What is the treatment for degenerative changes in the shoulder?

Treatment for Degenerative Changes in the Shoulder

The treatment for degenerative changes in the shoulder should follow a stepwise approach starting with conservative management including physical therapy, NSAIDs, and activity modification, progressing to injections if needed, and considering surgical options only when conservative measures fail.

Initial Conservative Management

Pain Management

• First-line medications:
  • NSAIDs for pain relief and anti-inflammatory effects 1
  • Acetaminophen as an alternative for those who cannot tolerate NSAIDs 2
  • Topical NSAIDs may be beneficial with fewer systemic side effects 1

Physical Therapy and Exercise

• Rest to prevent ongoing damage while allowing activities that don't worsen pain 1
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1
• Implement specific exercises:
  • Eccentric strengthening exercises 1, 3
  • Stretching focusing on external rotation and abduction 3
  • Rotator cuff strengthening to protect the glenohumeral joint 4

Cryotherapy

• Ice application through a wet towel for 10-minute periods to reduce pain and swelling 1
• Most effective for acute inflammatory conditions 1

Advanced Conservative Management

Injection Therapy

• Corticosteroid injections:

  • Consider for patients with significant pain unresponsive to initial conservative measures 3
  • Target intra-articular or subacromial injections rather than intramuscular 3
  • Methylprednisolone acetate 40mg with lidocaine 1% provides rapid pain relief 3
  • Note: The long-term effects of corticosteroid injections remain debated 1

• Alternative injection options:

  • Suprascapular nerve blocks can be as effective as glenohumeral triamcinolone injections 3
  • Hyaluronic acid injections have mixed evidence for efficacy 4

Advanced Physical Therapy

• If symptoms persist after 6-8 weeks, intensify physical therapy to prevent permanent dysfunction 3
• Focus on improving scapular motion which is often affected as an adaptation to restricted glenohumeral motion 4

Imaging for Assessment and Treatment Planning

• Plain radiography is the preferred initial imaging study 1, 3
  • Standard views: anteroposterior (AP) in internal and external rotation, axillary or scapula-Y view
• MRI or ultrasound for further evaluation of soft tissue structures 1
  • Ultrasound rated 9/9 for suspected bursitis or rotator cuff evaluation 1, 3
  • MRI helpful for evaluating rotator cuff quality, fatty degeneration, and muscle atrophy 1

Surgical Options

Consider surgical referral if conservative management fails after 3-6 months 3, 2:

• Arthroscopic options:

  • Arthroscopic debridement for mild to moderate degenerative changes 2
  • Arthroscopic capsular release for significant stiffness 2

• Joint replacement options:

  • Hemiarthroplasty or total shoulder arthroplasty for severe degenerative changes 2

Prognostic Factors and Considerations

• Approximately 80% of patients recover within 3-6 months with appropriate conservative treatment 3
• Factors that may affect outcomes:
  • Workers' compensation status may correlate with less favorable outcomes 1
  • Rotator cuff muscle quality (fatty degeneration and atrophy) affects healing potential and outcomes 1
  • Age-related factors: patients over 50 have higher rates of full-thickness rotator cuff tears 1
  • Coexisting pathologies are common: rotator cuff degeneration (81%), labral tears (33%), and biceps tendon disease (22%) 5

Common Pitfalls to Avoid

• Delaying physical therapy intervention 3
• Prolonged immobilization which can lead to frozen shoulder 3
• Using overhead pulley exercises for hemiplegic shoulder pain 3
• Relying on advanced imaging before obtaining plain radiographs 1, 3
• Overlooking associated conditions like acromioclavicular joint degeneration 5