Marc Darrow, MD.
Glenohumeral osteoarthritis is the degenerative breakdown of the ball and socket of the shoulder. If you went to the doctor with shoulder pain, and you had a shoulder MRI, and that MRI revealed shoulder osteoarthritis, the next discussion you will probably have with your doctor is what can you do about it? That answer is not clear cut. What treatments you take can be influenced by the amount of pain and function that you have.
The shoulder examination
A physical examination should include screening for physical abnormalities—swelling, deformity, muscle weakness, and tender areas—and observing the range of shoulder motion—how far and in which directions the arm can be moved. Although x-rays may be helpful in defining problems, more elusive ones may require computerized tomography (CT scan), which provides a more detailed view of the bones. Electrodiagnostic studies such as the electromyogram (EMG) and a nerve conduction study can indicate whether pain or weakness in the area is coming from a pinched nerve in the neck, or a peripheral nerve injury away from the neck, or down the arm. Magnetic Resonance Imaging (MRI) and ultrasound are other safe and effective diagnostic tools, providing images of the soft tissues without using radiation. An arthrogram is an x ray, CT or MRI in which dye is injected into the joint for added contrast. However, as outlined in other sections of this website, studies have shown that the advanced technologies commonly used to diagnosis injuries are grievously insufficient to show where the pain is coming from.
Treatment options for shoulder or glenohumeral osteoarthritis
We also see people who already had many surgeries and now so little is left of their shoulder they have to have a shoulder replacement. I myself had arthroscopic shoulder surgery many years ago. It did not help me and it took a year of rehab just to get it back to what it felt like just before the surgery. I see this in people all the time. They have a shoulder surgery, they rehab for a year, the shoulder still hurts, they have another shoulder surgery, they rehab for one year then it is deiced that they have reached the point of no return, shoulder replacement, they only decision left is reverse shoulder replacement or a shoulder replacement. So now that this person is waiting to get a shoulder replacement, what happens next? For some, cortisone injections to hold them over. Cortisone injections, as it has been demonstrated, can accelerate avascular necrosis or bone death. So a person has had two surgeries and they may have no cartilage left, now they are getting cortisone, now they will have no bone left.
A February 2022 paper (1) examined the treatment options for older patients with shoulder or glenohumeral osteoarthritis and provides the basis of treatment. Many of the people who come to us for care options have already followed and unfortunately failed many of these interventions.
Here are the learning points of this research:
Glenohumeral osteoarthritis (arthritis of the ball and socket of the shoulder) is a common cause of shoulder pain and is characterized by articular cartilage thinning, glenoid bone loss and deformity, osteophytosis (bone spurs), and other associated changes.
Non-pharmacological treatment options may serve as adjuvants to other therapies and should be incorporated for a more holistic approach to management. Pharmacological treatments include oral agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids and antidepressants.
Intra-articular injections such as platelet-rich plasma, cortisone, and hyaluronic acid are usually used to control symptoms in moderate to advanced arthritis or in non-surgical candidates. Other non-surgical treatment options include suprascapular nerve block and radiofrequency ablation, and these options have been studied on different levels of evidence. Surgical treatment of Glenohumeral osteoarthritis is reserved for patients who do not respond to conservative management or who suffer from debilitating symptoms that severely impair their quality of life.
Conservative treatment is this a realistic plan to get pain-free range of motion?
Physical therapy for shoulder arthritis
Here is a summary from a June 2023 paper from a team of international doctors (2) to include a description and goals of physical therapy:
- “Physical therapy is performed to (1) decrease pain, (2) increase shoulder range of motion, and (3) protect the glenohumeral joint. Physical therapy may be effective for motion pain rather than rest pain.”
- To increase shoulder shoulder range of motion, the soft tissues (ligaments, tendons, labrum) responsible for the range of motion loss need to be identified and targeted for intervention.
- To protect the glenohumeral joint, rotator cuff strengthening exercises are recommended.
The use of anti-inflammatories is recommended to reduce pain and lessen the inflammation in the shoulder. This “interrupts the chronic inflammatory state in the joint and in turn enables pain-free physical therapy.”
When someone comes into our office it is usually after the “conservative treatments” have failed their shoulder injuries and damage and that a surgery is being strongly recommended. What people, perhaps one day like yourself, who come into our office want is a realistic plan to get them to a pain-free range of motion in a functioning shoulder. Many times we can get people to this goal, many times we come close to getting people to this goal with significant improvement to their quality of life. There are times when we can only help a little. There are times we cannot help at all. People we cannot help would be significantly advanced cases of degenerative shoulder disease. Perhaps 10 to 20% of patients who seek regenerative medicine will not be good candidates. This is why I invite people to email me to discuss before they make an appointment. You can do so as well by using the form below.
