Treatment Options and Physical Limitations for Shoulder Strain and Shoulder Osteoarthritis
Initial Conservative Management
For glenohumeral osteoarthritis, begin with exercise-based physical therapy as the foundation of treatment, though evidence quality is limited. 1
Exercise and Physical Therapy
Exercise is strongly recommended for all patients with shoulder OA, with the primary goals of decreasing pain, increasing range of motion, and protecting the glenohumeral joint through rotator cuff strengthening. 1, 2
Physical therapy should target the specific soft tissues responsible for ROM loss, with rotator cuff strengthening exercises to protect the joint. 2
Progressive shoulder exercises over 12 weeks have shown clinically meaningful improvements, with patients experiencing a mean 23-point improvement in shoulder-specific function scores and acceptable pain levels during exercise. 3
Exercise is most effective for motion-related pain rather than rest pain, and patients should focus on exercises they find acceptable and can access consistently. 1, 2
No specific exercise prescription (duration, intensity, frequency) has proven superior, so recommendations should focus on patient preference and access, including walking, cycling, resistance training, or neuromuscular training. 1
Pharmacologic Options
Oral NSAIDs are recommended as first-line pharmacologic therapy for pain reduction and inflammation control, with acetaminophen as an alternative. 4, 2, 5
Oral vitamin C and vitamin D supplementation may help slow cartilage degeneration. 2
Injectable corticosteroids have insufficient evidence to recommend for or against their use (Grade I recommendation), though they are widely used in clinical practice. 1
Viscosupplementation (hyaluronic acid injections) is an option (Grade C recommendation), typically administered as three weekly injections, with improvements in pain and function scores at 1,3, and 6 months. 1, 6
Surgical Intervention
When conservative treatment fails, total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty for patients with glenohumeral OA (Grade B recommendation, Level II evidence). 1, 7
Arthroplasty Decision-Making
TSA provides statistically superior pain relief and global health assessment scores compared to hemiarthroplasty, with 14% of hemiarthroplasty patients requiring revision to TSA due to progressive glenoid arthrosis and pain, while no TSA patients required revision to hemiarthroplasty. 1, 7
Both TSA and hemiarthroplasty significantly improve pain, function, and quality-of-life scores, but TSA demonstrates better outcomes overall. 1
Hemiarthroplasty may be appropriate only when the glenoid is naturally concentric or can be reamed to concentricity. 1, 6
Arthroscopic treatments have insufficient evidence to recommend for or against their use (Grade I recommendation), though they may be considered for younger patients with early-stage OA who are not candidates for arthroplasty. 1, 6
Critical Surgical Contraindications and Considerations
TSA should NOT be performed in patients with irreparable rotator cuff tears (consensus recommendation); reverse total shoulder arthroplasty should be considered instead. 1, 7, 8
Avoid arthroplasty in patients under 50 years when possible due to increased risk of prosthetic loosening and decreased survivorship. 1, 7, 6
Refer to surgeons performing at least 2 shoulder arthroplasties per year to reduce immediate postoperative complications and length of stay. 7, 6, 8
When performing TSA, use keeled or pegged all-polyethylene cemented glenoid components, as metal-backed glenoids have higher revision rates (6.8% vs 1.7%). 1, 6
Physical Limitations in Shoulder OA
Patients with glenohumeral OA experience:
Painful limitations in shoulder elevation and internal/external rotation movements, with stiffness on accessory glide testing. 9
Rotator cuff and scapular musculature weakness associated with pain, contributing to functional impairment. 9
Abnormal scapular motion as adaptation to restricted glenohumeral motion, which should be addressed in physical therapy. 2
Progressive loss of shoulder rotation due to joint capsule thickening as the disease advances. 5
Perioperative Management for Surgical Candidates
Use mechanical and/or chemical venous thromboembolism prophylaxis for all shoulder arthroplasty patients (consensus recommendation). 7, 8
Pre-operative imaging is essential to evaluate glenoid morphology, bone loss, retroversion, and bone quality before arthroplasty. 7, 8
Shoulder arthroplasty complications occur in up to 39.8% of cases, with revision rates up to 11%, including glenoid erosion (20.6%) for hemiarthroplasty and glenoid loosening (14.3%) for TSA. 7
Common Pitfalls to Avoid
Do not rely solely on corticosteroid injections, as evidence for their efficacy in glenohumeral OA is insufficient, and they should be used cautiously in athletes. 1, 2
Do not perform traditional TSA in patients with irreparable rotator cuff tears, as this will lead to poor outcomes and likely revision surgery. 1, 8
Do not extrapolate all treatment recommendations from hip and knee OA literature, as shoulder-specific evidence is limited and most recommendations are based on lower-quality evidence. 7, 6
Physical therapy following shoulder arthroplasty is commonly practiced but lacks high-quality evidence demonstrating improved outcomes (Grade I recommendation). [1, @16@]