Shoulder Arthritis: What's Causing Your Pain & How to Treat It

Hi, I'm Dr. Patrick Denard. I'm an orthopedic surgeon who's a shoulder specialist. I practice at the Oregon Shoulder Institute. And here I just want to provide an overview of shoulder arthritis. What is it? What are the treatment options? So first of all, what are the symptoms of shoulder arthritis? The biggest thing that drives people to see me is pain. That is typically pain that stops people from sleeping at night. When you have shoulder arthritis, you typically have pain with deep inside the shoulder joint that becomes worse at sleep because you're sleeping directly on the shoulder and there's more pressure. There's also thought to potentially be some hormonal relationship that impacts shoulder pain at night. That is, it's modulated to uptick at night, which is unfortunate, but that's the biggest symptom that drives people to see me. The second thing that occurs with shoulder arthritis, because you get narrowing of the joint and destruction of the cartilage, which is the padding of the joint, you typically lose range of motion. Now, Another cause of range of motion loss can be frozen shoulder, or somebody just has the capsule layer, which is the closest to the shoulder, affected. So these are often confused. For instance, many people will come to me with arthritis and say, yeah, I had frozen shoulder before. Well, it was probably their shoulder arthritis itself. With arthritis, you have X-ray findings that go along with that loss of range of motion, and that is typically manifested or seen as narrowing of the joint space under x-ray and loss of the joint space with bone spurs. Sometimes you can also see cysts within the joint. So what is the cause of shoulder arthritis? Most of the time shoulder arthritis occurs in people over the age of 50 because it's a generative process. So it's age-related and genetic-related. It's not uncommon, for instance, for people to have arthritis in multiple joints if they have arthritis in the shoulder. And those people will often get knee or hip arthritis earlier because it's a weight-bearing joint. Shoulder arthritis, if it occurs at an earlier age, is typically in somebody who does a lot of lifting, or you can have a post-traumatic instance where somebody, say, dislocates their shoulder at a young age and then they are more prone to get arthritis down the line because of that initial trauma or injury makes them more susceptible to degeneration of the joint later down the line. So let's talk about the treatment. So it really varies from mild to severe arthritis. Really across the board, you want to start with conservative things. Some simple things that can be done are anti-inflammatories over the counter like Advil, ibuprofen, Aleve. If people are not responding to those, there are prescription anti-inflammatories like Mobic or Celebrex. I really like Celebrex, for instance, if somebody's gonna be taking anti-inflammatories frequently. That's because it has lower side effects on the gut because anti-inflammatories, one thing you need to be careful about is it breaks down the stomach lining. So that makes people susceptible to ulcers. The other thing that makes Celebrex safer than some alternatives, especially when people are using a lot, is that it has a lower cardiac side effect profile. So in other words, less effect on the heart for long-term use. Anti-inflammatories are probably not something you want to take consistently because like any medication, there are some downsides. So if somebody can use it in a judicious manner, or say for instance they're going to go do an activity and they know they want to use it just prior, that I think is a reasonable way to use arthritis or use anti-inflammatories for arthritis. As we bump up the chain, we move into other things like physical therapy. The focus here is really stretching exercises. One thing that I will often see is that somebody will go to a physical therapist and they'll be told to do aggressive strengthening. And while strengthening and maintaining muscle is a good thing, sometimes in the early phase, especially with arthritic pain, it's really important to focus on stretching. So check out my exercises, especially my shoulder stretches, that are both on YouTube and on my website for some guidelines. You want to focus on things like doorframe stretches and sleeper stretches, essentially maintain your mobility before you really work on getting into the strengthening aspect. When you look at the effectiveness of physical therapy, a lot of this can be done on your own with stretching. If you actually look at going and seeing, seeing therapists and working with them, I think there's some benefit there, but you're particularly going to get the benefit in more mild to moderate cases. When you start getting to severe arthritis, when somebody has passive and active range of motion restriction, in other words, they can simply not get out no matter what they do because of the actual loss of the joint space, therapy is probably going to provide little benefit. Now, The insurance companies don't always agree with that, but the American Shoulder and Elbow Surgeons and American Society of Shoulder and Elbow Therapists have a joint statement which says essentially that with severe arthritis, physical therapy is not effective. So what about injections? So most commonly we do injections of cortisone or steroid. The steroid I use is called Kenalog. I prefer to do that under ultrasound guidance in the office. That way I can directly see into the joint, make sure the injection's placed at the right location. Injections can be very effective. Essentially what happens with arthritis, you'll you'll see a progressive loss of joint space and generation over time, but the pain or inflammation can kind of come and go. It can wax and wane. So are there times if the pain is really accelerated or inflamed, an injection can help calm that down. So it's a good first-line treatment. It's also a good consideration