According to the Arthritis Foundation currently one in four adults in the US is affected by arthritis. In rural areas one in three adults have some form of arthritis. There are more than 100 different types of arthritis, yet the majority of arthritis cases are osteoarthritis (OA).
A study done by the Arthritis Foundation in 2015 suggests that arthritis prevalence in the United States has been grossly underestimated, especially among adults younger than 65 years old.
- Based on adjusted estimates, 92.1 million adults either have doctor diagnosed arthritis or report joint symptoms consistent with arthritis
- For people ages 18 to 64, nearly one in three have doctor diagnosed arthritis or reported symptoms consistent with the diagnosis of arthritis
- For those over 65, the numbers are much worse: more than one in two men may have arthritis and more than two in three women may have arthritis.
The three most affected joints by arthritis are:
Shoulder Joint consists of three boney structures:
The head of the humerus fits into a round socket like structure called the glenoid. The structure is held in place by muscles and tendons, and movement of the shoulder joint is supplied by the rotator cuff. Shoulder arthritis usually results from the gradual wear of daily life. The cartilage wears away exposing the bony surface to damage. The cartilage is about 2 to 3 mm thick and covers the bones providing a smooth surface for the motion of the joint. It is also covered in hyaluronic acid, a lubricant that also provides cushioning. When the hyaluronic acid decreases, the cartilage is now exposed to the friction of motion and it wears away. A car cannot run without oil as the pistons would seize and the engine would stop. Hyaluronic acid is the bodies oil to prevent cartilage breakdown.
There are two major joints of the shoulder:
- The clavicle meets the tip of the scapula, this joint is called the acromio-clavicular joint
- Where the head of the humerus fits into the area created by the scapula is called the gleno-humeral joint
Five Types of Shoulder Arthritis
- Osteoarthritis- This arthritis is primarily caused by age related wear and tear on and the deterioration of the smooth articular cartilage in these joints. This condition destroys the articular cartilage covering the bone. As the cartilage wears away, it becomes frayed and fragmented and during movement with the protective covering lost, pain ensues.
- Rheumatoid Arthritis is an auto immune disease attacking many joints throughout the body. The joints are covered by a lining called the synovium. This is where hyaluronic acid resides providing cushioning and lubrication to the joint space. RA attacks the lining causing swelling and pain in this region.
- Post traumatic arthritis- this arthritis develops after repeated trauma such as chronic dislocation of the shoulder joint.
- Rotator cuff arthropathy- Tears in the rotator cuff cause anatomical instability of the humerus in the glenoid fossa and movement will cause rubbing against structure such as the acromion of the scapula. This damages the bony surfaces and arthritis can develop.
- Avascular necrosis is a condition that develops when the blood supply to the bone is disrupted. This will cause necrosis of the bone and ultimate collapse. In the initial stages the articular cartilage is damaged then, as this disease progresses, the entire boney head is necrotic.
Hip and knees are weight bearing joints and as such are susceptible to increased stress and weight placed on them.
Shoulders are less susceptible to the wear and tear of weight bearing but the range of motion of the shoulder joint, held in place by muscle and ligament support, only attributes to the arthritic process in this area. The shoulder joint can flex, extend, abduct, adduct, internally and externally rotate.
Shoulder osteoarthritis is caused by a combination of biological and behavioral factors such as:
- Repetitive stress- work related lifting or manual labor working overhead can accelerate osteoarthritis of the shoulder
- Athletics- Repeated shoulder movement which can lead to cartilage loss. Also, stress to the shoulder, in football for example, can develop into post traumatic arthritis
- Gender- women are more common than men for this disease process
Risk Factors for Osteoarthritis of the Shoulder
- Advancing age with natural wear and tear will make the cartilage degenerate
- Trauma such as dislocation or fractures
- Congenital Disorders or Diseases- many disease states affect bone and bony metabolism such as septic arthritis, rheumatoid arthritis
- Genetics- heredity factors
- Joint stiffness and loss of normal range of motion
- Swelling, Redness, Heat around the joint area
- Pain and painful palpation
- Crepitation and grinding on range of motion
- Loss of normal function
- Physical exam and x-rays- x-rays normally show a loss of normal joint space and possibly bony spurs
- If rotator cuff involvement is determined, CT or MRI to examine these structures
- Lab analysis to determine the type of arthritis
- Initially activity modification with rest, ice, heat followed by a gradual resumption of ranges of motion
- Physical Therapy to increase normal range of motion while decreasing stiffness and pain
- Activity modification, this can be difficult if the activity is work related
- Pain control with ice and heat. NSAIDS for short term only, to avoid long term side effects of this class of medicine
Injections for Osteoarthritis of the Shoulder
- Cortisone- this medication is used to decrease pain and inflammation. The effects may be short in duration and repeated shots can damage the tissues and joint space. Also, there are many systemic side effects and therefore cannot be used in all patients.
- Hyaluronic Acid- This is a normal physiologic lubricant naturally present in joint spaces in the body. This liquid substance has been used for years in the United Stated for osteoarthritis of the knees.
