ARTHRITIS

WHAT IS IT?

A xray of the shoulder showing arthritis.

Osteoarthritis essentially means ‘wear and tear’ of the joint and occurs when the protective surface (cartilage) becomes thinned and breaks down. The surface becomes very worn and uneven and this is painful and the joint feels stiff.

There are two joints in the ‘shoulder’ which can be arthritic. The main shoulder joint (the gleno-humeral joint) is the larger of the two and is the ‘ball and socket’ joint. The second is much smaller and is the acromio-clavicular joint between the end of the clavicle (collar bone) and the acromion (bony shelf formed by the scapula) as it comes round from the back. This joint twists particularly when one lifts their arm above shoulder height and can become arthritic particularly in heavy manual workers or people who regularly use their arms for repetitive activity above shoulder height. Arthritis of the acromio-clavicular joint is dealt with under a different section on this website.

Osteoarthritis of the shoulder is less common than in the hip, knee, ankle or hand. However, it can still cause significant pain and since the main purpose of the shoulder joint is to position the hand for activity, it leads to major loss of function of the arm.

The precise cause of arthritis is not fully understood but several factors have been identified in predisposing its onset. These include a family history, previous trauma especially fractures or dislocations and overuse of the shoulder, eg. long term heavy manual work, weight lifting and racquet sports. There are two other causes of arthritis of the shoulder: inflammatory arthritis, eg. rheumatoid arthritis and rotator cuff arthropathy.

Rheumatoid arthritis is a widespread disease found throughout the body in which the patient’s own immune system mistakenly attacks the joints causing widespread inflammation and damage.

Rotator cuff arthropathy is the term that is given to arthritis that occurs after long standing large tears of the rotator cuff (deep tendons of the shoulder). Although it is far less common than the other forms of arthritis, it is often far more disabling as the mechanics of the joint are significantly altered. It is also much more difficult to treat. Fortunately just because someone has a large tear of the rotator cuff, it does not mean that they will necessarily progress to disabling arthritis. Indeed the majority do not develop disabling arthritis.

WHAT ARE THE SYMPTOMS?

The symptoms that patients commonly experience with arthritis of the shoulder include:

Pain - which is worse on use of the arm and often associated with painful “catching” and ‘creaking’.

Stiffness – lacking the full range of movement - especially lifting the arm above shoulder height or rotating the arm, especially going behind the back.

Night pain - sleep is frequently disturbed and patients have difficulty lying on the affected side

Loss of function - limited ability to perform normal activities, especially activities at head height, eg. reaching items out of high cupboards, doing hair etc

These symptoms generally deteriorate with time although it can be impossible to say at what rate the deterioration will be.

HOW IS IT INVESTIGATED?

Your surgeon will take a detailed history and perform an examination of your shoulder. Usually a simple X-ray of the shoulder is sufficient to complete the diagnosis (see fig 9) but occasionally a CT scan is required.

HOW CAN IT BE TREATED?

Preventative measures or very early treatment is recommended and includes maintaining a healthy body weight and remaining active to keep muscle strength from diminishing. Work up to a well-designed and well-balanced exercise program and you can keep or even improve joint flexibility. One should keep repetitive overhead activity to a minimum and rest joints only if they become very painful.

Osteoarthritis of the shoulder is initially treated by physiotherapy including exercises to maintain movement and strength. This is often combined with painkillers including paracetamol, codeine and anti-inflammatories such as ibuprofen. Your GP can advise you regarding these medications. Supplements such as Glucosamine tablets may help in early stage arthritis.

Patients who suffer from Rheumatoid arthritis need advice from a specialist Rheumatologist who can provide expert management regarding medications that can suppress the effects and progression of the Rheumatoid disease.

A steroid injection into the shoulder joint (glenohumeral joint) may give temporary benefit and relief of pain. If the measures described so far fail to control the symptoms then surgery may be considered.