Intra-articular hyaluronic acid injections in the shoulder
A June 2023 review study in the Journal of orthopaedic research (3) researchers evaluated the current evidence regarding the effectiveness of intra-articular hyaluronic acid on pain relief in patients suffering from glenohumeral osteoarthritis and found that intra-articular hyaluronic acid injections might be effective on pain relief with significant improvements compared to baseline and compared to corticosteroid injections in patients affected by glenohumeral osteoarthritis.
Can people who had previous failed glenohumeral arthroscopic shoulder surgery have a successful shoulder replacement?
Many people come into our office with a history of failed shoulder surgeries. Some will be in our office because they are exploring options to the “final” surgical recommendation, a total shoulder replacement. For some, with the history of failed surgery, they have obvious concerns. Being a failed should surgery patient myself, I would have concerns too about another surgery.
A June 2021 paper (4) examined if people who had a failed arthroscopic shoulder surgery would be at risk for a failed total shoulder replacement. In this study of 56 patients all under the age of 70, doctors examined 19 patients had the arthroscopic surgery first then total shoulder replacement and 37 patients had the total shoulder replacement without prior arthroscopic shoulder surgery to measure the failure rates of the surgery.
- There were 4 patients (7.1%) who had failure, and failure rates did not differ significantly between the arthroscopic surgery first then total shoulder replacement (5.3%) and primary total shoulder replacement only group.
- Additionally, 2 patients underwent revision arthroplasty because of trauma.
- A total of 50 patients who did not experience failure (17 arthroscopic surgery first then total shoulder replacement and 33 primary primary total shoulder replacement) completed patient surveys at almost five years after their last surgery measures with no significant difference between the arthroscopic surgery first then total shoulder replacement and primary primary primary total shoulder replacement.
- Both groups improved significantly from preoperatively to postoperatively in all survery scores.
The conclusion of this research: “Patients with severe glenohumeral osteoarthritis who failed previous arthroscopic surgery benefited similarly from total shoulder replacement compared with patients who opted directly for total shoulder replacement.”
The bone marrow stem cell procedure uses adult stem cells or mesenchymal stem cells.
We have published research on the treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow derived stem cells. The research appears in the peer-reviewed journal Cogent Medicine. The study can be found here in its entirety: Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections with a June 20, 2019 publication date.
The learning points of this research are as follows:
- Patients who received either one and two treatments of bone marrow derived stem cells reported significant improvements in resting pain, active pain, and functionality score when compared to baseline.
- These groups also experienced a 42.25% (one treatment) and 50.17% (two treatments) overall improvement respectively after receiving the stem cells.
- The group that received two treatments experienced statistically significant improvements in active pain when compared to the group that received one injection.
- There were no significant outcome differences between rotator cuff tear and osteoarthritis patients.
Conclusions: Our study demonstrated that patients diagnosed with shoulder osteoarthritis or rotator cuff tears experienced symptomatic improvements in pain and functionality when injected with bone marrow concentrate (BMC) stem cells or whole bone marrow (WBM) stem cells. Further randomized control studies are needed to validate these findings.
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With over 25 years experience in regenerative medicine techniques and the treatment of thousands of patients, Dr. Darrow is considered a leading pioneer in the non-surgical treatment of degenerative Musculoskeletal Disorders and sports related injuries. He is one of the busiest Regenerative Medicine doctors in the world. Dr. Darrow has co-authored and continues to co-author leading edge medical research including research on bone marrow derived stem cells. He also comments and writes on research surrounding the treatment of chronic tendon injury, ankle and foot pain, elbow, hand and finger pain.
References
1 Al-Mohrej OA, Prada C, Leroux T, Shanthanna H, Khan M. Pharmacological Treatment in the Management of Glenohumeral Osteoarthritis. Drugs & Aging. 2022 Feb;39(2):119-28.
2 Yamamoto N, Szymski D, Voss A, Ishikawa H, Muraki T, Cunha RA, Ejnisman B, Noack J, McCarty E, Mulcahey MK, Itoi E. Non-Operative Management of Shoulder Osteoarthritis: Current Concepts. Journal of ISAKOS. 2023 Jun 13.
3 Familiari F, Ammendolia A, Rupp MC, Russo R, Pujia A, Montalcini T, Marotta N, Mercurio M, Galasso O, Millett PJ, Gasparini G. Efficacy of intra‐articular injections of hyaluronic acid in patients with glenohumeral joint osteoarthritis: a systematic review and meta‐analysis. Journal of Orthopaedic Research®.
4 Nolte PC, Elrick BP, Arner JW, Ridley TJ, Woolson TE, Tross AK, Midtgaard KS, Millett PJ. Total shoulder arthroplasty after previous arthroscopic surgery for glenohumeral osteoarthritis: a case-control matched cohort study. The American Journal of Sports Medicine. 2021 Jun;49(7):1839-46.