By Dr. Pier Boutin, MD
Arthritis affects many joints throughout the body, including the shoulder. Arthr- stands for joint and -itis stands for inflammation. Over the past decades I have observed a progressive increase in the prevalence of shoulder arthritis. Primary arthritis in the shoulder has no specific cause. I suspect that environmental and nutritional changes over the past several decades have become a trigger for systemic inflammation in many people, resulting in an increase in joint arthritis. Secondary arthritis has a known cause or predisposing factor, such as major shoulder trauma, chronic dislocations, infection or chronic rotator cuff tear.
However you developed arthritis in one or both of your shoulders, you’re here because you want to know your options for relief, including how to decide whether or not to have shoulder replacement surgery. So, let’s look at how to weight different courses of action.
What’s causing your shoulder pain?
Before deciding what to do to find relief, you need to understand the underlying mechanism that is causing you so much grief. In both primary or secondary arthritis, the smooth cartilage cap at the socket (glenoid) and the ball (humeral head) deteriorate. This leads to rough joint surfaces, which cause swelling and pain of the joints. Eventually, the bony surfaces with their many nerve endings are exposed and rub together. This causes grinding and the pain you know so well.
What can you do to relieve shoulder arthritis pain?
Treating shoulder arthritis pain can range from diet and arthritis-friendly exercise changes to taking OTC pain relief medications to total shoulder replacement surgery. Some treatment options are like bandaids that only focus on reducing pain and discomfort, while others do a better job at fixing the underlying driving forces of the arthritis.
Here are some non-surgical options you may wish to explore.
Lifestyle changes. Changing your diet to eat anti-inflammatory foods, getting more cardiovascular exercise and taking helpful bone and joint health supplements are all measures which can reduce inflammation and inflammation-related pain and — best of all — possibly stop the progression of arthritis. Here are some tips for how to adopt anti-inflammatory lifestyle habits.
Platelet rich plasma (PRP) injections. Early studies show that platelet rich plasma (PRP) injections not only reduce pain, but also stop joint deterioration in the early to moderate stages of arthritis. PRP is a way to harness your body’s innate ability to heal. [Read my blog on knee arthritis pain to learn more about the benefits of PRP treatments and how it’s done.]
Anti-inflammatory medications. Ibuprofen, Naprosyn and other anti-inflammatory medications reduce inflammation — offering temporary pain relief — but do not change the natural course of the disease. Cortisone injections also help to quickly reduce inflammation but again do not change the natural course of the disease. Some patients feel wonderful after these treatments only to have the pain and discomfort eventually return. Hyaluronic acid injections (HA, a gel-like substance) also reduces pain in some patients.
When is shoulder replacement surgery a good option?
Because the shoulder is not a weight bearing joint, patients can function quite well for a long time with non-surgical treatment. Once non-surgical management fails to relieve pain and function and lifestyle are affected, a total shoulder replacement (arthroplasty) may become the best option.
There are two kinds of shoulder replacement, however, and it’s important to work with your doctor to choose the right one!
Anatomic shoulder arthroplasty (ASA). This traditional form of shoulder replacement surgery was initially introduced as a great option for comminuted shoulder fractures — bones broken into too many pieces so they cannot be reconstructed and rarely heal. Surgeons replaced the fragmented chards of bones with metal a ball and stem to give patients quicker and least painful recovery and function.
Over the ensuing years, the use of ASA expanded to shoulder arthritis, specific to the glenohumeral joint. This is the larger of the two joints around the shoulder – the ball and socket joint. Both glenoid surface and the humeral ball are replaced with metal and polyethylene to give smooth painless motion. ASA can work beautifully in many patients to effectively relieve pain.
However, there’s a significant problem. ASA does not improve movement for patients with a weak, damaged or torn rotator cuff which patients with degenerative arthritis of the shoulder more often than not have developed. These patients will not do well with an anatomical shoulder replacement.
This problem is compounded when it’s an older person with shoulder arthritis. With age, the rotator cuff tendons becomes very thin and difficult to repair. Surgical rotator cuff reconstruction fails more often than not in older people. The tissues are friable and easily re-tear. Another negative factor is that recovery from rotator cuff is painful and lengthy.
Reverse Total Shoulder Replacement. If you meet the criteria above (older and/or have known rotator cuff weakness), don’t despair! About 15 years ago, a new procedure called the Reverse Total Shoulder Replacement was developed to give patients with weak or damaged rotator cuff pain relief with the ability to activate and move the arm.
Just like standard anatomical shoulder replacement, both glenoid surface and the humeral ball are replaced in a reverse shoulder replacement; however, the center of rotation between the two components is moved medially (closer to the midline). Centralizing the fulcrum of rotation amplifies the power of the secondary shoulder muscle groups – the deltoid, pectoralis major and latissimus dorsi. With this newer procedure, the secondary muscles, which are usually intact, can now actively move the arm. The Reverse Total Shoulder has become the go-to operation for patients with arthritis and associated rotator cuff weakness/tear. This surgery restores motion while alleviating pain.
While this is a truly great advancement, you should know that complications from Reverse Total Shoulder are slightly higher than for Anatomical Total Shoulder surgery. As a rule of thumb, it is important to consult with a surgeon who performs at least 40 reverse shoulder procedures per year as the learning curve is higher than for anatomical shoulder replacement surgery. Studies show that complications from RSA become similar to ASA when a surgeon has a lot of experience.
To know if surgery would eliminate your shoulder pain, a diagnostic lidocaine injection is quite useful. It anesthetizes the joints, thus should temporarily numb the pain. Total shoulder replacement implant survival rate approaches that of total hip surgery. Speaking from a surgeon’s perspective, it can be a great option with relatively quick recovery for shoulder pain from arthritis.
So, see if a non-surgical treatment — especially lifestyle-based changes! — work for you. If not, the great news is that you have options.
What’s causing your joint pain? Find out if you should be worried about your symptoms.
