Shoulder Pain Management
Myths About Shoulder Pain
Myth: Shoulder pain is just part of aging.
Reality: Pain and stiffness of the shoulder are common complaints, particularly in the 40-80 year age group. Shoulder complaints are typically the result of injury or degenerative disease. A review of CPT codes of medical issues for various joints indicates the shoulder is the most commonly coded joint region, surpassing spine, hip, or knee.1 There are several causes of painful, stiff shoulders, but the most common cause in the fifth decade of life is frozen shoulder. The most common cause for pain in the shoulder is a disorder of the rotator cuff complex. Stiffness is often secondary to pain, but also can be caused directly by capsular tightness and loss of glenohumeral joint capsular volume. Shoulder pain and stiffness also may be caused by glenohumeral arthritis.2 Arthritic cartilage differs from aging cartilage in the levels of Type II collagen, water and degenerative enzyme activity found in the cartilage.3
Although conservative treatment for shoulder pain includes medication, there are additional ways in which shoulder pain can be treated, such as weight management, physiotherapy, arthroscopic debridement, arthrodesis and arthroplasty.3
Myth: Elderly patients are not candidates for shoulder surgery.
Reality: Although age >75 may predict a lower surgical treatment success rate, shoulder surgery may be possible for eligible patients of advanced years.5
In a prospective study of 125 patients (ages 32-80 with a mean age of 56) with chronic full-thickness rotator cuff tear, researchers evaluated the relationship between medical comorbidities (the presence of two or more diseases in the same individual) and the postoperative outcome of rotator cuff repair. The patients were evaluated on the basis of a history (including medical comorbidities) and use of outcome tools preoperatively and at one year after rotator cuff repair. Outcome was evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire, the Simple Shoulder Test (SST), visual analog scales (pain, function, and quality of life), and the Short Form-36 (SF-36). The patient history self-assessment questionnaire addressed general medical problems. This questionnaire asked a series of yes-or-no questions regarding the presence of comorbid medical conditions including: heart disease, high blood pressure, lung disease, diabetes, ulcer or stomach disease, kidney disease, liver disease, anemia or other blood disease, cancer, depression, osteoarthritis or degenerative arthritis, back pain, rheumatoid arthritis and the presence or absence of hypertension, coronary artery disease, other heart problems (valvular or arrhythmia), respiratory problems, pulmonary embolus, cerebral vascular accident, headaches/migraines. In general, rotator cuff repair resulted in substantial improvements in outcomes, with significant improvements recorded in physical function [p=0.02], role physical [p<0.001], bodily pain [p=0.001], vitality [p=0.04], social function [p=0.02], and role emotional [p=0.03].6 Only mental health [p=.17] and general health [p=.78] did not improve significantly. Patients with more medical comorbidities had a worse general health status after rotator cuff repair. It also appeared that these patients had greater improvement in overall shoulder pain, function, and quality of life scores compared with preoperative scores. Therefore, despite a negative effect of comorbidities on outcomes, patients with more comorbidities had greater improvement after the repair, to the point where postoperative shoulder function and pain were not significantly influenced by medical comorbidities. Even though this study does not extrapolate results specific to those patients of advanced years, the study group did include patients older than 65 years old (exact number not specified).6
In another prospective, randomized, double-blind clinical trial of 41 patients (ages 61-79) with osteoarthritis of the shoulder, researchers compared the quality-of-life outcome following hemiarthroplasty with that following total shoulder arthroplasty.4 The patients included in the study had a diagnosis of primary osteoarthritis of the shoulder, had a failure of a minimum of six months of nonoperative treatment (including analgesics, anti-inflammatory medication, and physiotherapy), and wished to have surgical intervention. Primary osteoarthritis of the shoulder was defined as shoulder pain; no history of major trauma, infection, osteonecrosis, cuff tear arthropathy, chronic dislocation, or a secondary cause of osteoarthritis; and radiographic evidence of joint space narrowing, osteophyte formation, and/or subchondral sclerosis. The 41 patients were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. One patient died, and all others were evaluated preoperatively and at six weeks and three, six, twelve, eighteen, and twenty-four months postoperatively with use of a standardized format including a disease-specific quality-of-life measurement tool (Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder rating scales (University of California at Los Angeles [UCLA] shoulder scale, Constant score, and American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (McGill pain score and visual analogue scale), and a global health measure (Short Form-36 [SF-36]). When a patient required revision of a hemiarthroplasty to a total shoulder arthroplasty, the last score before he or she “crossed over” was used for the analysis. Significant improvements in disease-specific quality of life were seen two years after both the total shoulder arthroplasties and the hemiarthroplasties. There were no significant differences in quality of life (WOOS score) between the group treated with total shoulder arthroplasty and that treated with hemiarthroplasty (90.6 + 13.2 and 81.5 + 24.1 points, respectively; p=0.18). The other outcome measures demonstrated similar findings. Two patients in the hemiarthroplasty group crossed over to the other group by undergoing a revision to a total shoulder arthroplasty because of glenoid arthrosis. Both total shoulder arthroplasty and hemiarthroplasty improved disease-specific and general quality-of-life measurements of physical symptoms, sports/recreation/work, lifestyle, and emotions.
