What is the recommended treatment for patients with shoulder degenerative changes?

Treatment of Shoulder Degenerative Changes

For shoulder degenerative changes, initiate conservative management with physical therapy focused on gentle stretching, mobilization techniques, and progressive strengthening exercises, combined with acetaminophen or NSAIDs for pain control, reserving corticosteroid injections for refractory cases and surgical intervention only for severe disease unresponsive to 6-8 weeks of conservative treatment. 1, 2

Initial Conservative Management

Physical Therapy as First-Line Treatment

• Begin with gentle stretching and mobilization techniques to address range of motion limitations, particularly focusing on external rotation and abduction 3
• Active range of motion should be increased gradually while restoring joint alignment and strengthening weak muscles in the shoulder girdle 3
• Physical therapy is most effective for motion-related pain rather than rest pain, so assess pain patterns before initiating treatment 2
• Rotator cuff strengthening exercises should be incorporated to protect the glenohumeral joint from further degeneration 2

Pharmacological Management

• Start with acetaminophen or NSAIDs as first-line pharmacological therapy if there are no contraindications 3, 1
• NSAIDs are recommended as first-line therapy to reduce pain and diminish inflammation in the joint 2
• Consider supplementation with oral vitamin C and vitamin D to help slow cartilage degeneration 2

Treatment for Refractory Cases

Corticosteroid Injections

• Subacromial corticosteroid injections can be used when pain is thought to be related to injury or inflammation of the rotator cuff or bursa 3
• These injections are appropriate for more advanced cases of osteoarthritis refractory to nonoperative management 1
• The American Heart Association/American Stroke Association notes that the usefulness of subacromial or glenohumeral corticosteroid injection is not well established (Class IIb, Level B evidence), so use judiciously 3

Botulinum Toxin for Spasticity-Related Pain

• If degenerative changes are accompanied by spasticity (particularly in post-stroke patients), botulinum toxin injections into the subscapularis and pectoralis muscles can be used 3
• The American Heart Association/American Stroke Association recommends botulinum toxin injection to reduce severe hypertonicity in shoulder muscles (Class IIa, Level A evidence) 3

Surgical Intervention

Indications for Surgery

• Surgery is indicated for severe cases with pain unresponsive to medical management after 6-8 weeks of conservative treatment 1, 4
• The primary indication for surgery is pain that does not respond to conservative measures 4

Surgical Options

• Arthroscopic debridement and capsular release for moderate disease 1
• Hemiarthroplasty or total shoulder arthroplasty for severe glenohumeral joint degeneration, with choice depending on glenoid condition 1, 4
• Results of shoulder arthroplasty are good to excellent in 86-94% of patients 4

Critical Diagnostic Considerations

Assessment Components

• Evaluate tone, strength, soft tissue length changes, joint alignment of the shoulder girdle, pain levels, and orthopedic changes 3
• Physical examination findings are more valuable than imaging in younger patients, using tests such as painful arc, Neer and Hawkins-Kennedy tests, cross-body adduction test, and empty can test 5
• Imaging is not immediately necessary unless trauma occurred or symptoms persist beyond 6-8 weeks of conservative treatment 5
• Plain radiographs are the first-line imaging modality if needed, followed by ultrasound or MRI only if surgical intervention is considered 5

Common Pitfalls to Avoid

• Avoid overhead pulley exercises, as these are not recommended (Class III, Level C evidence) 3
• Do not continue physical therapy indefinitely without functional improvement—standard treatment should show progress within 12-16 weeks 6
• Be aware that radiological evidence of degenerative changes does not always correlate with symptoms; 72% of spinal cord injury patients showed radiological changes but only 11% had pain 7
• Consider cervical spine and upper limb neural tissue impairments as potential contributors to shoulder symptoms, as addressing these may improve outcomes 8