Shoulder Osteoarthritis

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Introduction

Please not this article relates to the glenohumeral joint of the shoulder only.
Shoulder joint.png

The glenohumeral joint forms where the head of the humerus fits into the glenoid fossa. .Glenohumeral osteoarthritis (GH OA) is defined as progressive loss of articular cartilage, resulting in bony erosion, pain, and decreased function. The glenohumeral joint is the third most common large joint to be affected following the knee and hip.

Trauma precedes the condition in most cases, although the injury may have occurred years earlier. Injuries that are associated with the development of osteoarthritis include previous dislocation, humeral head or neck fracture, and large rotator cuff tendon tears and may also include detachments of the superior glenoid labrum from anterior to posterior (SLAP lesions)[1].

It causes significant pain, functional limitation and disability. The loss of shoulder function can lead to depression, anxiety, activity limitations, and job-performance problems[2].

While the true prevalence of glenohumeral OA is difficult to ascertain, population-based studies have demonstrated that 16.1%–20.1% of adults older than 65 years have radiographic evidence of glenohumeral OA[3]. Primary glenohumeral osteoarthritis is more common in women and in patients over the age of 60.

[4]

Mechanism of Injury / Pathological Process

GH OA causes gradual, progressive, mechanical, and biochemical breakdown of the articular cartilage and other joint tissues, including bone and joint capsule. As the articular surface wears, friction within the joint increases, causing progressive loss of the normal load-bearing surfaces with pain and disability.

The below video gives a great run down of GH OA starting with details of the pathological process, and goes on to nicely summarise the management and future directions.

[5]

Clinical Presentation

The typical presenting symptoms are

  • progressive, activity-related pain that is deep in the joint and often localized posteriorly.
  • As the disease progresses, night pain becomes more common.
  • For many patients, the pain is present at rest and interferes with sleep.
  • In advanced cases, the stiffness creates significant functional limitations.
  • crepitus on ROM
  • joint effusion

NB. In younger patients, prior trauma, dislocation, or previous surgery for shoulder instability are factors associated with the development of osteoarthritis.

Diagnostic Procedures

X-ray of osteoarthritis of the shoulder.jpg

Imaging studies are essential to diagnosing degenerative joint disease. In most cases, conventional xrays demonstrates shoulder osteoarthritis. Early in the disease process, radiographic evidence of degenerative joint disease may include joint-space narrowing (mild), osteophytes (small), subchondral sclerosis, cysts, and eburnation or advanced articular cartilage loss. The axillary view provides the best image to look for joint-space narrowing and helps rule out dislocations. Anteroposterior radiography, with the arm held at 45 degrees of abduction, may also show early joint-space narrowing. Computed tomography arthrograms can localize articular defects, whereas MRI reveals soft-tissue pathologies and subtle changes in articular cartilage. Subchondral edema visible on MRI suggests advanced articular cartilage involvement.[6]

Outcome Measures

DASH Outcome Measure

Upper Extremity Functional Index

Constant-Murley Shoulder Outcome Score

SPADI[7]  Shoulder Pain and Disability Index (SPADI) was developed to measure current shoulder pain and disability in an outpatient setting. The SPADI contains 13 items that assess two domains; a 5-item subscale that measures pain and an 8-item subscale that measures disability.

Management / Interventions

Treatment of shoulder OA is often controversial and includes both nonoperative and surgical modalities.

Nonoperative modalities should be offered before operative treatment is considered, particularly for patients with mild-to-moderate OA or when pain and functional limitations are modest despite more advanced radiographic changes.

If conservative options fail, surgical treatment should be considered. Although different surgical procedures are available, as in other joints affected by severe OA, the most effective treatment is joint arthroplasty.[8]

Physiotherapy

Perform a thorough shoulder assessment. This will guide you then your tailored approach to the client.

Education plays an important role. Lifestyle modifications and occupational changes discussed.

Therapy ideally should be initiated before the development of atrophy or contracture, and it should be tailored to the specific needs of the patient. Typical programs include gentle range of motion and isometric strengthening of the rotator cuff and scapulothoracic musculature.

Physitrack shoulder trunk rotations with band.jpg

A good home program (HEP) of basic exercises should be given. This could include the following- Pendulum exercise; Passive Internal Rotation; Crossover Arm Stretch; Passive External Rotation; Wall Crawl; Wall Push Up; NB don't give client many exercises in HEP as they are more likely to follow a program that is simple and short. Provide sheet with exercises and dosage.

Rotator Cuff strengthening see link for how to perform and prescribe

Techniques that could be employed include:

Acupuncture and Dry Needling

Scapular Stabilisation Exercises and Scapulohumeral Rhythm Exercises

Rotator Cuff Exercises

Shoulder Exercises including Strength Exercises and Stretching Exercises

Biomechanical Analysis

Proprioception & Balance Exercises

Soft Tissue Massage

Physitrack shoulder pnf band.jpg

Electrotherapy & Local Modalities eg TENS Machine. see also Current Concepts in Electrotherapy

Thermotherapy

Joint Mobilisation Techniques, see also Manual Techniques for the Shoulder and here

Kinesiology Tape, Supportive Taping & Strapping

Neurodynamics

Medical Management

Includes: salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs), which can all be effective in relief of pain and inflammation. In particular randomized trials indicate that NSAIDs are more effective than both paracetamol and placebo for pain relief of OA. See risks of NSAIDs here

