Overview of Arthritis
It is estimated that 1/3 of the adult population in America, more than 100 million people, have some form of arthritis in at least one of their joints. Furthermore, it is the leading cause of disability in adults.
Osteoarthritis, or degenerative arthritis, is generally caused by a deterioration of cartilage over time due to the normal aging process. Cartilage is the smooth, shiny white covering on the end of bone that keeps the bones from rubbing together. It acts like a lining to the joint. It is very thin (3 mm or less) and unable to heal once injured. The normal wear-and-tear of life or the brisk tempo of sports can gradually wear it down. Furthermore, the development of this condition can be from many possible factors. One factor that is present in many patients is a genetic predisposition to develop arthritis over their lifetime. In other words, the genes they received from their parents may increase their risk of osteoarthritis.
As the cartilage begins to fray, you may feel pain after strenuous activities and during your sleep. If it wears away completely, the bone under the cartilage starts to rub against the opposite side of the joint. At this point, you are likely to feel pain whenever the joint is used repetitively or with heavy demands on the joint. This leads to a far less smooth motion which can be felt or even heard, called crepitus. Also, the breakdown of the cartilage (and subsequently the bone under the cartilage) leads to chronic inflammation often punctuated by episodes of more severe pain.
Shoulder Arthritis Treatment Options
During the early phases of arthritis, treatment consists of:
- avoiding activities that worsen symptoms
- applying ice to the area of discomfort to reduce swelling and pain
- using anti-inflammatory medications to treat the inflammation
- doing exercises to keep the joint mobile and strengthen the muscles that help make sure the joint moves smoothly and with good stability.
As symptoms worsen, corticosteroid injections can provide temporary relief. Recently, there is increasing evidence that orthobiologic substances such as platelet rich plasma (PRP) can equal the symptomatic relief of cortisone, with additional longer-term benefit by reducing the ability of proteins and cells to contribute to the recurrence of inflammation.
Shoulder Arthritis FAQ
What parts of the shoulder can be affected by arthritis?
Arthritis can affect any of the three shoulder joints: the glenohumeral (GH) joint, the acromioclavicular (AC) joint, and occasionally the sternoclavicular joint. When any kind of arthritis affects the shoulder joint, cartilage on one or both sides of the joint starts to wear out.
The acromioclavicular (AC) joint: This joint is located between the clavicle (collar bone) and the acromion (roof of the shoulder). It moves a little when the shoulder moves and can be injured in a shoulder separation. Arthritis of the AC joint is very common. In fact, after 40 years of age, most people will have changes on their shoulder x-rays that show some osteoarthritis of the AC joint. If there is no significant pain, then no treatment is necessary despite abnormal x-rays. Persistently painful AC joint arthritis that limits the use of the shoulder is uncommon. Glenohumeral (GH) joint: This larger joint is the ball and socket joint connecting the top part of the arm (humerus) to the shoulder blade (scapula). It allows the shoulder to have a wide range of motion in all directions. In the course of a lifetime, this joint is constantly in motion. When arthritis develops in it, it restricts motion and causes pain. Since the purpose of the shoulder is to help position the hand for daily functions, sports, and other activities, any loss of motion or restricted use of the shoulder due to pain will significantly limit the function of the entire arm and hand.
Are there different types of arthritis?
Actually, there are more than 100 types of arthritis! My colleagues in Rheumatology can provide more information about the many types of arthritis that can affect our joints. However, the majority of arthritis conditions affecting the shoulder are often separated into two major categories:
Osteoarthritis (OA): This is the “wear-and-tear” type of arthritis that often appears in later life. In some cases, OA can present after an injury or fracture to the shoulder and is called post-traumatic arthritis.
Inflammatory arthritis: This includes rheumatoid arthritis (RA) and affects patients at an earlier age. It typically affects multiple joints in the body (elbows, shoulders, knees, etc.).
What are the symptoms of shoulder arthritis?
