Shoulder Pain Management

Glenohumeral Arthritis

Glenohumeral arthritis may affect 1 in 5 adults and is much less common than arthritis of the knee or hip. Osteoarthritis is the most common etiology of glenohumeral arthritis. However, other diseases, such as rheumatoid or inflammatory arthritis, osteonecrosis, rotator cuff arthropathy and posttraumatic or postsurgical arthritis, can cause the condition.^1-3 Etiology may dictate potentially appropriate treatment.

Pain is the most common complaint in patients with glenohumeral arthritis. Some patients will also complain of shoulder stiffness, and some may have a sensation of crepitus with shoulder movement. Symptoms usually begin gradually, but become chronic and progressive. Discomfort is worsened with activity and may affect sleep, especially if they sleep on the affected shoulder.¹ Functional limitations may include the inability to perform overhead activities or reach behind the back or under the opposite axilla with the affected arm.³

Key Observations
• Glenohumeral arthritis occurs much less frequently than arthritis in the knee or hip
• Pain and stiffness are the most common complaints
• Onset is gradual and becomes chronic and progressive
• Patient history may provide important diagnostic clues

It is important to characterize the onset and duration of symptoms as well as the degree of functional limitation and the patient’s activity level when taking the patient history.⁴ Document all prior treatments, including physical therapy, NSAIDs, steroid injections and surgeries on the shoulder. Obtaining an overall medical history can provide information about disease severity or predisposing factors for glenohumeral arthritis, such as steroid use in rheumatoid arthritis patients or radiation exposure in patients with osteonecrosis of the humeral head.^1,4

Clinical Clues
• More likely in older adult or senior patients with a long history of intermittent shoulder symptoms
• Progressive pain and limitation in motion are primary symptoms
• X-rays show degeneration of the joint

The physical examination will help to confirm the diagnosis when patient history suggests arthritis. Examination of the cervical spine will help rule out any abnormalities, including radiculopathy and degenerative joint disease that may cause referred pain, stiffness or weakness in the shoulder. Inspect the affected shoulder for any prominence, atrophy or asymmetry compared with the contralateral side, as well as prior surgical scars. Disuse of the affect shoulder may have resulted in atrophy.

Palpate the shoulder to define areas of tenderness. Although tenderness is often nonspecific, posterior joint line tenderness is typical in osteoarthritis, while anterior and lateral tenderness is more typical of inflammatory arthritis.¹ Muscle strength and range of motion should also be assessed. Range of motion should be assessed actively and passively and compared with the unaffected side. Typically, both active and passive motion are restricted in glenohumeral arthritis in multiple planes. Chronic stiffness and anterior capsular contracture commonly cause decreased external rotation (Fig. 1).⁴

Prior trauma or surgery may have caused specific patterns of restricted motion, such as a loss of external rotation in patients with previous surgical stabilization for anterior shoulder instability. Active or passive motion can provoke pain and crepitus in the glenohumeral joint.³ Rotator cuff, deltoid and other shoulder girdle muscle strength should be assessed.⁴

Figure 1: Decreased external rotation of the right shoulder from osteoarthritis of the glenohumeral joint.⁵

Confounding Sources of Pain
• Charcot or neuropathic arthropathy
• Septic shoulder
• Adhesive capsulitis
• Brachial plexus injury
• Peripheral nerve injury
• Radiculopathy
• Axillary-subclavian venous thrombosis
• Referred pain of cardiac, pulmonary or visceral origin
• Soft tissue or bone tumor

Clinical Course

Patients with glenohumeral arthritis will have a similar clinical course to other joints with osteoarthritis. Symptoms are usually intermittent, but gradually become more severe and will depend on activity. It may take decades for symptoms to become significant. Surgical interventions, such as total shoulder arthroplasty, provide good results, but should be reserved for patients failing conservative therapy and with significant structural changes within the joint.

Glenohumeral arthritis is less common than arthritis of the hip or knee, but it can be just as debilitating. Initial management should consist of nonoperative treatment. For those patients who fail nonoperative management, shoulder replacement with the primary goal of relieving pain may be the best option.

Know When to Refer
• Patient not responding to nonoperative treatment after 6 months
• Suspected rheumatoid or inflammatory arthritis
• Suspected osteonecrosis
• Rotator cuff arthropathy
• Posttraumatic or postsurgical arthritis (i.e., prior arthritis or instability surgery)
• Intractable shoulder instability
• Charcot or neuropathic arthropathy

The ICD9 code for glenohumeral arthritis of the shoulder joint is 716.91 (Unspecified arthropathy involving shoulder region).

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References