In 2011, more than 50 million people in the United States reported that they had been diagnosed with some form of arthritis, according to the National Health Interview Survey. Defined in simple terms, arthritis is the inflammation of one or more of your joints. In a diseased shoulder, inflammation causes pain and stiffness.
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Although there is no cure for shoulder arthritis, there are many treatment options available. Using these options, most people can manage pain and remain active.
Anatomy
Your shoulder is made up of three bones: the upper arm bone (humerus), the shoulder bone (shoulder blade), and the neck bone (clavicle).
The head of the arm bone fits into the rounded cavity of the shoulder blade. This is called the glenoid cavity. A combination of muscles and tendons keeps the bone in your arm centered in the shoulder cavity. These tissues are called the rotator cuff.
There are two joints in the shoulder and both can be affected by arthritis. An articulation is located where the clavicle meets the tip of the scapula (acromion). This is called acromioclavicular joint (AC joint).
The place where the head of the humerus fits into the shoulder blade is called the glenohumeral joint.
- To indicate an effective treatment, your doctor will need to determine which joint is affected and what type of arthritis you have.
- Los huesos y las articulaciones del hombro.
- The bones and joints of the shoulder.
- Reproduced with the permission of J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopedic Surgeons, 2003.
Description
Five main types of arthritis typically affect the shoulder.
Osteoarthritis
Also known as "wear and tear arthritis", osteoarthritis is a condition that destroys the smooth outer covering (articular cartilage) of the bone. As the cartilage wears out, it deteriorates and becomes rough, and the space of protection between the bones decreases. During movement, the bones of the joint rub against each other, causing pain.
Osteoarthritis usually affects people older than 50 years and is more common in the acromioclavicular joint than in the shoulder glenohumeral joint.
( Left ) An illustration of damaged cartilage in the glenohumeral joint. ( Right ) This X-ray image of the shoulder shows osteoarthritis and reduced joint space ( arrow ).
Illustration on the left reproduced with the permission of JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopedic Surgeons, 2010.
Rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic disease that attacks multiple joints throughout the body. It is symmetrical, which means that it generally affects the same joint on both sides of the body.
The joints of your body are covered with a membrane, called the synovium, which lubricates the joint and facilitates movement. Rheumatoid arthritis causes the membrane to swell, which causes pain and stiffness in the joint.
Rheumatoid arthritis is a disease caused by autoimmunity. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection are those that damage normal tissue (such as cartilage and ligaments) and weaken the bone.
Rheumatoid arthritis is equally common in both shoulder joints.
Post-traumatic arthritis
Post-traumatic arthritis is a form of arthritis that develops after an injury, such as a fracture or dislocation of the shoulder.
Rotator cuff tear arthropathy
Arthritis can also develop after a large and prolonged tear of the rotator cuff tendon. The torn rotator cuff can no longer support the head of the humerus in the glenoid, and the humerus can move up and rub against the acromion. This can damage the surfaces of the bones, causing the development of arthritis.
Artropatía del manguito rotador.
Rotator cuff arthropathy.
The combination of a large tear of the rotator cuff and advanced arthritis can lead to severe pain and weakness, and the patient may not be able to raise the arm.
Avascular necrosis
Avascular necrosis of the shoulder (AVN) is a painful condition that occurs when the blood supply to the head of the humerus is altered. Bone cells die without blood supply, so AVN can eventually lead to destruction of the shoulder joint and arthritis.
Avascular necrosis develops in stages. As it progresses, the dead head gradually collapses, damaging the articular cartilage that covers the bone and leads to arthritis. Initially, the AVN affects only the head of the humerus, but as the AVN progresses, the collapsed head of the humerus can damage the glenoid cavity.
The causes of AVN include the use of high doses of steroids, excessive alcohol consumption, sickle cell anemia and traumatic injuries, such as shoulder fractures. In some cases, a cause can not be identified, this is called idiopathic AVN.
Pain. It is the most common symptom of arthritis of the shoulder, aggravates with activity and progressively worsens.
- If the shoulder glenohumeral joint is affected, the pain is centered in the back of the shoulder and may intensify with changes in weather. Patients complain of deep pain in the joint.
- Arthritis pain in the acromioclavicular joint (AC) is concentrated in the upper part of the shoulder. This pain can sometimes radiate or travel to the side of the neck.
- A person with rheumatoid arthritis may have pain around the shoulder if both joints, the glenohumeral and the AC joint, are affected.
Limited range of movement. Limited movement is another common symptom. You may find it more difficult to raise your arm to comb your hair or reach a shelf. You may hear squeaks, clicks, or cracks (joint crepitus) when moving the shoulder.
As the disease progresses, any movement of the shoulder causes pain. Night pain is common and sleeping can be difficult.
Medical exam
Medical history and physical examination
After discussing your symptoms and medical history, your doctor will examine your shoulder.
During the physical examination, your doctor will look for:
- Weakness (atrophy) of muscles
- Pain on palpation
- Amplitude of the range of passive (assisted) and active (self-directed) movement
- Any sign of injury to the muscles, tendons and ligaments that surround the joint
- Signs of previous injuries
- Involvement of other joints (an indication of rheumatoid arthritis)
- Joint crepitus (sensation of noises and irritation within the joint) with movement
- Pain when pressure is applied to the joint
X-rays
X-rays are tests with the use of images that create detailed figures of dense structures such as bone. They can help distinguish between various forms of arthritis.