Arthritis can progress slowly or quickly. The speed at which arthritis develops depends on a variety of factors, including lifestyle and genetics.
- At first, you may only experience mild discomfort. The first sign that you are developing shoulder arthritis is pain in the glenohumeral joint, which feels “deep” inside your shoulder, and may radiate towards the back of your shoulder. The pain will occur as you move your arm and sometimes even when it is at rest. It can be aggravated by lifting activities, especially overhead.
- As the arthritis becomes more severe, you may feel pain in the arm itself, down to your elbow joint. Gradually there is also stiffness and a loss of range of motion, especially the ability to reach behind your back or out to your side.
- In the final stages of arthritis, pain can be severe due to loss of all of the cartilage with bone rubbing on bone, bone spurs, loose fragments of cartilage and bone, and a change in the shape of the bones. At this point, arthritis affects daily activities and sleep quality. For example, patients with advanced shoulder arthritis may have pain while combing their hair or reaching things above shoulder level. Some patients report feeling the shoulder bones grinding against each other, with a sensation of clicking or cracking. The shoulder may feel unstable and unreliable, even briefly freezing up.
Is surgery the only answer?
Sometimes. There are other treatments to try first:
- Exercise & Physical Therapy: Although exercise does not make the cartilage grow back or remove any bone spurs, it improves the motion and strength of the shoulder. Range-of-motion exercises and stretching add flexibility and strength to the muscles surrounding the joint, taking pressure off the cartilage. This is associated with less pain and more function. Physical therapy under the guidance of a licensed therapist, collaborating with Dr. Romeo, can provide additional therapeutic treatments and unique exercise programs when the self-directed exercise program no longer helps.
- Activity Modification: Reduce or eliminate the activities in your life that are causing the most pain. It may be time to pass up the neighborhood pick-up basketball game, or let the kids carry in the groceries.
- Hot & Cold Compresses: For temporary relief, both hot and cold compresses can be effective. Experienced Chicago orthopaedic surgeon Dr. Anthony Romeo recommends ice packs, particularly after a busy day or exercises, but some patients actually find applying heat to the joint works best, especially when spasm in the muscles surrounding the shoulder are causing discomfort.
- Cortisone injection: An injection of the shoulder joint with corticosteroids can provide temporary relief of the inflammation and pain related to arthritis. Sometimes these injections can offer relief for many months. They are particularly helpful when a bad flare-up will not go away despite adjusting activities and working on your shoulder motion and strength. However, corticosteroids can temporarily lower your resistance to infection, so any surgery on the shoulder should be postponed for 3 months or longer after an injection.
- Hyaluronic acid injection Sometimes referred to “gel injections”, hyaluronic acid (HA) injections are popular for knee joint arthritis. Their value in treating shoulder arthritis has never been proven in a scientific study, so they are not covered by insurance. In fact, the only injection currently approved for the shoulder by the FDA is a cortisone injection. The procedure is considered safe and does not interfere with future treatments. Patients who have had a good result with HA injections for their knee arthritis may be expected to have a good response for their shoulder arthritis too.
- Orthobiologics: A new class of injections, these includes platelet rich plasma (PRP) and stem cell injections that come from your own blood, bone marrow, or fat. The benefits of these injections for shoulders have not been clearly defined, so these treatments are considered investigational. They do not grow back cartilage or restore the deformed shoulder joint. Insurance companies will not pay for this treatment so if you and Dr.Romeo agree to this treatment, self-pay options are available.
Since the injection material comes from you, they are considered to be safe if the provider practices good sterile technique when harvesting the material and performing an injection. Dr. Romeo offers these injections for patients who truly want to try everything before considering surgical treatment, and they understand that sometimes the injections provide only a short period of benefit.
Surgical Options for Shoulder Arthritis?
There are different surgical options available for patients suffering from shoulder arthritis. If conservative treatment options have not worked, Dr. Romeo can discuss the risks and benefits of proceeding with surgery.