Intra-articular injections

May provide pain relief in patients with shoulder OA. Because of the lack of evidence supporting their efficacy, no more than three corticosteroid injections in a single joint are recommendable unless there are special circumstances. Some evidence exists supporting viscosupplementation for shoulder OA. Some evidence reported that glenohumeral viscosupplementation resulted in a significant improvement in shoulder pain and function outcome scores 6 months following injection[8]

[9]

Surgical Treatments

Shoulder surgery is considered for GH OA pain that does not respond to nonsurgical measures. Improved function is not the goal of surgery and is less predictably achieved than pain relief. The choice of treatment then depends on both patient and disease features. Patient features include age, occupation, activity level, and the expectations for functional recovery. Disease features include the lesion size and the extent of chondral involvement.[8]

Differential Diagnosis

  • Labral Tear
  • Septic Arthritis
  • Adhesive Capsulitis.jpg
    Rotator Cuff Injury
  • Cervical Disc Disease with radiculopathy into Shoulder
  • Adhesive Capsulitis (Frozen Shoulder)
  • Polymyalgia Rheumatica (affects Shoulder in 95% of cases)
  • Pseudogout
  • Systemic Lupus Erythematosus[10]

Future Directions

In the future having a great physiotherapist (up to date on the topic) will continue to be essential. That means having

  • A solid background on the pathology of arthritis

Research in 2018 reports of a bright spot on the horizon using hyaluronic acid. It is a choice given in the non surgical options for management of OA. Osteoarthritis is a debilitating disease that affects a large portion of the population, and as the population continues towards an older age, the prevalence of the disease is going to go up. Hyaluronic acid potentially helps lower the side effects of OA on joints. Its effectiveness is due to the many methods of actions it deploys, including lubrication, anti-inflammatory and chondroprotective effects. Treatment can be done both orally and through intra-articular injections. New products are continuously being developed that change the composition of the molecule as well as pairing it with other drugs to maximize the effect[11]. However a 2015 report on the effects of these injections versus physiotherapy treatment concluded tha physical therapy agents seemed have greater effects than intra-articular viscosupplementation on disability and pain. In the other cases both intra-articular viscosupplementation and physical and rehabilitative interventions seemed to be equally effective in improving disability, pain, and quality of life[12].

References

  1. Patzer T, Lichtenberg S, Kircher J, Magosch P, Habermeyer P. Influence of SLAP lesions on chondral lesions of the glenohumeral joint. Knee Surgery, Sports Traumatology, Arthroscopy. 2010 Jul 1;18(7):982-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19838677 (last accessed 20.11.2019)
  2. Memel DS, Kirwan JR, Sharp DJ, Hehir M. General practitioners miss disability and anxiety as well as depression in their patients with osteoarthritis. Br J Gen Pract. 2000 Aug 1;50(457):645-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313776/ (last accessed 20.11.2019)
  3. Ansok CB, Muh SJ. Optimal management of glenohumeral osteoarthritis. Orthopedic research and reviews. 2018;10:9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209346/ (last accessed 20.11.2019)
  4. Howard Council Hospital Shoulder osteoarthritis Available from: https://www.youtube.com/watch?v=iCmvvnJZNl8 (last accessed 20.11.2019)
  5. N Wei The agony of shoulder arthritis Available from: https://www.youtube.com/watch?v=L7x5JA74d1o (last accessed 20.11.2019)
  6. Millett PJ, Gobezie R, Boykin RE. Shoulder osteoarthritis: diagnosis and management. Am Fam Physician. 2008 Sep 1;78(5):605-11. Available from: https://www.aafp.org/afp/2008/0901/p605.html (last accessed 20.11.2019)
  7. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2009 May 15;61(5):623-32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19405008 (last accessed 21.11.2019)
  8. 8.0 8.1 8.2 Chillemi C, Franceschini V. Shoulder osteoarthritis. Arthritis. 2013;2013. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3556427/ (last accessed 21.11.2019)
  9. London Pain Clinic Intra Articular injections for the treatment of shoulder pain Available from: https://www.youtube.com/watch?v=JMc213q9EgU&app=desktop (last accessed 21.11.2019)
  10. Rheumatological conditions affecting the shoulder. Family Practice Available from: https://fpnotebook.com/Ortho/Rheum/RhmtlgcCndtnsAfctngThShldr.htm (last accessed 21.11.2019)
  11. Bowman S, Awad ME, Hamrick MW, Hunter M, Fulzele S. Recent advances in hyaluronic acid based therapy for osteoarthritis. Clinical and translational medicine. 2018 Dec;7(1):6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814393/ (last accessed 22.11.2019)
  12. Monticone, Marco & Frizziero, Antonio & Rovere, Giancarlo & Vittadini, Filippo & Uliano, Domenico & Bruna, Silvano & Gatto, Renato & Nava, Claudia & Leggero, Vittorio & Masiero, Stefano. (2015). Hyaluronic acid intra-articular Injection and exercise therapy: effects on pain and disability in subjects affected by lower limb joints osteoarthritis. The Italian Society of Physical and Rehabilitation Medicine (SIMFER) systematic review. European journal of physical and rehabilitation medicine. 52. Available from: https://www.researchgate.net/publication/281780420_Hyaluronic_acid_intra-articular_Injection_and_exercise_therapy_effects_on_pain_and_disability_in_subjects_affected_by_lower_limb_joints_osteoarthritis_The_Italian_Society_of_Physical_and_Rehabilitatio/citation/download (last accessed 22.11.2019)