Shoulder Arthritis (Glenohumeral Arthritis)

Definition

Glenohumeral arthritis (more commonly known as shoulder arthritis) is defined as the loss of articular cartilage within the shoulder joint. The shoulder joint is made up of the humeral head and the shallow glenoid fossa of the scapula. Soft tissue contractures, rotator cuff dysfunction, and bone erosion often accompany arthritis of the shoulder and are important considerations when deciding on an appropriate treatment plan. When dealing with an arthritic shoulder it is vital to consider the integrity of the rotator cuff; the outcome of surgery is greatly dependent on the integrity or reparability of the rotator cuff. Conditions such as osteoarthritis, posttraumatic arthritis, and avascular necrosis are usually associated with an intact or reparable rotator cuff. However, rotator cuff arthropathy, a unique form of glenohumeral arthritis, only occurs in the context of a large, irreparable rotator cuff tear. Other conditions, including inflammatory arthritides, may also been associated with a non-functional cuff and is an important consideration for surgery.

 XRay illustrating advanced, end-stage osteoarthritis of the glenohumeral (shoulder) joint.

XRay illustrating advanced, end-stage osteoarthritis of the glenohumeral (shoulder) joint.

Pathogenesis

In most cases, the specific cause of glenohumeral arthritis is unknown, termed primary or idiopathic osteoarthritis. However, the loss of articular cartilage may be associated with previous trauma or fractures of the joint (post-traumatic arthritis), avascular necrosis, or various autoimmune or inflammatory conditions affecting the shoulder (ex. rheumatoid arthritis). Primary osteoarthritis may be related to anatomic factors such as glenoid hypoplasia or increased retroversion, but for most patients no cause is evident. In avascular necrosis (AVN), arthritis results after collapse of the humeral head. Involvement of glenoid articular cartilage does not occur until the later stages of the disease when the irregular humeral head has been articulating with the previously normal glenoid surface. Rheumatoid arthritis (RA) is caused by the immune system activating and releasing excessive lymphocytes into the joint and synovial tissue. Cytokines, destructive enzymes, interleukins, and tumor necrosis factor are also released, which trigger the gradual destruction of the articular cartilage over time.

Natural History

Glenohumeral arthritis leads to progressive stiffness, pain, and loss of function of the shoulder. Full thickness rotator cuff tears only occur in 5% to 10% of the patients with primary arthritis. Rheumatoid arthritis results in progressive regional osteopenia, central glenoid bone erosion, and rotator cuff tears. Full thickness rotator cuff tears in RA occur in 25% to 40% of the patients, but rotator cuff dysfunction and tearing are very common.

Clinical Presentation

A patient with shoulder arthritis typically presents with severe, escalating shoulder pain, loss of range of motion (primarily external rotation of the shoulder), difficulty sleeping, and loss of shoulder function. Physical examination will focus on the integrity and function of the rotator cuff, which is important to consider when deciding on the appropriate treatment approach.

Differential Diagnosis

  • Frozen shoulder

  • Posttraumatic or post-surgical infection

  • Cervical stenosis

  • Cervical radiculopathy

  • Neoplasm

 Nonoperative Management

  • Avoid activities that exacerbate the pain such as weight lifting or overhead activities (activity modification).

  • NSAIDs (Non-steroidal anti-inflammatories)

  • Intra-articular injections:

    • Corticosteroid injections

    • Hyaluronic Acid (not yet approved by the FDA)

    • Platelet-rich plasma or BMAC injections

  • Physical therapy

Surgical Management

Surgical options for the management of advanced glenohumeral arthritis include:

  • Total shoulder arthroplasty/replacement (TSA)

  • Hemiarthroplasty

  • Reverse shoulder arthroplasty (RSA)

  • Arthroscopic debridement

  • Arthrodesis

The primary indications for a total shoulder arthroplasty (TSA) include the failure of an extensive course of non-operative management with an intact rotator cuff in the context of advanced osteoarthritis. In comparison, the primary indication for a reverse shoulder arthroplasty (RSA) is an irreparable rotator cuff tear in the context of advanced osteoarthritis.

If you are suffering from shoulder pain or arthritis, contact Dr. Dold for a consultation today!

Clinical Studies

 Xray of the left shoulder following total shoulder arthroplasty (TSA).

Xray of the left shoulder following total shoulder arthroplasty (TSA).

   

Adhesive Capsulitis (Frozen Shoulder)

Definition

Adhesive capsulitis, more commonly referred to as “frozen shoulder”, is a poorly defined syndrome. However, most can agree that adhesive capsulitis is characterized by the restriction or loss of both passive and active range of motion (ROM) without an osseous basis for this limitation due to soft tissue contracture of the glenohumeral joint. Shoulder stiffness can be caused by tissue scarring or intra-articular, subacromial, and/or subdeltoid adhesions, as well as changes in the osseous structures of the shoulder. The key component to recognize adhesive capsulitis is the loss of range of motion, primarily passive external rotation, of the glenohumeral joint. One exception to this key component is calcific tendonitis, which may be distinguished from adhesive capsulitis on a plain radiograph.

Adhesive capsulitis is broken down into two forms:

  1. Primary Adhesive Capsulitis (Idiopathic)

  2. Secondary Adhesive Capsulitis:

-       Intrinsic: Corresponding with rotator cuff disorders, biceps tendinitis, calcific tendinitis, previous shoulder surgery, and proximal humerus fracture.

