Other causes, include after injury (post-traumatic) or inflammatory (rheumatoid arthritis).
Wear-and-tear arthritis is a degenerative process, whereby the cartilage in the shoulder wears away. Cartilage is the smooth covering at the ends of the bones. When two or three bones come together, they form a joint. When that cartilage (at the ends of the bones in the joint) wears away, we call that arthritis.
Arthritis can be classified in many ways. However, it is usually referred to as mild, moderate, or severe. This distinction is made by looking at an x-ray of the joint (the bones). When we look at an x-ray, there is typically space between the different bones. This “space” we see is actually the cartilage, as you cannot see cartilage on an x-ray. However, when you start to see the bones align closer together on an x-ray and therefore a loss of that original space between the bones, then we know that there is a loss of the cartilage cap at the ends of the bones. Thus, arthritis is present.
To date, there is nothing that we can do to prevent arthritis in the shoulder. Most commonly, it is a genetic problem inherited from your parents. Unfortunately, there is no food, drink, supplement, exercise, etc. that can either prevent or slow down the arthritic process. So, as physicians, we are left with just treating the symptoms of arthritis. These symptoms typically include pain and stiffness. The pain is often felt with extreme motion, such as reaching fully overhead, outward or behind your back. Pain at night is also common.
There are many treatment options for shoulder arthritis. We typically recommend non-operative care as a starting point for patients with arthritis. This can include anti-inflammatories (Advil, Aleve, Meloxicam, Celebrex, etc.) and glucosamine. Glucosamine is a safe dietary supplement that may help with arthritic pain. There are not necessarily great scientific studies to prove the efficacy of glucosamine in the shoulder, but glucosamine is extremely safe and inexpensive. Therefore, doctors suggest “It can’t hurt, but it may be helpful”. In addition to anti-inflammatories and glucosamine, we recommend patients keep their shoulders “loose”. Stiffness in the shoulder is typically painful. Therefore, if you can improve range-of-motion, that can often help with pain. This stretching can be done on your own at home, or with formal physical therapy with a licensed physical therapist who can work with you. We also recommend heat and ice to relieve and soothe pain. Heat, such as a hot shower, hot tub or heating pad is good for stiffness, and ice is good for pain. However, each patient should experiment with ice and heat to see which works best for them. Finally, a steroid injection can be highly effective to help with pain. The steroid medication cannot alter the arthritic process from progressing, but it can help with pain. It can be extremely helpful to lessen the sharp pain that occurs with arthritis especially at night. We encourage patients to consider a shoulder joint steroid injection when they have significant pain. Often we will give patients (unless otherwise contraindicated) a couple shoulder injections per year if they continue to be effective for pain control.
When the non-operative care described above does not work, there are surgical options for shoulder arthritis. Two main types of surgery include shoulder arthroscopy, done through small incisions and shoulder replacement, also known as, total shoulder arthroplasty. Shoulder arthroscopy can be a helpful tool in certain patients. The key to the success of a shoulder arthroscopy for shoulder arthritis understanding who is the right patient for this procedure. It can be effective only when there is no significant joint deformity, of loss of overhead function prior to surgery. In the right patient, it can be a highly effective, but often temporary, solution. The benefit to the arthroscopic procedure is that it is less invasive and a much faster recovery. During the procedure, we clean up loose cartilage pieces, release tight tissue and may remove bone spurs, also caused by arthritis, as needed. Patients can use their arm as much as they want as soon as they want depending on their pain. A sling is not typically needed more than a couple of days. We typically allow patients to get back to unrestricted activity, as they tolerate it, at 3 months after surgery. Unfortunately, because we do not remove the arthritis with this procedure, the arthritic process will typically continue to progress over time necessitating more surgery, such as a joint replacement, down the road. Hopefully, patients can get two years or more of adequate pain relief with the arthroscopic procedure.
The other common surgical procedure for shoulder arthritis is joint replacement (total joint arthroplasty). During this procedure, we cut out the arthritis by removing just the ends of the bones. Then, we replace this worn-out cartilage cap with metal and plastic. This surgery is typically done through a 2 ½ inch incision on the front of the shoulder. Most patients spend one night in the hospital and then go home the next day. Unlike the arthroscopic procedure, patients wear a sling for the first 6 weeks and typically to go back to unrestricted activities, as tolerated, at 4 ½ months after surgery. Joint replacement is a much more permanent surgical solution to arthritis that usually lasts at least 12-15 years.
There are two different types of shoulder joint replacements. Anatomic shoulder replacement (for shoulder arthritis with a good rotator cuff tendon), and reverse shoulder replacement (for shoulder arthritis with a torn rotator cuff tendon). Overall, joint replacement is a fantastic surgical option for patients and has a long track record of over a 90% success rate.
So, how do you decide when to proceed with surgery for the treatment of shoulder arthritis?
“You will tell me when you are READY for surgery…I will never tell you that you MUST HAVE surgery, “ says Dr. Fagelman, shoulder expert at OrthoTexas. When a patient’s pain and limitations are interfering with their quality of life, and they have tried some or all the non-operative care listed above it makes sense to proceed with surgery. That is always the patient’s decision. We typically hear patients say, “I have had enough” of the pain and “I am ready for a more permanent solution”. At that point we recommend a thorough conversation to determine which surgery is right for you.
Dr. Mitchell Fagelman is an orthopedic surgeon and sports medicine specialist at OrthoTexas. He specializes in the treatment of injuries and arthritis in the shoulder.