Arthroscopic Shoulder Debridement
An arthroscopic shoulder debridement is done as an outpatient. It uses a camera and a light source to visualize the inside of the shoulder joint, with tools inserted through small incisions to remove torn cartilage, debride frayed or degenerative tissues, and restore integrity to the joint. During the procedure, Dr. Romeo may release the tight joint capsule to improve motion if the arthritis has not caused deformity of the bone. The procedure is a short-term solution that is appropriate for earlier stages of arthritis. In a best-case scenario, this procedure can provide 3 to 5 years of relief, although sometimes the pain returns earlier and other options need to be considered.
Total Shoulder Replacement
During a total shoulder replacement, which is also referred to as an anatomic shoulder replacement, the damaged area is removed and replaced with a shoulder prosthesis (artificial joint). To get to the shoulder joint, an incision is made on the front of your shoulder. After exposing the shoulder joint, the damaged ends of the bone are removed. The humeral bone is prepared for the placement of an artificial joint made of metal—usually titanium inside the bone, with cobalt-chrome alloy used for the humeral head replacement. Traditionally, the stem of the humeral component is placed inside the humerus and impacted into its final resting position. Cement to help secure the stem is rarely used in a first procedure. However, Dr. Romeo may need to add cement or cadaver bone when performing a revision of a previous shoulder replacement.
Want to see how it’s done? In this video, Dr. Romeo demonstrates an anatomic shoulder replacement procedure, using the short stem APEX prosthesis, a pegged glenoid, and a unique repair technique for the subscapularis tendon. (The video was created with the consent of the patient and intended to be used for educational purposes.)
Want to read more about a total shoulder replacement?
STEMLESS Total Shoulder Replacement
Today, Dr. Romeo primarily uses a prosthesis that does not have a stem that goes down the arm (humeral bone) when treating patients with osteoarthritis. Years ago, Dr. Romeo helped design a unique stemless humeral prosthesis, the Eclipse Prosthesis that has been used in Europe for more than 10 years, and now is available in the United States. Dr. Romeo recently published an extensive investigation on the Eclipse Shoulder System that included more than 300 cases demonstrating its safety and effectiveness.
The studies in Europe have reported results 10 years after the procedure demonstrating excellent outcomes. Dr. Romeo believes that the stemless shoulder replacement is the best surgical method when treating osteoarthritis as it associated with high patient satisfaction, minimal removal of bone, and great potential to return patients back to their desired activities. Find out more about it here.
Want to see more? In this video, watch Dr. Romeo use the Eclipse Shoulder System to treat a patient with Osteoarthritis.
In this video, you’ll see an animation of the surgical steps for the Eclipse Shoulder Prosthesis System.
Most patients with arthritis also benefit from the placement of a glenoid component. The glenoid component is made of a special plastic and cemented into place. On rare occasions, Dr. Romeo will use a metal-backed glenoid. Not every patient requires a glenoid component, so the final decision of whether to use one is made during the surgery. In some active young people who want to lift heavy weights or continued their responsibilities as first responders or in the military, Dr. Romeo performs a unique procedure known as a “Ream and Run”. After the components are in place, the shoulder joint is checked for stability and potential range-of-motion.
Reverse Total Shoulder Replacement
is like a total shoulder replacement. There is one big difference: the placement of the ball and socket is reversed!
The shoulder joint is a ball-and-socket joint. The shoulder joint consists of a ball at the top of the arm bone (humerus) that fits into a socket at the shoulder blade (scapula). A reverse shoulder replacement uses an artificial device to replace the damaged shoulder joint in a reversed manner—it uses a ball at the shoulder and a socket at the end of the arm.
During surgery, a hole is made down the center of the arm bone to insert the stem of the socket implant.. A ball-shaped implant affixes to the socket of the shoulder blade using screws. Proper alignment of these two pieces is critical to the success of the surgery. Any imbalance will cause rotation issues that can result in damage to the shoulder.
