Treatment of Shoulder Arthritis

What is shoulder arthritis?

The shoulder is a complex joint made up of 3 bones: The scapula (shoulder blade), the clavicle (collar bone) and the humerus (upper arm). Arthritis develops when the cartilage inside the joint starts to break down exposing the underlying bone. Shoulder arthritis normally refers to arthritis in the big ball-and-socket-joint called the glenohumeral
joint. The second joint in the shoulder is between the scapula and the outer end of the clavicle called the AC (acromioclavicular) joint. Although this joint often looks arthritic on an X-ray, it seldom is a cause of significant pain.

The main reasons for the development of arthritis are:

  • Wear and tear arthritis because of ageing also known as degenerative joint disease.
  • Post traumatic / injury related arthritis that may develop after an old injury.
  • Arthritis as a result of an old rotator cuff (shoulder tendon) tear.
  • Repeated joint dislocations leading to damage to the joint and arthritis.
  • Arthritis because of an old fracture to the shoulder / post-traumatic arthritis.
  • Chronic inflammatory diseases like rheumatoid arthritis.
  • Shoulder arthritis due to avascular necrosis – where the blood supply to the head becomes interrupted. This leads to collapse of the head and the head of the humerus becoming uneven.

How is shoulder arthritis diagnosed?

Symptoms of shoulder arthritis includes pain in and around the shoulder. Early on, pain is usually experienced after using the arm, but as the arthritis gets worse, pain will be present at rest. Shoulder arthritis also causes loss of range of motion in all directions and there might be symptoms of grinding, clicking or clunking (also called crepitus).

A complete history and physical examination will be done – this includes assessing range of motion, strength, and stability of the joint.

You might need to have further tests done to confirm the arthritis.

These tests include:

  • X-ray of the shoulder.
  • CT (Computed Tomography) scan.
  • Magnetic resonance imaging (MRI) of the shoulder.

Treatment of shoulder arthritis:

Unlike the knee and hip which are weight-bearing joints, the shoulder does not carry a lot of weight. Therefore,shoulder arthritis can often be treated without surgery for a relatively long time.

Treatment for early osteoarthritis consists of the following:

  • Range of motion exercises to keep the shoulder as mobile and flexible as possible. A physiotherapist might help you with this in the early stages, but long-term physiotherapy is normally not needed.
  • Modification of activities – this is to try and avoid activities that cause pain and discomfort in your shoulder. This might mean reducing the number of times you play certain sports, like tennis or golf.
  • Cold and heat packs. Heat packs are a great idea to use before exercises and cold packs are great for soothing after activities and exercise.
  • Medication to treat arthritis may help, but they do have potential complications. Oftentimes initial treatment will be Paracetamol and you might also benefit from anti-inflammatory medication. This should be used with caution and only when needed.
  • Injection of cortisone: This is normally done with ultrasound control and in combination with a local anaesthetic. It is an injection that helps prevent inflammation in the shoulder for about 3 months. Cortisone injections can increase the risk of infection with total shoulder replacements and should be avoided for at least 6 months before surgery.
  • Injection of hyaluronic acid: It is also called viscosupplementation. It is an injection of synthetic joint fluid that can give pain relief for a period. It has been used in the treatment of arthritis for a long time.

 

Surgical treatment of shoulder arthritis:

Once the non-operative treatments fail and the shoulder pain becomes severe, you can consider surgical treatment. The decision to proceed with surgery should be made with care and only after discussion of the surgery with your surgeon. He / she will discuss the risks, benefits and limitations that surgery might have.

Types of Surgery:

The type of surgery depends on the severity of the arthritis as well as the age of the patient.

Shoulder Arthroscopy:

With this type of surgery, a small camera is placed inside the shoulder joint and instruments placed through small incisions to “clean out” or debride the joint. This surgery is normally done in patients with low-grade / early arthritis. Although this gives pain relief for some time, the surgery is not a permanent solution.

