What is the initial management for shoulder degenerative joint disease?

Initial Management of Shoulder Degenerative Joint Disease

Begin with conservative non-operative treatment including physical therapy focused on rotator cuff strengthening, NSAIDs or acetaminophen for pain control, and activity modification, reserving surgical intervention for cases refractory to conservative management. 1, 2, 3

Conservative Treatment Approach

First-Line Therapy

• NSAIDs or acetaminophen are recommended as the initial pharmacological intervention to reduce pain and inflammation 2, 3
• Physical therapy should target three specific goals: (1) decreasing pain, (2) increasing shoulder range of motion, and (3) protecting the glenohumeral joint through rotator cuff strengthening 3
• Rehabilitation must focus on strengthening the rotator cuff, periscapular muscles, and core musculature 1
• Patients can expect significant improvement in pain and function with conservative treatment, even in chronic cases 4

Injection Therapy

• Corticosteroid injections may be considered for advanced cases refractory to initial conservative management, though evidence is insufficient to formally recommend their use specifically for glenohumeral arthritis 1, 2
• Multiple corticosteroid injections should be avoided as they may compromise rotator cuff integrity 5
• Viscosupplementation with hyaluronic acid is an option (Grade C, Level of evidence IV), though evidence is mixed 1, 5, 3
• Biologics (platelet-rich plasma, bone marrow aspirate, mesenchymal stem cells) may decrease shoulder pain but do not stop progression or improve osteoarthritis, and further evidence is needed 3

Diagnostic Imaging Requirements

• Standard radiographic evaluation must include at least three views: anteroposterior in internal and external rotation, and an axillary or scapula-Y view 1
• Radiographs should be performed in a standing position because poor shoulder alignment may be underestimated when supine 1

Surgical Indications

Total shoulder arthroplasty (TSA) is recommended over hemiarthroplasty when conservative treatment fails and surgery becomes necessary (Grade B, Level of evidence II) 6, 1, 5

Key Surgical Considerations:

• TSA provides statistically significant better pain relief and global health assessment scores compared to hemiarthroplasty 6
• 14% of hemiarthroplasty patients required revision to TSA due to progressive glenoid arthrosis and pain, while no TSA patients required revision to hemiarthroplasty 6
• Both TSA and hemiarthroplasty provide significant improvements in pain, function, and quality-of-life scores 6
• Surgical options for less severe cases include arthroscopic debridement and arthroscopic capsular release 2

Critical Surgical Contraindications and Precautions:

• Do not perform TSA in patients with irreparable rotator cuff tears (Consensus recommendation) 6, 5
• Exercise caution in patients younger than 50 years due to potential risk of prosthetic loosening and decreased implant survival 5
• Patients should be referred to surgeons performing more than two shoulder arthroplasties per year to reduce immediate postoperative complication rates (Grade C, Level of evidence IV) 6, 5

Clinical Pitfalls to Avoid

• Physical therapy is more effective for motion-related pain rather than rest pain 3
• Identify the specific soft tissues responsible for ROM loss to target interventions appropriately 3
• Abnormal scapular motion commonly develops as adaptation to restricted glenohumeral motion and must be addressed 3
• Distinguish shoulder degenerative joint disease from other conditions like synovial chondromatosis, as treatment approaches differ significantly 7

Venous Thromboembolism Prophylaxis

• Use perioperative mechanical and/or chemical prophylaxis to prevent venous thromboembolism in shoulder arthroplasty patients, though the risk is lower than in lower extremity surgery 6
• Each patient should be assessed individually for pulmonary embolism risk, weighing this against potential bleeding risk 6