Degenerative Arthritis of the Shoulder

THE CLINICAL SYNDROME

The shoulder joint is susceptible to the development of arthritis from a variety of conditions that have in common the ability to damage the joint cartilage. Osteoarthritis is the most common cause of shoulder pain and functional disability. It may occur after seemingly minor trauma or may be the result of repeated microtrauma. Pain around the shoulder and upper arm that is worse with activity will be present in most patients suffering from osteoarthritis of the shoulder. Difficulty in sleeping is also common, as in progressive loss of function.

Range of motion of the shoulder can precipitate the pain of osteoarthritis of the shoulder.

SIGNS AND SYMPTOMS

The majority of patients presenting with shoulder pain secondary to osteoarthritis, rotator cuff arhtropathy, and post-traumatic arthritis pain will present with the complaint of pain that is localized around the shoulder and upper arm. Activity makes the pain worse, with rest and heat providing some relief. The pain is constant and characterized as aching in nature. The pain may interfere with sleep. Some patients will complain of a grating or popping sensation with use of the joint, and crepitus may be present on physical examination. In addition the pain, patients suffering from arthritis of the shoulder joint will often experience a gradual decrease in functional ability with decreasing shoulder range of motion, making simple everyday tasks such as hair combing, fastening a brassiere, or reaching overhead quite difficult. With continued disuse, muscle wasting may occur and a frozen shoulder may develop.
Osteoarthritis of the joint is the most common form of arthritis that results in shoulder joint pain. However, rheumatoid arthritis, post-traumatic arthritis, and rotator cuff tear arhtropathy are also common causes of shoulder pain secondary to arthritis. Less common causes of arthritis-induced shoulder pain include the collagen vascular diseases, infection, villonodular synovitis, and Lyme disease. Acute infectious arthritis will usually be accompanied by significant systemic symptoms, including fever and malaise, and should be easily recognized by the astute clinician and treated appropriately with culture and antibiotics, rather than injection therapy. The collagen vascular diseases will generally present as a polyarthropathy rather than as a monoartropathy limited to the shoulder joint, although shoulder pain secondary to collagen vascular disease responds exceedingly well to the intra-articular injection technique described here.

TREATMENT

Initial treatment of the pain and functional disability associated with osteoarthritis of the shoulder should include a combination of the nosteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. For patients who do not respond to these treatment modalities, an intra-articular injection of local anesthetic and steroid may be a reasonable next step. Intra-articular injection of the shoulder is performed by placing the patient in the supine position and preparing with antiseptic solution the skin overlying the shoulder, subacrominal region, and joint space. A sterile syringe containing 2.0 mL of 0.25% preservative-free bupivacaine and 40 mg methylprednisolone is attached to a 1 ½ inch 25-gauge needle using strict aseptic technique. With strict aseptic technique, the midpoint of the acromion is identified. The needle is then carefully advance through the skin and subcutaneous tissues through the joint capsule into the joint. If bone is encountered, the needle is withdrawn into the subcutaneous tissue and redirected superiorly and slightly more medial. After entering of the joint space, the contents of the syringe are gently injected. There should be little resistance to injection. If resistance is encountered, the needle is probably in a ligament or tendon and should be advanced slightly into the joint space until the injection proceeds without significant resistance. The needle is then removed, and a sterile pressure dressing and ice pack are placed at the injection site.

Osteoarthritis of the shoulder. The radiograph shows all the features of a "hypertrophic" form of osteoarthritis of the glenohumeral joint, with joint space narrowing, subchondral sclerosis, large cysts in the glenoid, and the massive inferior osteophytosis that is characteristic of this condition.

Osteoarthritis of the shoulder is a common complaint encountered in clinical practice. It must be separated from other causes of shoulder pain, including rotator cuff tears. Intra-articular injection of the shoulder is extremely effective in the treatment of pain secondary to the aforementioned causes of arthritis of the shoulder joint. Coexistent bursitis and tendonitis may also contribute to shoulder pain and may require additional treatment with more localized injection of local anesthetic and methylprednisolone acetate steroid. This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile technique to avoid infection, and to use universal precautions to avoid risk to the operator. The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection. The use of physical modalities including local heat as well as gentle range of motion exercises should be introduced several days after the patient undergoes this injection technique for shoulder pain. Vigorous exercises should be avoided because they will exacerbate the patient’s symptomatology. Simple analgesics and nonsteroidal anti-inflammatory drugs or a cyclooxygenase-2 inhibitor may be used concurrently with this injection technique.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue .Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.