Total Shoulder replacement:

A total shoulder replacement is a major surgical procedure. During this procedure the damaged joint is replaced a by an artificial (prosthetic) joint. Depending on the age of the patient and the condition of the rotator cuff (tendons from the shoulder blade) there are 2 main types:

  • Anatomic total shoulder replacement: Where the humeral head (ball of the humerus) is replaced by a metal ball normally on a short stem and the glenoid by a plastic socket.
  • Reverse total shoulder replacement: This is normally done for patients over 70 years of age and patients with no rotator cuff tendons. In this case the ball and socket switch places. The ball is placed on the glenoid side and the socket on the arm side.

General risks of surgery:

  • Shoulder replacement surgery is done using general anaesthesia when a patient is put to sleep. Unexpected death from an anaesthetic is very rare.
  • Antibiotics are routinely used during surgery to prevent infection – some patients may have an allergic reaction or anaphylaxis.
  • Wound infection.
  • Bleeding in the wound with haematoma (big collection of blood) formation.
  • Pain / numbness around the incision.
  • Allergies to antiseptic solutions used to clean the surgical site.
  • Allergies to sutures and / or dressings.
  • Deep vein thrombosis – there is always a risk of DVT with surgery.
  • Nausea and vomiting after surgery.

 

Specific Risks of Total Replacement:

  • The patient will be asked to wash the shoulder daily for 3 days before the surgery with a shampoo called,Benzoyl peroxide, to prevent an infection by an organism (Cutibacterium Acnes) living in hair follicles which can cause a low-grade infection with shoulder surgery – this might cause an allergy.
  • The patient is positioned in the ‘beach chair’ position for the surgery, which is a seated position. Because this can lead to a drop in blood pressure, the anesthetist will insert an arterial line into the opposite arm to monitor your blood pressure very carefully. The anaesthetist will also administer a nerve block to help with pain relief,
    which will be done after you go to sleep.
  • The nerve block normally last about 12 hours – during this time your arm will feel very heavy and numb.
  • Injury to the nerves around the shoulder. The nerve that supply the deltoid muscle is called the axillary nerve (Nervus Axillaris) and is especially at risk of injury.
  • Dislocation of the new ball and socket joint.
  • Because the shoulder is sling for a period of about 6 weeks, stiffness is common after the surgery. It will take a long time for movement to return. Persistent stiffness may need further surgery.
  • Over time the artificial joint can wear out or may become loose – this may lead to additional surgery.
  • Ongoing pain and discomfort.

 

Recovery after Surgery

You will wake up in the recovery room and you will have a shoulder brace on the operated arm. The nurses in the recovery room will regularly check your vital signs (pulse, blood pressure etc), as well as pain and consciousness levels.

When you get home, you will need to continue using the shoulder sling. Oftentimes it is easier to sleep in a recliner after the surgery.

You will be discharged home with strong pain medication. Try to use the stronger pain medication only when regular type pain medication like Paracetamol is not effective.

It is important to keep the surgical site clean and dry and to keep the wound dressings intact. The dressings on your shoulder should be waterproof. Please change any wet dressings.

You will be supplied with a follow-up date for removal of sutures and a wound review.

A physiotherapist will see you in hospital and will supply you with some initial exercises. These are very gentle exercises that you will do for the first 6 weeks. It is important for you to book an appointment with the physiotherapist of your choice to continue with your rehabilitation after 6 weeks.

Recovery after surgery is different for every patient. It is very important to follow the instructions from your healthcare team. Recovery is a slow and gradual process and can take up to 12 months. It is common to have some discomfort and stiffness after surgery. You will be advised about return to sport and other activities.

Please contact the surgery immediately if you have any of the following:

  • Any redness, swelling, bleeding or drainage from your incision site.
  • Any fever or chills.
  • Any increase in pain around the incision site.
  • Any tingling / numbness in arm.

For further information on these topics, please have a read at the following links:

You can also follow the following links for wonderful animation videos:

Total Shoulder Replacement

Reverse Total Shoulder Replacement