The Shoulder - Glenohumeral Joint Osteoarthritis

Shoulder (glenohumeral) joint osteoarthritis (OA) is one of the most common causes of shoulder pain among older people and like other forms of OA, it can be debilitating with respect to pain, restricted joint motion and impaired functional ability. A degenerative, multifactorial joint condition, OA of the shoulder is the third most common joint requiring surgical reconstruction (behind the knee and hip). Many different treatment options exist including conservative, pharmacological and surgical, and are largely dictated by patient age, severity of symptoms, findings on x-ray and comorbidities of the individual.

A little bit of anatomy

The shoulder or glenohumeral joint is an unstable, shallow, ball and socket joint, often described as a golf ball (the head of the humerus) sitting on a tee (the glenoid socket). The joint requires both static and dynamic stabilisers for effective shoulder function. The static constraints include the glenohumeral ligaments, glenoid labrum, and the joint capsule, and the dynamic constraints include the rotator cuff and scapular muscles.

Both the head of the humerus (the ball) and the glenoid fossa (the socket) are lined with softer chondral cartilage. This provides a smooth surface for joint movement and, in healthy shoulders, is effective at distributing force and load across the joint.

Osteoarthritis affects all the structures of the joint including the ligaments, nerves, and muscles, but mainly the articular cartilage.

Normally, there is a balance between the body making new cartilage to replace older cartilage. In osteoarthritis this balance is impacted, affecting the amount of healthy cartilage. Pain arises from changes to surrounding tissues, particularly the joint capsule, which becomes sensitive and tight. Progressive cartilage and eventually bone loss, joint space narrowing and muscle weakness impact biomechanics of the joint result in notable dysfunction, disability and healthcare costs. 

Who gets it?

Primary shoulder OA represents a spectrum of disease, with factors such as mechanical trauma (injury, fracture, dislocation), comorbidities (obesity, inflammation), and intrinsic factors (age, genetics, gender) all contributing to its development. has no specific causative factor. It can occur over a broad age range, though is most seen in patients older than 60 years of age and is more common in women.

Studies from the USA indicate that shoulder arthritis affects about a third of world’s population over 60 years of age, and up to 94% of men and women over the age of 80..

Obesity remains one of the most important risk factors for the incidence and progression of osteoarthritis. An Australian study found that obese females aged 55-64 with shoulder joint OA were 8.6 times more likely to receive joint replacement surgery compared to their normal weight counterparts. For males the likelihood was 2.5 times greater. 

If you have a history of shoulder joint injury, are overweight, and aged over 60, you have an increased risk of developing shoulder joint OA.

What happens?

Over time, chondral cartilage becomes thinner and wears. This is a normal part of the ageing process and for many people presents no issue. In some cases, particularly if there has been previous shoulder trauma and/or surgery, or in the presence of comorbidities (eg. obesity, inflammatory conditions), osteoarthritis can develop. This is characterized by progressive cartilage loss, adaptive changes to the subchondral bone, and abnormal bone formation (called osteophytes). These changes affect the shape and biomechanics of the shoulder, resulting in narrowing of the joint space and shoulder joint instability. The combined effect of this is further cartilage damage and, eventually, subchondral bone loss. 

Diagnosing shoulder OA

Shoulder osteoarthritis can be clinically diagnosed by a physiotherapist. A thorough interview will often identify key factors in the past and current history that correlate with osteoarthritis. Patient reported symptoms including gradual onset pain, which may or may not be present at rest, and difficulty with activities of daily living such as personal hygiene, dressing and hanging washing. Movement may be accompanied by crepitus (crunching, grinding sensation).

Signs of osteoarthritis include loss of range of motion in multiple directions, shoulder instability, weakness of the rotator cuff muscle group, and shoulder blade (scapula) dysfunction. A battery of tests to assess these structures will assist in making a diagnosis of shoulder OA.

What else could it be?

There are a variety of conditions that present with similar symptoms and signs to shoulder osteoarthritis. These include rotator cuff tendonitis, rotator cuff tears, subacromial impingement, and frozen shoulder. Subtle differences in the behaviour of these conditions help us to determine the primary cause of your symptoms and treat it effectively.

Do I need a scan?

Scans are generally not recommended for diagnosing osteoarthritis. One of the reasons for this is that what is seen on a scan does not normally match very well with a person’s symptoms, and generally will not change the recommended management. A scan is only required if you have an atypical presentation, or if surgery might be indicated, which is a small percentage of people. Your physio will work with you to decide whether a scan is necessary. 