Finally, a study conducted between 1992 and 2002 included a total of 316 primary total shoulder arthroplasties in 275 patients having a diagnosis of degenerative joint disease (DJD) - 204 shoulders, secondary DJD (2°DJD) - 53 shoulders, capsulorrhaphy arthropathy (CA) - 23 shoulders, or rheumatoid arthritis (RA) - 36 shoulders. A minimum of 2-year follow-up data was available for 272 shoulders in 229 patients (86% follow-up) and mean age across the entire group of 57 years old. The study compared patients’ self-assessed deficits in comfort, function, and health status before and after total shoulder arthroplasty for the four different diagnoses of degenerative joint disease (DJD), secondary DJD (2°DJD), rheumatoid arthritis (RA), and capsulorrhaphy arthropathy (CA). Deficits were assessed by the Simple Shoulder Test and Short Form-36 (SF-36) questionnaires. There was a significant difference among diagnoses for preoperative and postoperative functional deficits. The profiles of improvement within the categories of comfort, motion, strength, and function were different for each diagnosis. Patients with DJD and CA were most improved in the category of motion, whereas those with 2°DJD and RA were most improved in the category of comfort. There was also a statistically significant difference in 5 of the 8 domains of the preoperative SF-36 among diagnoses. Total shoulder arthoplasty resulted in significant improvement in comfort and function in the treatment of glenohumeral joint disease, but the magnitude of this improvement, as well as the profile of gains in the individual categories of comfort, motion, strength, and ability, differs according to presenting diagnosis. Factors associated with each diagnosis played a significant role in determining the magnitude of preoperative deficits and postoperative improvement in shoulder function.7
Myth: Patients should wait as long as possible to undergo shoulder replacement surgery.
Reality: While a short period of conservative treatment (maximum 3-6 months) is appropriate for many patients and may provide symptom resolution, patients should be referred to an orthopaedic shoulder specialist for:8
- Pain and significant disability lasting more than 6 months, despite activity modification, physical therapy and corticosteroid injections, where indicated.
- A history of instability or acute, severe posttraumatic acromioclavicular pain.
- Pain that impacts the lifestyle and activities of the patient, such as disturbed sleep, difficulty brushing hair, eating soup or reaching for objects.
- Diagnostic uncertainty.
Because unsatisfactory prognosis is associated with severe or recurrent symptoms at presentation,8 early referral to an orthopaedic shoulder specialist, regardless of patient’s age, may impact the potential for post-surgery success. This clinical review utilized a simplified classification of shoulder problems, incorporating diagnostic techniques applicable to a primary care consultation and a “red flag” system to identify potentially serious disease. The review incorporated the latest consensus from systematic review and publications. The review concluded that shoulder pain is a common and important musculoskeletal problem. Management should be multi-disciplinary and include self help advice, analgesics, relative rest, and access to physiotherapy. Steroid injections have a marginal short term effect on pain. Poorer prognosis is associated with increasing age, female sex, severe or recurrent symptoms at presentation, and associated neck pain. Mild trauma or overuse before onset of pain, early presentation, and acute onset have a more favorable prognosis. Surgery should be considered when conservative measures fail.8
Myth: Shoulder replacement is an experimental procedure.