The X-rays of an arthritic shoulder will show a narrowing in the joint space, changes in the bone and the formation of bone spurs (osteophytes).
Estos rayos X muestran osteoartritis severa de la articulación glenohumeral.
These X-rays show severe osteoarthritis of the glenohumeral joint.
Reproduced with the permission of Crosby LA (ed): Total Shoulder Arthoplasty. Rosemont, IL, American Academy of Orthopedic Surgeons, 2000, p. 18.
To confirm the diagnosis, your doctor may inject a local anesthetic into the joint. If it temporarily relieves pain, it supports the diagnosis of arthritis.
Treatment
Non-surgical treatment
As with other arthritic conditions, the initial treatment of arthritis of the shoulder is non-surgical. Your doctor may recommend the following treatment options:
- Rest or a change in activities to avoid causing pain. You may need to change the way your arm moves to do things.
- Physical therapy exercises that could improve the range of motion in your shoulder.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, may reduce inflammation and pain. These medications can irritate the lining of the stomach and cause internal bleeding. They should be taken with food. Consult your doctor before taking over-the-counter NSAIDs if you have a history of ulcers or are taking blood-thinning medications.
- Injections of corticosteroids in the shoulder can drastically reduce inflammation and pain. However, the effect is often temporary.
- Humid heat.
- Application of ice on the shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and relieve pain.
- If you have rheumatoid arthritis, your doctor may prescribe a medication that modifies the disease, such as methotrexate.
- Dietary supplements, such as glucosamine and chondroitin sulfate can help relieve pain. (Note: there is little scientific evidence to support the use of glucosamine and chondroitin sulfate to treat arthritis, and the Food and Drug Administration does not control dietary supplements, which could cause negative interactions with other medications. to your doctor before taking dietary supplements).
Surgical treatment
Your doctor may consider surgery if the pain causes you disability and you have no relief with the non-surgical options.
Arthroscopy Cases of mild glenohumeral arthritis could be treated with arthroscopy. During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera obtains images that are displayed on a television screen and the surgeon uses these images to guide miniature-sized surgical instruments.
Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts) instead of the larger incision needed for standard open surgery.
During the procedure, your surgeon can debride (clean) the inside of the joint. Although the procedure relieves pain, it will not eliminate arthritis from the joint. If arthritis progresses, another surgery may be needed in the future.
Replacement of the shoulder joint (arthroplasty). Advanced arthritis of the glenohumeral joint can be treated with shoulder replacement surgery, in which the damaged parts of the shoulder are removed and replaced with artificial components, called prostheses.
( Left ) A conventional total shoulder replacement ( arthroplasty ) mimics the normal anatomy of the shoulder. ( Right ) In a total inverse shoulder replacement, the plastic capsule is inserted into the humerus and the screws of the hemispherical metal component into the shoulder cavity
Surgical replacement options include:
- Hemiarthroplasty. Only the head of the humerus is replaced with an artificial component.
- Total shoulder arthroplasty. The head of the humerus and the glenoid cavity are replaced. A plastic cavity ("cup") fits into the glenoid cavity and a metal hemisphere attaches to the upper part of the humerus.
- Total reverse arthroplasty of the shoulder. In a total inverse shoulder replacement, the cavity and the metal hemisphere are opposite to a conventional total shoulder arthroplasty. The metal hemisphere is fixed to the glenoid cavity, and the plastic cavity (cup) is attached to the upper end of the humerus. A total reverse shoulder replacement works best for people with arthropathy due to a tear in the cuff because it is supported by different muscles - not the rotator cuff - to move the arm.
Resection arthroplasty. The most common surgical procedure used to treat arthritis of the acromioclavicular joint is a resection arthroplasty. Your surgeon may choose to perform this surgery arthroscopically.
In this procedure, a small amount of bone is removed from the end of the clavicle, leaving a space that gradually fills with scar tissue.
Recovery. The surgical treatment of shoulder arthritis is usually very effective in reducing pain and restoring movement. Recovery time and rehabilitation plans depend on the type of surgery performed
Complications As with all surgeries, there are some risks and possible complications. Potential problems after shoulder surgery include infection, excessive bleeding, blood clots, and damage to blood vessels or nerves.
Your surgeon will discuss possible complications with you before your operation.
Future developments
Research is being done on arthritis of the shoulder and its treatment.
- In many cases, it is not known why some people develop arthritis and others do not. Research is being done to discover the causes of shoulder arthritis.
- Joint lubricants, which are currently being used for the treatment of knee arthritis, are also being studied in the shoulder.
- New drugs are being investigated to treat rheumatoid arthritis.
- Much research is being done on shoulder joint replacement surgery, including the development of different prosthetic designs for joints.
- The use of biological materials for the resurfacing of an arthritic shoulder is also being studied. Biological materials are tissue grafts that promote the growth of new tissues in the body and stimulate healing.
Source: Department of Research & Scientific Affairs, American Academy of Orthopedic Surgeons. Rosemont, IL: AAOS; January 2013. Based on data from the National Health Interview Survey, 2008-2011; US Department of Health and Human Services, Centers for Disease Control and Prevention; National Center for Medical Statistics.