Shoulder Pain Management

Glenohumeral Arthritis

Nonoperative management is the typical initial treatment course for glenohumeral arthritis, although treatment may vary depending on disease etiology. Nonoperative treatment goals include symptomatic relief and maintenance of function.

Figure 5: CT scan of glenohumeral osteoarthritis showing posterior glenoid erosion and joint space narrowing, humeral head osteophyte formation and an anterior loose body.¹

Treatment Options
• Modified activity
• Maintain range-of-motion with physical therapy
• NSAIDs
• Total shoulder replacement for advanced arthritis

Key Clinical Points

Patients should be advised to modify activity that exacerbates symptoms, especially activities that heavily tax the glenohumeral joint. Pain may be controlled in the short term by the use of NSAIDs and intra-articular corticosteroids. Corticosteroid injections should be limited to four per year, as overuse may cause cartilage and cuff degeneration. Steroid injections may be accompanied by these side effects:

• Skin blanching
• Local fat atrophy
• Infection
• Transient hyperglycemia in patients with diabetes

A maximum 3 to 6 month course of conservative treatment is recommended prior to surgical evaluation. Conservative therapy has been shown to improve post-surgical outcomes for those patients who require surgery.
Physical therapy should be encouraged to increase strength and range-of-motion. Physical therapy typically begins with gentle stretching and focuses more on strengthening as pain resolution allows. Repetitive, low-impact exercises should be encouraged to maintain flexibility.

Patient Considerations

The main goals of nonoperative treatment are symptomatic relief and maintenance of function. Therefore, patient activity modification should focus on avoiding activities that place large loads on the glenohumeral joint. Physical therapy is typically performed as a home program and is aimed at regaining motion and strength.² Exercises are first directed at regaining motion and flexibility by gentle, frequent stretching. As pain, inflammation and/or stiffness resolve, more attention can be focused on strengthening the deltoid, rotator cuff and other periscapular muscles. Aerobic activities that involve repetitive, nonimpact shoulder motion, such as swimming and walking, can also be encouraged to maintain flexibility.³

Clinical Course

The clinical course for patients with glenohumeral arthritis is much like other joints with osteoarthritis. Over time, the arthritis gradually becomes more severe and it may take decades for the symptoms to become very severe. Throughout the clinical course, symptoms are usually intermittent and may depend upon activity level. Surgical interventions may be effective but should be reserved for patients failing conservative therapy over a prolonged period of time and having significant structural changes within the joint.

Know When to Refer
• Patient not responding to nonoperative treatment after 6 months
• Rheumatoid or inflammatory arthritis
• Osteonecrosis
• Rotator cuff arthropathy
• Post-traumatic or postsurgical arthritis (i.e., prior arthritis or instability surgery)
• Intractable shoulder instability
• Charcot or neuropathic arthropathy

References