Shoulder Replacement Surgery Recovery
If a patient undergoes either type of shoulder replacement surgery, extensive time is needed for healing. Recovery is adjusted based on the time it takes for bone to grow into the implants, as well as the strength of the repair of the section of the rotator cuff that was released and moved out of the way so that the implants could be accurately secured to the bone in the ideal location. More advanced procedures that include bone grafts or specially designed prostheses for complex cases will require a slower start and progression to rehabilitation after surgery.
After shoulder replacement, you should be able to move your elbow, wrist and fingers the day after surgery. Within a few days, you may be able to eat, bathe, and dress independently, as long as you rely on your non-surgical hand for most of the activities.
The pain from the procedure is experienced differently from every patient, however, most patients regain significant comfort within the first one to two weeks. Dr. Romeo will give you specific instructions for post-op pain management. Simple home exercises for the shoulder joint will be prescribed for the first two to four weeks and then a to a supervised physical therapy program. Driving can begin once there is enough control of the arm to assist with steering, which is usually 4-6 weeks after surgery.
Motion for activities of daily life will begin at four to six weeks and strengthening generally begins after six weeks. By three months you can resume your usual routine and starting light recreational activities such as golf, swimming, ground strokes in tennis, fitness strengthening at the gym, and almost any cardio routine that does not require full strength of your shoulder. By six months or earlier, patients are back to all activities without restrictions. To achieve the best possible outcome, patients should develop a routine schedule of exercise for their shoulder with the help of their physiotherapist and continue those exercises for at least the first year after surgery.
For more information on causes and treatment of shoulder arthritis, including options for highly complex conditions such as persistent pain or instability after a previous shoulder replacement, infection, or severe bone loss and deformity, please request an appointment with experienced Chicago orthopaedic surgeon Dr. Anthony Romeo. Call or email our office today to schedule your visit.
Want to learn more? Dr Romeo has developed this informative booklet with Arthrex, Inc. that you may find very helpful.
In this video, see why one of Dr. Romeo’s patients said: “My surgery saved me emotionally.”
In this video, watch Dr Romeo’s patient, Reid W, discuss his shoulder replacement and recovery.
Shoulder Surgery Videos & Animations
Anatomy of the Shoulder as it relates to Surgery
Shoulder Arthritis & Shoulder Replacement Additional Links
Want to know more? Here a few of Dr. Romeo’s recent medical journal articles about shoulder arthritis:
- Comparative Clinical Outcomes of Reverse Total Shoulder Arthroplasty for Primary Cuff Tear Arthroplasty Versus Severe Glenohumeral Osteoarthritis with Intact Rotator Cuff: A Matched-Cohort Analysis: American Academy of Orthopaedic Surgeons
- Glenohumeral Osteoarthritis in the Young Patient: Journal of the American Academy of Orthopaedic Surgeons
- Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study examining Utilization, Adverse Events, Length of Stay, and Cost: American Journal of Orthopaedics
- Irreparable Rotator Cuff Tears WithoutArthritis Treated With Reverse Total Shoulder Arthroplasty: Open Orthop J.
- Surgical Treatment Options for Glenohumeral Arthritis in Young Patients: A Systematic Review and Meta-Analysis
- The High Failure Rate of Biologic Resurfacing of the glenoid in Young Patients with Glenohumeral Arthritis: J Shoulder Elbow Surg 2013 Sep.
- Sershon RA, Mather RC, Sherman SL, McGill KC, Romeo AA, Verma NN. Low Accuracy of Interpretation of rotator cuff MRI in Patients with Osteoarthritis:Acta Orthop.
Anthony Romeo, MD
Dr. Anthony Romeo is one of the nation’s leading orthopaedic surgeons specializing in the management and surgical treatment of shoulder and elbow conditions. His state-of-the-art practice employs minimally-invasive arthroscopic techniques to accelerate the recovery process for a range of challenging conditions.