Background and Etiology
The shoulder is composed of three osseous joints and one articulation, with stability provided by muscles, ligaments, the glenoid labrum and joint capsule.
Bone and Joint
The glenohumeral joint of the shoulder is a ball and socket joint between the head of the humerus, the upper arm bone (ball) and the glenoid fossa of the scapula (socket) or shoulder blade. The head of the humerus is large and the glenoid fossa is small, resulting in an unstable but mobile joint.
The bony joint surfaces of the head of the humerus and the glenoid fossa are covered with articular cartilage. The articular cartilage has a smooth and shiny surface that allows the ends of the bones to slide freely over each other. This is what enables the joint to move smoothly.
Arthritis is described as the wearing, degeneration, or loss of articular cartilage in a joint. The three most common types of joint arthritis are osteoarthritis, rheumatoid arthritis, and traumatic arthritis..
Glenohumeral Arthritis is also known as shoulder arthritis. It is a gradual wearing and degeneration of the joint surfaces or articular cartilage in the glenohumeral joint. Glenohumeral Arthritis is a common source of shoulder pain in older individuals, affecting as much as 20% of the older population. It can affect young people, though this is less common. This type of arthritis is also less common than arthritis in the hips, knees, or hands.
- Genetics and family history can predispose individuals to developing glenohumeral arthritis or joint degeneration
- Traumatic injury or fracture of the shoulder can result in the development of glenohumeral arthritis.
- Repetitive strain injuries to the shoulder can damage and accelerate wear on the joint surfaces
- Ligament or glenoid labrum damage can affect the stability and integrity of the shoulder joint, placing more stress on the joint or articular cartilage.
- Excessive use of steroids or steroid medication can result in degeneration of the joint and cartilage.
- Diseases of the joint cartilage, including Rheumatoid Arthritis.
- Pain and aching feeling in the shoulder
- Loss of range of motion of the shoulder
- Swelling around the joint
- Increased size or visible deformity of the joint
- Weakness that makes daily activities, particularly those that require lifting or over the head motion difficult
- A sensation of “cracking” or “crunching” in the shoulder joint
Treatment of glenohumeral arthritis will depend on the severity of the condition. Some important guidelines should be followed at the onset:
- Rest: Avoid the activities that produce the pain, including heavy lifting or over the head motions.
- Ice or moist heat: Applying ice to the joint or area of pain or inflammation. It is one of the fastest ways to reduce swelling, pain, and inflammation. The application of moist heat may be helpful with stiff joints. The application of ice or heat should be done at intervals for about twenty minutes at a time. Do not apply directly to the skin.
- Compression: When using ice apply light compression. This is especially helpful if swelling is present.
- Movement: Keep your joints moving whenever possible. The tendency is not to move but this will only result in further motion loss leading to more pain and loss of function.
Mild: Individuals with mild shoulder joint degeneration respond well to conservative treatment, which includes medication for pain and inflammation and a program of exercises for stretching and strengthening of the shoulder joint and surrounding muscles. Most patients show improvement in pain and function in 4-6 weeks.
Moderate: Individuals with moderate degenerative changes usually experience greater loss of motion, pain, weakness and loss of function. In some cases a arthroscopic surgery may be indicated. Recovery may take from 6-12 weeks following surgery with emphasis on reduction of swelling and restoration of range, strength, stability and function.
Severe: Individuals with severe joint degeneration have significant pain, stiffness, loss of motion and function. The cartilage on the joint surfaces has been eroded and X-rays reveal a loss of joint space and “bone on bone” contact. At this point quality of life becomes a concern. Joint replacement is the treatment of choice.. Following a joint replacement the artificial shoulder will be different from the natural joint and there will be some limitations of motion and function. However, a patient’s quality of life is usually significantly improved following a total joint replacement. Recovery following shoulder replacement can take 3-6 months of intensive physical therapy and rehabilitation. Improvements and functional gains can continue to develop for up to a year following the procedure.
Physical Therapy Interventions
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Joint: A series measurements will be performed to determine which joint is involved and how acute the inflammation is.
- Strength: Resisted testing is performed to determine if there is associated weakness or strength imbalances
- Flexibility: Range of motion measurements will be take to determine if there is a loss of joint movement
- Technique and ADL: The therapist will go over what activities you are having difficulty with and help you make modifications in technique to reduce stress on the involved joint.
Physical therapy for shoulder arthritis must remain conservative at the onset in order to not aggravate the condition. Emphasis will be on rest, reducing the inflammation, protecting the joint and increase the blood circulation for healing. Once the initial inflammation has reduced a program of stretching and strengthening will be initiated to restore flexibility and improve strength to reduce stress on the shoulder joint. Taping, bracing or strapping to rest and protect the joint while promoting healing may be indicated.
Common Physical Therapy interventions in the treatment of Glenohumeral Arthritis include:
- Manual Therapeutic Technique (MTT): Hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the shoulder. Use of mobilization techniques also help to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the shoulder and upper extremity to support, stabilize and decrease the stresses place on joint cartilage and shoulder joint.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the upper extremity, and improve movement techniques and mechanics (for example, lifting, reaching, and over head activities) of the involved upper extremity.
- Modalities including the use of electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved joint.
Avoiding the activities that produce the pain or stress the involved tendon is the first line of treatment.
- RICE: Rest, Ice, Compression, and Elevation should be used to reduce the stress on the burse.
- NSAIDS to reduce pain and inflammation.
- Immobilization, strapping or bracing may be beneficial to rest, protect the joint, and promote healing.
- Injection of steroids may be indicated to reduce inflammation of the involved joint.
- In severe recurrent conditions surgery may be indicated. In less severe cases arthroscopic surgery to clean the joint surfaces (debridement) may be indicated. In the situation of severe arthritis or joint degeneration a shoulder replacement would be recommended.
Once the pain and inflammation is reduced, and motion and strength are improved it is important that the patient returns to full activity gradually. Instruction in daily activities and a comprehensive home program are helpful for reducing a reoccurrence of flare-ups and slowing the degenerative process. As a preventive measure individuals should:
- Movement: keep moving and avoid a sedentary lifestyle. Joints are meant to move and depend on movement for lubrication. Remaining sedentary will reduce the joint’s available range of motion.
- Stretching: stretching regularly, in addition to before and after activity, will reduce the chances of developing joint stiffness and pain. Stretching will also improve and maintain the elasticity and flexibility of muscles and tendons of the joint. Hold stretches for 20 seconds and do not bounce. Remember, as joints age flexibility is lost. It is part of the aging process.
- Strength: performing a regular strength program will keep muscles strong enough to absorb the stresses placed on the joints. Weak muscles allow the stress and forces of every day activities to be transferred to the joint surfaces. Remember, as people get older weakness increases.
- Protection: Avoid activities that place increased stress on the shoulder. This includes heavy lifting or overhead motion activities.