Glenohumeral Osteoarthritis
Osteoarthritis of the shoulder joint is less common than that of the weight-bearing joints of the lower limbs. However, it is certainly not uncommon in an ageing population; the prevalence of glenohumeral joint osteoarthritis in a primary care shoulder pain population referred for radiographs is up to 28%, with 70–79-year-olds having both radiographic and symptomatic glenohumeral arthrosis in primary care.
Osteoarthritis, simply put, is the ‘wear and tear’ of the normal cartilage covering the ball (humeral head) and the socket (glenoid) of the shoulder joint, resulting in exposure of the underlying subchondral bone and subsequent pain and stiffness.
What are the signs and symptoms?
Patients can present with global shoulder symptoms, usually poorly localised, where symptoms can be felt anteriorly, anterolaterally, posteriorly and even into the biceps/upper arm region. The joint will be stiff and painful both actively (you moving it) and passively (someone else moving it). This may or may not be associated with weakness depending on the integrity of the rotator cuff.
Patients typically have trouble sleeping due to the pain, and the stiffness makes simple day-to-day tasks such as washing your hair or reaching for objects from a top shelf difficult or impossible.
How is it diagnosed?
The diagnosis of shoulder osteoarthritis will usually be made from a combination of your clinical history, examination findings and a plain film X-ray of your shoulder. An MRI scan can also confirm the diagnosis. Ultrasound is not typically used here but can be helpful to assess the integrity of the rotator cuff tendons, which is important if surgery is being considered.
How is it treated?
Treatment options are divided into conservative and surgical.
Conservative options:
- Oral analgesia in combination with modifications of daily activities may help alleviate some of the symptoms.
- A local anaesthetic and steroid injection into the shoulder joint can be helpful at easing some of the inflammation associated with osteoarthritis. This can provide some temporary pain relief; how long this lasts and how beneficial it is will vary in patients depending on the severity of the arthrosis and how active the patient is with their shoulder. They can be repeated if they are helpful, but it is typically advisable to have a 6-monthly interval between them.
- A suprascapular nerve injection/block is a further conservative option which involves injecting local anaesthetic and steroid around the nerve (suprascapular nerve) on top of the shoulder. This is typically done under ultrasound guidance. The nerve supplies the sensory input to the shoulder and can be effective in providing longer periods of pain relief. Unfortunately, it does not work for everyone.
- In less severe cases of arthrosis, hyaluronic acid injections into the shoulder joint, typically under ultrasound guidance, can be helpful as a potential alternative to repeated steroid injections. They have a very safe injection profile without the potential risks that steroids can have on the articular cartilage.
Surgical options:
If conservative options mentioned previously do not provide adequate relief or if there is already substantial arthrosis on a plain film X-ray at the time of initial presentation, then there are surgical options.
- Arthroscopy (keyhole), In rare cases for high demand, younger patients (55 or less) with established shoulder arthrosis, arthroscopy may be considered to potentially delay arthroplasty (shoulder replacement). This involves ‘washing out’ the joint, removing any excess bone that may have formed (osteophytes) and releasing the tight capsule. The outcome of this surgery has less reliable outcomes than replacement surgery.
- Reverse or anatomical shoulder replacement. For suitable patients there are two types of shoulder replacement that are available. The appropriateness of which one is right for you depends on the integrity of your rotator cuff; an equal degree of pain relief can be expected for both. An ‘anatomical’ shoulder replacement is advisable when the rotator cuff remains intact. ‘Reverse’ is recommended when the rotator cuff is torn, meaning the ball and socket prosthesis is swopped around. This new design arrangement is able to compensate for the lack of rotator cuff function by recruiting the larger deltoid muscle, which has been shown to reduce the risks of early prosthesis loosening.
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