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- 1 Introduction
- 2 Mechanism of Injury / Pathological Process
- 3 Clinical Presentation
- 4 Diagnostic Procedures
- 5 Outcome Measures
- 6 Management / Interventions
- 7 Differential Diagnosis
- 8 Future Directions
- 9 References
IntroductionPlease note this article relates to the glenohumeral joint of the shoulder only.
The glenohumeral joint forms where the head of the humerus fits into the glenoid fossa. Glenohumeral osteoarthritis (GH OA) is defined as progressive loss of articular cartilage, resulting in bony erosion, pain, and decreased function. The glenohumeral joint is the third most common large joint to be affected following the knee and hip.
Trauma precedes the condition in most cases, although the injury may have occurred years earlier. Injuries that are associated with the development of osteoarthritis include previous dislocation, humeral head or neck fracture, and large rotator cuff tendon tears and may also include detachments of the superior glenoid labrum from anterior to posterior (SLAP lesions).
It causes significant pain, functional limitation and disability. The loss of shoulder function can lead to depression, anxiety, activity limitations, and job-performance problems.
While the true prevalence of glenohumeral OA is difficult to ascertain, population-based studies have demonstrated that 16.1%–20.1% of adults older than 65 years have radiographic evidence of glenohumeral OA. Primary glenohumeral osteoarthritis is more common in women and in patients over the age of 60.
Mechanism of Injury / Pathological Process
GH OA causes a gradual, progressive, mechanical, and biochemical breakdown of the articular cartilage and other joint tissues, including bone and joint capsule. As the articular surface wears, friction within the joint increases, causing progressive loss of the normal load-bearing surfaces with pain and disability.
The below video gives a great rundown of GH OA starting with details of the pathological process and goes on to nicely summarise the management and future directions.
The typical presenting symptoms are:
- Progressive, activity-related pain that is deep in the joint and often localized posteriorly.
- As the disease progresses, night pain becomes more common.
- For many patients, the pain is present at rest and interferes with sleep.
- In advanced cases, the stiffness creates significant functional limitations.
- Crepitus on ROM
- Joint effusion
NB. In younger patients, prior trauma, dislocation, or previous surgery for shoulder instability are factors associated with the development of osteoarthritis.
Imaging studies are essential to diagnosing degenerative joint disease. In most cases, conventional xrays demonstrate shoulder osteoarthritis. Early in the disease process, radiographic evidence of degenerative joint disease may include joint-space narrowing (mild), osteophytes (small), subchondral sclerosis, cysts, and eburnation or advanced articular cartilage loss. The axillary view provides the best image to look for joint-space narrowing and helps rule out dislocations. Anteroposterior radiography, with the arm held at 45 degrees of abduction, may also show early joint-space narrowing. Computed tomography arthrograms can localize articular defects, whereas MRI reveals soft-tissue pathologies and subtle changes in articular cartilage. Subchondral edema visible on MRI suggests advanced articular cartilage involvement.
SPADI Shoulder Pain and Disability Index (SPADI) was developed to measure current shoulder pain and disability in an outpatient setting. The SPADI contains 13 items that assess two domains; a 5-item subscale that measures pain and an 8-item subscale that measures disability.
Management / Interventions
Treatment of shoulder OA is often controversial and includes both nonoperative and surgical modalities.
Nonoperative modalities should be offered before operative treatment is considered, particularly for patients with mild-to-moderate OA or when pain and functional limitations are modest despite more advanced radiographic changes.
If conservative options fail, surgical treatment should be considered. Although different surgical procedures are available, as in other joints affected by severe OA, the most effective treatment is joint arthroplasty.
Perform a thorough shoulder assessment. This will guide you then your tailored approach to the client.
Education plays an important role. Lifestyle modifications and occupational changes discussed.
Therapy ideally should be initiated before the development of atrophy or contracture, and it should be tailored to the specific needs of the patient. Typical programs include gentle range of motion and isometric strengthening of the rotator cuff and scapulothoracic musculature.
A good home program (HEP) of basic exercises should be given. This could include the following- Pendulum exercise; Passive Internal Rotation; Crossover Arm Stretch; Passive External Rotation; Wall Crawl; Wall Push Up; NB don't give client many exercises in HEP as they are more likely to follow a program that is simple and short. Provide sheet with exercises and dosage.
Rotator Cuff strengthening see link for how to perform and prescribe
Techniques that could be employed include:
Acupuncture and Dry Needling
Scapular Stabilisation Exercises and Scapulohumeral Rhythm Exercises
Shoulder Exercises including Strength Exercises and Stretching Exercises
Soft Tissue Massage
Electrotherapy & Local Modalities eg TENS Machine. see also Current Concepts in Electrotherapy
Kinesiology Tape, Supportive Taping & Strapping
Includes: salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs), which can all be effective in relief of pain and inflammation. In particular randomized trials indicate that NSAIDs are more effective than both paracetamol and placebo for pain relief of OA. See risks of NSAIDs here
May provide pain relief in patients with shoulder OA. Because of the lack of evidence supporting their efficacy, no more than three corticosteroid injections in a single joint are recommendable unless there are special circumstances. Some evidence exists supporting viscosupplementation for shoulder OA. Some evidence reported that glenohumeral viscosupplementation resulted in a significant improvement in shoulder pain and function outcome scores 6 months following injection
Shoulder surgery is considered for GH OA pain that does not respond to nonsurgical measures. Improved function is not the goal of surgery and is less predictably achieved than pain relief. The choice of treatment then depends on both patient and disease features. Patient features include age, occupation, activity level, and the expectations for functional recovery. Disease features include the lesion size and the extent of chondral involvement.
- Labral Tear
- Septic Arthritis
- Rotator Cuff Injury
- Cervical Disc Disease with radiculopathy into Shoulder
- Adhesive Capsulitis (Frozen Shoulder)
- Polymyalgia Rheumatica (affects Shoulder in 95% of cases)
- Systemic Lupus Erythematosus
In the future having a great physiotherapist (up to date on the topic) will continue to be essential. That means having
- A solid background on the pathology of arthritis
- Excellent MSK examination skills
- Knowledge of evidence-based treatments
- Knowledge of exercise prescription for special populations
- Strong communication skills
Research in 2018 reports of a bright spot on the horizon using hyaluronic acid. It is a choice given in the non surgical options for management of OA. Osteoarthritis is a debilitating disease that affects a large portion of the population, and as the population continues towards an older age, the prevalence of the disease is going to go up. Hyaluronic acid potentially helps lower the side effects of OA on joints. Its effectiveness is due to the many methods of actions it deploys, including lubrication, anti-inflammatory and chondroprotective effects. Treatment can be done both orally and through intra-articular injections. New products are continuously being developed that change the composition of the molecule as well as pairing it with other drugs to maximize the effect. However a 2015 report on the effects of these injections versus physiotherapy treatment concluded that physical therapy agents seemed to have greater effects than intra-articular viscosupplementation on disability and pain. In the other cases, both intra-articular viscosupplementation and physical and rehabilitative interventions seemed to be equally effective in improving disability, pain, and quality of life.
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