- Platelet Rich Plasma is an autologous blood concentrate that contains cytokines, growth factors and bio-active proteins that can enhance tissue rejuvenation and cartilage.
- Other injections include prolotherapy, ozone therapy
- Arthroscopic surgery to debride damaged tissue and bony spurs, this is commonly used for lower grades of joint involvement. Although bony spurs are not removed, this procedure is done for pain relief and is not a permanent solution for shoulder arthritis.
- Hemiarthroplasty, a procedure that replaces only the ball of the humeral head
- Cup Arthroplasty, a procedure that replaces only the surface of the bone under the humeral head (similar to hemiarthroplasty)
- Shoulder replacement where the ball and socket parts of the shoulder joint are replaced
As with any surgery, there are risks and complications. Risks are infection, bleeding, blood clots, damage to other nerves and blood vessels and failure to reach the desired results.
Hyaluronic acid injections into the shoulder joint have been studied and used for years with excellent success. These injections can be done in the office with little to no risk to the patient and minimal if any side effects.
In September 2005, the United States Food and Drug Administration (FDA) accepted the filing of a pre-market approval supplement to expand the indication of Hyalgan (Sodium Hyaluronate) to include treatment of shoulder pain due to OA or OA in association with rotator cuff tears and/or adhesive capsulitis in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics, eg. acetaminophen. Hyalgan is currently indicated for the treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and to simple analgesics eg. acetaminophen. Sanofi-aventis is the sole distributor in the US of Hyalgan, which is licensed and manufactured by Fidia Farmaceutici of Italy.
- NASHA Hyaluronic Acid for the Treatment of Shoulder Osteoarthritis; A Prospective, Single-Arm Clinical Trial
Med Devices 2019;12:227-234 PMID 31354368
Background: Osteoarthritis of the shoulder or glenohumeral joint is a painful condition that can be debilitating. Intra-articular injection with hyaluronic acid should be considered for patients not responding adequately to physical therapy or anti-inflammatory medicine.
Conclusion: This study provides preliminary evidence that a single injection of HA may be efficacious over 6 months and well tolerated in patients with symptomatic glenohumeral osteoarthritis.
Orthopade 2018 May;47(5): 368-376 PMID 29464283
Pathogenesis: Osteoarthritis of the shoulder is characterized by a progressive degenerative process which is based on chronic inflammation with intra-articular release of different cytokines and proteolytic enzymes. The main predisposing factors are a history of trauma or surgery as well as overuse or instability of the glenohumeral joint. Treatment options will be evaluated here.
Treatment: Conservative treatment options are oral pain medication, physical therapy and intra-articular injections whereby, in comparison to corticosteroids, hyaluronic acid seems to be advantageous especially with respect to the duration of a positive clinical effect
- Treatment of Persistent Shoulder Pain with Sodium Hyaluronate: A Randomized, Controlled Trial. A Multicenter Study
J Bone Joint Surg Am 2008 May; 90(5): 970-9 PMID 18451387
Background: Presently, there are no approved nonoperative therapies for the ongoing treatment of persistent shoulder pain. Preliminary data suggest that intra-articular hyaluronate injections may be beneficial for the treatment of persistent shoulder pain resulting from various etiologies. The present study evaluated the efficacy and safety.
Conclusions: The end points indicate that sodium hyaluronate is effective and well tolerated for the treatment of osteoarthritis and persistent shoulder pain that is refractory to other standard nonoperative treatments
- The Effect of Intra-Articular Hyaluronate and Tramadol Injection on Patients with Adhesive Capsulitis of the Shoulder
J Back Musculoskelet Rehabil 2017; 30(4): 913-920 PMID 28453454
Background: Local administration of opioids causes effective analgesia without adverse effects related to central nervous system. After the beneficial demonstration of peripheral opioid receptors in joint synovia, intra-articular opioid injections were used for pain treatment. Clinical studies have reported the safety and efficacy of hyaluronate injection in the shoulder joint of patients with osteoarthritis, periarthritis, rotator cuff tears and adhesive capsulitis. The objective of this study was to estimate the efficacy of intra-articular hyaluronate and tramadol injection for adhesive capsulitis of the shoulder compared with that of hyaluronate injection alone.
Conclusion: Range of motion in both groups improved without significant inter-group difference. Pain was reduced in the tramadol group, as expected in the short term, but overall both groups showed no significant difference overall.
Medicare has not covered Hyaluronic acid injections in the shoulder in the past. Presently, the coverage has changed and the following states appear to have coverage:
- New York
- New Hampshire
- Rhode Island
Integrative Practice Solutions has collaborated for many years with physicians treating patients with osteoarthritis. We have developed and patented the Advanced Arthritis Relief Protocol™ and it has been successful in providing those osteoarthritic patients, not only relief from their arthritis pain, but a benefit in their overall quality of life. Injections, guidance, bracing, physical therapy and administrative and medical support are key components of this program.
Our sister company, Juventix Regenerative Medical, offers regenerative options for clinicians to augment their care when clinically necessary and provide restorative options to their patients.
Quality of care, cost effective treatment options and clinical support are paramount at Integrative Practice Solutions.
Dr. Robert McGrath