-       Extrinsic: Problematic occurrence extrinsic to the glenohumeral joint such as a previous ipsilateral breast surgery, cervical radiculopathy, previous fracture of the shoulder, acromioclavicular joint arthritis, clavicular fracture, or a scapulothoracic abnormality.

-       Systemic: Corresponding with disorders such as diabetes mellitus, hyperthyroidism, hypothyroidism, hypoadrenalism, or myocardial infarction. Systemic adhesive capsulitis is most commonly associated with diabetes mellitus, and rarely these other conditions listed.

Anatomy

The motion of the shoulder is executed primarily at the articulation in the glenohumeral joint and scapulothoracic joint. The ratio of motion between the two articulations is 2:1, respectively. Capsuloligamentous structures are accredited with providing stability to the shoulder joint. Within the capsule are ligaments that provide support: the superior glenohumeral ligament, the coracohumeral ligament, the middle glenohumeral ligament, and the inferior glenohumeral ligament complex. The inferior glenohumeral ligament complex is comprised of the anterior band, axillary fold, and the posterior band. The superior glenohumeral ligament and coracohumeral ligament are located in the triangular shaped region, called the rotator interval, that lies between the anterior border of the supraspinatus tendon and the superior border of the subscapularis. During rotator cuff lengthening and shortening, these ligaments are tightened and loosened. Specific restrictions or loss of range of motion correspond to the contractures of the capsule regions and ligaments.

Contractures of the Capsuloligamentous Region & Correlation to Shoulder Motion:

Adhesive Capsulitis.png

Pathogenesis

Adhesive capsulitis is most commonly seen in women and in patients between the ages of 40 and 60. Clinically, the disorder is categorized into three different stages:

Stages of Adhesive Capsulitis.png

Natural History

The time course and final results are widely variable in adhesive capsulitis. There is also a weak correlation between pain and a restricted ROM. Some patients experience a very restricted ROM accompanied with no pain, while others experience normal ROM with significant shoulder pain. However, the impact that the restricted ROM will produce greatly depends on the patient’s functional demands. Adhesive capsulitis is more resistant to a nonoperative approach when it occurs in systemic cases, such as diabetes mellitus.

Patient History

Although patients with adhesive capsulitis deny a traumatic event, secondary adhesive capsulitis is often a result of trauma, surgery, or medical comorbidities. One should take note of previous fractures, extended immobilization, previous surgeries, diabetes mellitus, and thyroid disorders. Important surgeries to take note of include a prior rotator cuff repair, capsular shift, Putti-Platt, Bristow-Latarjet, open glenoid grafting, and ORIF (open reduction and internal fixation) of a fracture around the shoulder. Other symptoms that could be expressed by the patient are acromioclavicular (AC) joint pain, periscapular pain, radicular deltoid pain, and a painful arc motion.

Physical Exam

A physician may utilize the following in their diagnosis:

  • Bilateral passive ROM examination tests

  • Assessment of the anterosuperior capsule: Indicated by a loss of passive external rotation in adduction.

  • Assessment of the anteroinferior capsule: Indicated by a loss of passive external rotation with abduction of the arm.

  • Assessment of the inferior capsule: Indicated by a loss of passive flexion and abduction.

  • Assessment of the posterior capsule: Indicated by a loss of passive internal rotation.

 Furthermore, the shoulder may be examined for signs of trauma, past surgeries and deformities. Other tests such as manual motor testing, passive and active ROM testing, ROM testing in the supine position, and the Lidocaine intra-articular injection test may be performed to help make an accurate diagnosis.

Imaging/Diagnostics

Disuse osteopenia, calcific tendinitis, fractures, arthritis, and surgical hardware can be identified through routine radiographs in the anteroposterior (AP) view, neutral, internal and external rotation views, and the Y and axillary lateral views. An MRI (magnetic resonance imaging) is ordered only in the event of a suspected rotator cuff or soft tissue injury. The loss of axillary recess on an MR Arthrogram typically indicates contracture of the joint capsule which can be associated with adhesive capsulitis.

Differential Diagnosis

  • Glenohumeral Arthritis

  • Acromioclavicular Arthritis

  • Rotator Cuff Tendinitis

  • Subacromial or Subdeltoid Bursitis

  • Bicipital Tendinitis

  • Calcific Tendinitis

  • Septic Arthritis

  • Rotator Cuff Tears

  • Gout or crystalline arthropathy

  • Cervical Radiculopathy

  • Thoracic Outlet Syndrome

Nonoperative Treatment

A nonoperative approach is typically the first line of treatment in most cases. It is best utilized in patients with primary or secondary adhesive capsulitis within a time period of four to six months that have yet to have any treatment. Nonsteroidal anti-inflammatories (NSAIDs), physical therapy, and intra-articular steroid injections form the basis of a conservative management approach. This approach is successful in most cases, however the patient needs to understand the natural history and time course of the disorder. The most common complication is decreased range of motion compared to the contralateral shoulder. 

Surgical Management

Surgery is not the best option for early-stage adhesive capsulitis. In fact, surgery should be avoided during the “freezing stage” as it may limit ROM that could potentially be recovered nonoperatively. The primary indication for surgery in adhesive capsulitis is a failure to improve with an extensive course of conservative management, including NSAIDs, a organized course of physical therapy, and intra-articular steroid injections. Surgery consists of a manipulation under anesthesia followed by an arthroscopic lysis of adhesions and release of the rotator interval (anterior capsule).

If you are suffering from a stiff, painful (possibly frozen) shoulder, contact Dr. Dold for an appointment today! 469.850.0680

Clinical Studies