In his latest online article, renowned consultant orthopaedic surgeon Mr Phil Wright explains one of the conditions he specialises in, shoulder arthritis. Mr Wright explains the most common risk factors for shoulder arthritis, and the different treatments available, both surgical and non-surgical.
What are the most common causes and risk factors associated with shoulder arthritis?
The simple answer to this question is that we don't know why people develop arthritis. The most common type of arthritis is osteoarthritis which is often termed as wear and tear, and is associated with people later on in life. Sometimes we see it in surprisingly young individuals, yet despite decades of research, we don't know why some people are affected by arthritis and others aren't.
Having said that there are some conditions that can predispose somebody to developing arthritis. Sometimes if there's been an injury to the shoulder earlier on in life over time that can lead to wear and tear arthritis or osteoarthritis. An example of that kind of injury would commonly be a shoulder dislocation.
As soon as an individual has had one dislocation that does increase their chances of arthritis later on in life. Another example would be a fracture around the shoulder, although arthritis after fractures is relatively uncommon.
Some people develop issues with the rotator cuff tendons over time. This is a group of tendons that surround the ball in the ball and socket joint. These tendons can wear thin over time, and this can lead to a specific type of arthritis called rotator cuff arthropathy.
Other causes tend to be quite rare, for example, infection in the shoulder. Very rarely, there can be issues with the blood supply to the ball of the ball and socket joint. This can lead to a condition called avascular necrosis. This is when the bone effectively dies because it is starved of a blood supply. The bone collapses, and this leads to arthritis over time.
What are the primary symptoms a patient will experience when they are suffering from shoulder arthritis?
By far and away the most common symptom is pain. It tends to be a deep-seated pain felt within the shoulder joint and is often present with any attempt at any activity, or if you try to move the shoulder in any direction at all.
Some patients describe mechanical symptoms. For example, the shoulder can become stiff, making it difficult to reach in certain positions. The stiffness typically affects all movements in all directions, not just one movement.
Some patients can develop an unpleasant sensation of crunching or grinding as they attempt to move the shoulder. This is because arthritis causes the smooth covering of the ends of the bone to be lost, leaving areas of exposed rough bone.
Could you explain the different treatment options available for shoulder arthritis from just conservative management methods to surgical intervention?
We divide treatments for shoulder arthritis into non-surgical and surgical. Non-surgical treatments consist of modifying activities and avoiding things that cause or increase pain. Taking simple pain-killing tablets can often be helpful. Physiotherapy can often be useful to pace how much is done with the shoulder and avoid painful situations.
Some people benefit from injections of local anaesthetic and cortisone or steroid into the shoulder joint. The outcome of these injections can be a little unpredictable in terms of how well and how long they work, but many patients choose those as a treatment and are quite happy with them for some time. However, some people do get to a stage where they don't last long enough to make a significant difference.
Surgical treatments can be divided into treatments that preserve the patient's own shoulder joints or those that replace the shoulder joints.
Joint preserving procedures are generally done during a keyhole procedure. They typically aim to remove debris from within the ball and socket joint. Sometimes rough edges of cartilage or bone are smoothed out. Releasing tight scar tissue from within the shoulder joint can also increase movement.
The most durable treatment for arthritis is joint replacement surgery. This is when the worn ends of the bone are replaced, usually with metal and plastic.
What are the different types of shoulder replacements performed?
Many patients come to me having been told by their primary care physician that shoulder replacement isn't an option or that it isn't very successful. Perhaps 30 or more years ago that was the case, but technology has advanced quite considerably, even since I became a consultant 15 years ago.
One of the types of shoulder replacement is an anatomic replacement, which attempts to recreate the patient's own anatomy that they've lost. This involves replacing the ball of the ball and socket joint with a metal ball, and often involves replacing the socket with a plastic socket that is secured in place. This is the traditional shoulder replacement, and is successful in many cases.
Some patients tend to do less well with this type of shoulder replacement, for example, arthritis patients whose socket has worn away significantly, or those who have lost rotator cuff tendon tissue or have rotator cuff tears.
Reverse shoulder replacements, where the ball is converted to a socket and the socket is converted to a ball, are increasingly popular. They can be a very good option for somebody who doesn't have a function and rotator cuff, because it allows the deltoid muscle to perform the function of the rotator cuff that's no longer there.
It's also often useful in patients who've got arthritis and the socket has worn away quite considerably. This is because the way that the ball is secured to the socket provides a more reliable fixation than the traditional way of cementing a plastic socket.
When would you recommend shoulder replacement surgery as the treatment option for shoulder arthritis?
I routinely tell patients who see me considering a shoulder replacement that they should perhaps think of a shoulder replacement as a painkiller. It's a painkiller that's made out of metal and plastic and it requires an anaesthetic and an operation but it's a treatment for pain first and foremost. The patients who have the best rates of success tend to be those who are seeking relief from pain as their priority.
Many patients do get a more useful shoulder as well. It's easier to try to move a shoulder if it doesn't hurt to do so, and a lot of patients will get better movement and improved strength after a shoulder replacement.
Nevertheless, I always have a great deal of concern in suggesting a shoulder replacement for patients who don’t have significant pain. If pain is mild or controllable by other means such as tablets or injections, then often those are the best thing to try in the first instance. Shoulder replacement surgery should be left as a treatment further down the line when other methods are no longer controlling the pain.
Mr Phil Wright is a highly-experienced consultant orthopaedic surgeon based in Leeds and Bradford. If you would like to book a consultation with Mr Wright you can do so today via his Top Doctors profile.