What is the recommended treatment for shoulder hypertrophic changes?

Treatment of Shoulder Hypertrophic Changes

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

Initial Conservative Management

Physical Therapy Protocol:

• Focus rehabilitation on strengthening the rotator cuff, periscapular muscles, and core musculature 1
• Implement gentle stretching and mobilization techniques, particularly increasing external rotation and abduction 2
• Gradually increase active range of motion while restoring alignment and strengthening weak muscles in the shoulder girdle 2
• Target scapular stabilizing muscles and dynamic stabilizers of the shoulder 3

Pain Management:

• Use acetaminophen or ibuprofen as first-line analgesics if no contraindications exist 2
• Consider viscosupplementation with hyaluronic acid injections (Grade C evidence, though mixed results) 1, 4
• Subacromial corticosteroid injections can be used when pain relates to inflammation of the rotator cuff or bursa 2
• Exercise caution with multiple steroid injections as they may compromise rotator cuff integrity 4

When Conservative Treatment Fails

Surgical Indications:

• Total shoulder arthroplasty (TSA) is superior to hemiarthroplasty when surgery becomes necessary (Grade B, Level II evidence) 1, 4
• TSA provides statistically significant better pain relief and global health assessment scores compared to hemiarthroplasty 1
• 14% of hemiarthroplasty patients required revision to TSA due to progressive glenoid arthrosis, while no TSA patients required revision to hemiarthroplasty 1

Critical Contraindications and Precautions

Absolute Contraindications:

• Do not perform TSA in patients with irreparable rotator cuff tears (Consensus recommendation) 2, 1, 4

Relative Contraindications:

• Exercise extreme caution in patients younger than 50 years due to increased risk of prosthetic loosening and decreased implant survival 2, 1, 4

Surgeon Volume Requirements:

• Refer patients to surgeons performing more than two shoulder arthroplasties per year to reduce immediate postoperative complication rates (Grade C, Level IV evidence) 2, 1, 4

Diagnostic Requirements Before Surgery

Imaging Protocol:

• Obtain standard radiographs with at least three views: anteroposterior in internal and external rotation, plus axillary or scapula-Y view 1
• Perform radiographs in standing position because poor shoulder alignment may be underestimated when supine 1

Special Considerations for Spasticity-Related Changes

If hypertrophic changes are related to spasticity (post-stroke or neurological conditions):

• Botulinum toxin injections into subscapularis and pectoralis muscles can reduce pain related to spasticity (Evidence Level B) 2
• Suprascapular nerve blocks may be considered as adjunctive treatment (Grade IIb, Level B) 2
• Active, active-assisted, or passive range of motion exercises should be used to prevent complex regional pain syndrome 2

Common Pitfalls to Avoid

• Never use overhead pulley exercises (Grade III recommendation) 2
• Distinguish shoulder degenerative joint disease from other conditions like synovial chondromatosis, as treatment approaches differ significantly 1
• Assess each patient individually for venous thromboembolism risk when considering surgery, weighing this against potential bleeding risk 1