if somebody's going on a trip, for instance. But you want to be careful with the number of injections you have because injections, because especially with steroids, have a catabolic effect, meaning they break down tissue. That can have a negative consequence over time. With arthritis, one of the ways manifests or shows itself is those people who have a shoulder injection of steroid prior to a shoulder replacement are more likely to have infection, in particular if they have that injection within 3 months of the surgery. So I always advise, ideally, it's not a hard and fast rule because it probably declines with time, but ideally you avoid a steroid injection within 3 months of shoulder replacement. An alternative to steroid injections is use what's called platelet-rich plasma. Now, platelet-rich plasma involves taking blood off your own body, you spin it down, you get the growth factor-rich area that's concentrated and inject that back into the shoulder. Again, ideally under ultrasound. There are studies that show that that's effective for shoulder pain. There are studies in the knee that have looked at shoulder arthritis as well, knee arthritis, and shown that it's effective and perhaps more effective than alternatives. There's really no side effects of doing PRP, so it's a good frontline approach from mild to moderate arthritis. However, it's not covered by insurance, so that's really the major downside of that, and there's an out-of-pocket expense as a result of doing PRP. Personally, for me, if, if I'm not thinking about cost, I would actually prefer PRP as my frontline treatment because of the safety profile. Um, not that steroids aren't safe, they've had a long history of use, but that would be my preference to start. The reality is most people will start with a steroid injection because it's covered by insurance and they'll take that approach first and see how things go. Another injection that comes up quite commonly is prolotherapy. Prolotherapy is taking essentially glucose or sugar. The idea is you inject in the shoulder and create inflammation that stimulates healing. I would tell you there's really no evidence or studies that support this concept, although you'll see it quite widely. Alternatives can be things like stem cells. Again, here there's very little evidence to guide this, and I would encourage people to be thoughtful about spending thousands of dollars on stem cells because while it's appealing, the idea of taking and regenerating the, the reality is we can't direct the cells what to do. For me, I recommend sticking with the simple things that are proven to be effective rather than spending thousands of dollars on something that's unlikely to provide any benefit. Another area is peptides. People talk about peptides. That's really popular right now. There's really not evidence that this is effective in arthritis. I think if you're going to think about peptides, you're probably best off thinking about this in a recovery phase type of scenario, like after surgery or after injury. But it is not going to reverse arthritis symptoms. So what about if none of those things worked? Anti-inflammatories, physical therapy, injections didn't work as our mainstay treatment, maybe even some supplementation, some things that can reduce inflammation. Medication have been tried, alternatives like curcumin or even sulforaphane, reasonable things to consider, but you haven't gotten anywhere. Where do you go next with surgery? There's really two broad categories, okay? The first is a very narrow window for arthroscopic debridement. That is where you essentially clean up the inside of the joint through little stab incisions with a camera. The typical person that's going to benefit from that, based on the literature, is somebody who has relative preservation of the joint. So they have a little bit of spurring, they have reasonable range of motion, preserve— some preserved cartilage You can clean up the inside of the joint and you can see reasonable results. The caveat, highly motivated people. And if you look at the results there, it's about 60% of people are satisfied 5 years after the procedure, meaning they would do it again. One thing I would caution people for this is I have seen cases where they not only don't get relief, but it seems to accelerate the symptoms and they quickly go on to shoulder replacement. So my use for this is a young patient. Typically that's somebody under the age of 50, or in perhaps some select cases with very very mild arthritis in which we've confirmed that the rotator cuff is completely intact. After that, it really comes down to shoulder replacement. That means replacing the ball and socket joint. There's two types of replacements that are done, an anatomic or reverse shoulder replacement. I have longer explanations on other videos on my YouTube site that you can look at for detailed review of that. But essentially it's a 45-minute procedure that's done on an outpatient basis. The goal is to relieve pain, improve function. The recovery actually from shoulder replacement is quite short. I still tell people 6 months from everything, but when you're looking at recovery, usually people are about 80% recovered at 3 months. So it can be a very good solution if somebody's quality of life is limited. And what's interesting is even though that sounds invasive, the recovery from that is actually in many cases easier than the recovery from something even as minimally invasive as a rotator cuff repair. So hopefully that gives you a way to start to think about shoulder arthritis. How can you address this? I always address, I always think about it becoming, being conservative first and kind moving up the chain. But of course, if somebody comes in and they've let it go on for a long time and they have very limited range of motion, poor function, it might be that shoulder replacement is the first go-to treatment. Whereas if it's a mild case and somebody's younger, we're certainly going to try all the simple things first.