Treatment

Exercise is the number one treatment for osteoarthritis and should be the first line of treatment for all patients. This could include specific strengthening exercises or mobility exercises, or hydrotherapy. Often when getting started with exercise pain can initially flare up. Non-opioid pain medication can provide short term pain relief and improvements in function which in turn can improve participation in therapeutic exercise. You can discuss this approach with your physiotherapist to get the right balance.

The goal of physiotherapy is to decrease pain, increase shoulder ROM, improve shoulder and upper limb function,

and protect the shoulder joint from further damage.

Shoulder range of motion is frequently limited in multiple directions in people with shoulder OA. The cause of this can be multifactorial, including pain, decreased soft tissue flexibility, and joint deformity related to OA. Likewise pain and subsequent disuse can result in progressive muscle weakness. Studies have demonstrated that the rotator cuff muscle group is primarily affected in shoulder OA, adversely affecting shoulder and scapula movement patterns.

Physiotherapists utilise a range of interventions to address these impairments including soft tissue and manual therapy, joint mobilization, stretching, and therapeutic exercise. Strengthening of the rotator cuff muscle group and scapula stabilisers is critical and forms an important component of the early stages of shoulder OA management. For an example exercise program, click here.

While not a weight-bearing joint, shoulder joint OA may benefit from weight loss if you are overweight. Obesity doubles the lifetime risk of symptomatic osteoarthritis compared to individuals with a lower BMI. Studies have demonstrated that factors related to obesity – adipose deposition, insulin resistance, and altered immune responses – may lead to the initiation and progression of obesity-associated OA. Weight loss can be difficult and there are multiple factors involved in a person’s weight. Your physiotherapist can support you in planning if this is a priority for you. 

Should I get a steroid injection?

Most studies on injectable therapies have been conducted in people with hip or knee osteoarthritis, or on different causes of shoulder pain. However, there are some options which can be considered. It is important to recognize that injections are an invasive technique, and as such carry an increased risk profile for complications including infection. You can click on the links below for more information:

• Corticosteroid injections
• Hyaluronic acid
• Platelet rich plasma
• Stem cell therapy

What about surgery?

A small percentage of people will require joint replacement surgery. This is considered if the problem is not responding to other noninvasive treatments and is having a significant impact on quality of life.

Prior to considering surgery it is important that you have completed at least 3 months of a good quality exercise program.

This is the minimum timeframe necessary to ascertain the benefits of a non-surgical approach, to improve strength and shoulder joint biomechanics, and if indicated, to reduce weight. Failing this, your physiotherapist can provide guidance on available medical and surgical treatments, enabling you to make informed health care decisions. 

How long’s it going to take?

Effective non-surgical management for mild to moderate shoulder OA requires long-term lifestyle changes, regular exercise, and physiotherapy to ensure sustainable outcomes are achieved. An initial 6-week phase of intensive physiotherapy is beneficial to facilitate reduction in pain, improve joint range of motion and design an appropriate exercise program. Commitment to regular exercise can help to maintain improvements and function, while ‘top up’ physiotherapy sessions (3-4 times per year) can be used to modify exercise programs and manage any persistent symptoms.

If surgery is indicated, then expect a period of 6-12 months to recover and rehabilitate back to a satisfactory functional capacity. Most people who opt for surgical management will see good improvements in pain, albeit with some loss of range of motion (though probably better than pre-surgery!).

The Take Home

Shoulder joint OA is one of the most common causes of shoulder pain in people aged over 55. In younger and/or athletic populations, or where mild to moderate osteoarthritis is present, management should focus on non-operative options, where a combined approach of activity modification and lifestyle changes, physiotherapy, and therapeutic exercise can be effective. Surgical intervention should only be considered as a last resort where pain and loss of function have failed to improve with conservative management and health-related quality of life is affected. 

Got shoulder pain and want to get it sorted? Give us a call now.

At Movement for Life Physiotherapy, we can assess and diagnose the cause of your shoulder pain and let you know whether you have osteoarthiritis, frozen shoulder, a rotator cuff tear, or if there is something else going on. With a clear diagnosis and tailored management plan, we'll help get you back to the things you love sooner.

Call us now on 08 8945 3799 or click on BOOK AN APPOINTMENT to book online.

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