Reality: Shoulder implants were first introduced in the early 1950s.10 The shoulder is the third most replaced joint in America. Over 60,000 Americans had shoulder replacement procedures in 2008 and the number is expected to rise to over 64,000 by the year 2010.11
A 7-year study (1994-2001) showed that shoulder arthroplasty had low rates for complications, comparable to hip and knee arthroplasty.12 The study compared the inpatient mortality, complications, length of stay, and total charges of patients who had shoulder arthroplasty for osteoarthritis with those of patients who had hip and knee arthroplasties for osteoarthritis. A review of the Maryland Health Services Cost Review Commission discharge database identified 994 shoulder arthroplasties (average age 69.2 years), 15,414 hip arthroplasties (average age 66.5 years), and 34,471 knee arthroplasties (average age 68.1 years) performed for osteoarthritis. There were no in-hospital deaths after shoulder arthroplasty, whereas 27 (.18%) and 54 (.16%) deaths occurred after hip and knee arthroplasties, respectively. Compared with patients who had hip or knee arthroplasties, patients who had shoulder arthroplasties had, on average, a lower complication rate, a shorter length of stay, and fewer total charges. Patients who had shoulder arthroplasty had half as many in-hospital complications as those with hip or knee arthroplasties and were 1/6 as likely to have a length of stay 6 days or greater, and were 1/10 as likely to be charged more than $15,000. In this study, shoulder arthroplasty was considered comparable to the more commonly performed major joint arthroplasties.
Also, shoulder replacements have seen advanced technology in recent years. A study was conducted between 1985 and 1991 to determine the results, the risk factors for an unsatisfactory outcome, and the failure rates of total shoulder arthroplasty with a cemented metal-backed glenoid component. During that time period, 100 total shoulder arthroplasties with cemented metal-backed glenoid components were performed to treat osteoarthritis. The mean age (and standard deviation) of the patients was 68 ± 8 years. The study group included sixty-one men and thirty-three women. Ninety-five shoulders were followed for a minimum of two years (mean 10.8 years) or until the time of revision surgery. Patients were assessed with use of a modified Neer rating system at the time of the latest follow-up. Radiographs of eighty-three shoulders were assessed for the presence of glenoid erosion, glenohumeral subluxation, periprosthetic lucency, and a shift in component position. Total shoulder arthroplasty with a cemented metal-backed glenoid component was significantly associated with pain relief as well as with an improvement in abduction and external rotation. According to the modified Neer result-rating system, the result was excellent in forty-seven shoulders, satisfactory in twenty-seven shoulders, and unsatisfactory in twenty-one shoulders. Five patients underwent revision surgery because of component loosening (two patients), component subluxation (one patient), a fracture distal to the stem (one patient), and polyethylene wear (one patient). Glenoid periprosthetic lucency was present in sixty-nine (83%) of eighty-three shoulders at a minimum radiographic follow-up of two years. The survival rates at 5, 10 and 15 years for these implant components were estimated to be 98%, 97% and 93% respectively.9
- Joshi D. Pearldiver Inc., Orthopedic’s #1 Diagnosis. June 17, 2008. http://www.pearldiverinc.com. Accessed on 6/16/2009
- Bhargav D, Murrell GA. “Shoulder Stiffness: Diagnosis.” Aust Fam Physician. 2004;33:143-147.
- “Pathophysiology of Osteoarthritis.” John Hopkins Arthritis Center: http://www.hopkins-arthritis.org/arthritis-info/osteoarthritis/pathophysiology.html.
- Lo IK, Litchfield RB, et al. “Quality-of-Life Outcome Following Hemiarthroplasty or Total Shoulder Arthroplasty in Patients with Osteoarthritis: A Prospective, Randomized Trial.” J Bone Joint Surg Am. 2005;87:2178-2185.
- Simmen BR, Bachmann LM, et al. “Development of a Predictive Model for Estimating the Probability of Treatment Success One Year After Total Shoulder Replacement: Cohort Study.” Osteoarthritis Cartilage. 2008;16:631-634.
- Tashjian RZ, Henn RF, et al. “Effect of Medical Co-Morbidity on Self-Assessed Pain, Function, and General Health Status After Rotator Cuff Repair.” J Bone Joint Surg Am. 2006;88:536-540.
- Parsons IM, Campbell B, et al. “Characterizing the Effect of Diagnosis on Presenting Deficits and Outcomes After Total Shoulder Arthroplasty.” J Shoulder Elbow Surg. 2005;14:575-584.
- Mitchell C, Adebajo A, et al. “Shoulder Pain: Diagnosis and Management in Primary Care.” BMJ. 2005;331:1124-1128.
- Tammachote N, Sperling JW, et al. “Long-Term Results of Cemented Metal-Backed Glenoid Components for Osteoarthritis of the Shoulder.” J Bone Joint Surg Am. 2009;91:160-166.
- “Shoulder Joint Replacement.” American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=A00094
- Millennium Research Group. U.S. Markets for Small-Joint Devices 2008.
- Farmer KW, Hammond JW, et al. “Shoulder Arthroplasty Versus Hip and Knee Arthroplasties: A Comparison of Outcomes.” Clin Orthop Relat Res. 2007;455:183-189.