SURGERY FOR THE SHOULDER WITH ARTHRITIS

Picture showing anatomic shoulder replacement

A keyhole (arthroscopic) debridement of the joint may be performed which aims to smooth off the rough surfaces and remove debris. It is likened to giving the car tyres a re-tread. It does not give you a new joint, but it can buy some time before any further procedure is necessary. Results can vary. It is most helpful when a patient is on the young side for a total joint replacement and wishes to remain very physically active.

When symptoms significantly affect the quality of life, becoming severe with constant pain, night pain and loss of function then a shoulder joint replacement is indicated. The main surgical options are to perform either a total joint replacement (both the surface of the ball and socket are replaced) or a hemiarthroplasty joint replacement (only the surface of the ball, humeral head, is replaced but the socket surface is not replaced).

One of the major concerns with all joint replacements is how long the joint will last. There is usually one side of the joint that is easier to fix onto the bone than the other. In the hip, the stem in the femur is easier and more securely fixed than the socket in the pelvis. In the knee, the component at the end of the femur is usually more securely fixed than the one at the top of the leg. In the shoulder, the replacement for the head of the humerus (the ball) is usually well fixed. It is the socket on the glenoid which tends to loosen first. This is why, over many years, surgeons have tended to only replace the head with a metal ball and do nothing with the socket. We have come realise that whilst this is perfectly acceptable, patients can still experience pain from the socket side arthritis and so patients who have an artificial socket put in, get better reduction of the their pain. These patients though have the added risk that the socket may loosen requiring earlier revision (repeat) surgery.

The cut in the skin for the operation is usually about 15cm long and is on the front of the shoulder. Any remaining cartilage is removed and either a cap is placed over the existing ball or the existing ball is removed and replaced with a ball on a stem which is placed down the canal of the humerus. The socket is plastic and is either fixed to the bony socket with cementor screws. The surgery takes about 1-2 hours and after the surgery the arm is in a sling to allow the wound to heal. The arm can be removed for light activities below shoulder height and for washing and dressing. In order to access the shoulder during the surgery an important muscle must be detached and then repaired at the end. This muscle (subscapularis) is important for rotating your arm inwards for example, when reaching across your front or reaching round into your back pocket. Tendon heals slower than bone and so certain movements will be protected for 3 months after surgery to allow this tendon to heal.

SURGERY FOR THE SHOULDER WITH ARTHRITIS AND ROTATOR CUFF TEAR

A relatively new phenomenon in shoulder replacement surgery is the reverse shoulder replacement. Whilst the idea has been around for quite some time, it has only really been popularised in the UK in the last 5-10 years. Instead of the ball being on top of the humerus and the socket being on the shoulder blade, the positions are reversed so the socket is on the top of the humerus and the ball is mounted on the shoulder blade. This has huge benefits for the deltoid muscle in that the fulcrum is moved to make the muscle work more effectively. Of course, the deltoid is the only remaining functioning muscle since the rest of the rotator cuff has torn when this operation is considered. This operation can lead to a patient regaining reasonable over the shoulder movement and a huge improvement in their pain. The replacement can also be used if a patient has a poor result following a shoulder fracture and the rotator cuff becomes defunctioned because the lumps of bone which the tendons attach to are no longer in the correct position.

Spire Elland Hospital

Elland Lane
Elland
HX5 9EBT

For an appointment, telephone:
Outpatient Bookings on 01422 324069
Self pay enquiries on 01422 229 597
Main Hospital number is 01422 229 632

BMI The Huddersfield Hospital

Birkby Hall Road
Huddersfield
West Yorkshire
HD2 2BL

Reception: 01484 533 131

Department of Orthopaedics & Trauma

Calderdale and Huddersfield NHS Foundation Trust
Huddersfield Royal Infirmary
Acre Street
Lindley
Huddersfield
HD3 3EA

NHS Secretary:
Mrs Margaret Thomas
Tel 01484 342 343

NHS Clinics

Trauma:
Calderdale Royal infirmary, Halifax
Huddersfield Royal Infirmary

Elective Shoulder and Elbow problems:
Friday morning at Calderdale Royal Hospital, Halifax

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