What is the recommended management for a >60‑year‑old patient with severe shoulder osteoarthritis, chronic pain, limited motion, and functional impairment?

Management of Severe Shoulder Osteoarthritis in Patients Over 60

For a patient over 60 with severe shoulder osteoarthritis causing chronic pain, limited motion, and functional impairment, total shoulder arthroplasty is the definitive treatment, as it provides superior functional outcomes compared to hemiarthroplasty and should be pursued after a trial of conservative management that includes structured exercise, acetaminophen, and intra-articular corticosteroid injections. 1, 2

Initial Conservative Management (3-6 Month Trial)

Pharmacologic Treatment Sequence

• Start with acetaminophen at regular scheduled doses of 3000-4000 mg daily (consider 3000 mg maximum in patients over 60 for hepatotoxicity prevention), not "as needed" dosing, as first-line pain management 2, 3

• Apply topical NSAIDs (diclofenac gel) to the shoulder before considering oral NSAIDs, providing localized relief with minimal systemic absorption and substantially lower gastrointestinal, renal, and cardiovascular risks 2, 3

• Prescribe oral NSAIDs or COX-2 inhibitors only if topical treatments fail, using the lowest effective dose for the shortest duration, and always co-prescribe a proton pump inhibitor for gastroprotection in this age group 1, 2, 3

• Consider intra-articular corticosteroid injections for moderate to severe pain, which may provide temporary relief while other treatments take effect 1, 2

• Cautiously consider opioid analgesics if the patient cannot sleep due to pain and previous treatments are insufficient 2

Structured Exercise Program

Given the severe pain and functional limitation, the exercise progression must be carefully staged:

Phase 1: Isometric Strengthening (Weeks 1-4)

• Begin with isometric exercises as they produce low articular pressures and are well tolerated by patients with painful, inflamed joints 1, 2

• Start at 30% of maximal voluntary contraction intensity, gradually increasing to 75% as tolerated 2

• Hold contractions for no longer than 6 seconds 2

• Begin with one contraction per muscle group, gradually increasing to 8-10 repetitions as pain allows 2

• Do not exercise muscles to fatigue; resistance must remain submaximal 1, 2

Phase 2: Transition to Isotonic Exercise (Weeks 5-12)

• Once acute pain subsides, transition to isotonic (dynamic) strengthening exercises, as these closely correspond to everyday activities like overhead reaching 1, 2

• Each exercise session must include three phases: 1, 2

  • Warm-up (5-10 minutes): repetitive low-intensity range-of-motion exercises 1, 2
  • Training phase: provides overload stimulus to increase joint range of motion and muscle strength 1, 2
  • Cool-down (5 minutes): static stretching of muscles 1, 2

Daily Static Stretching Protocol

• Perform daily when pain and stiffness are minimal, ideally prior to bedtime 1, 2

• Precede stretching with a warm shower or superficial moist heat application 1, 2

• Move slowly and extend range of motion to a comfortable point producing slight resistance 1

• Hold terminal stretch position for 10-30 seconds before slowly returning to resting length 1, 2

• Modify stretching to avoid pain when the joint is inflamed by decreasing range of motion or duration 1, 2

Adjunctive Non-Pharmacologic Measures

• Apply local heat or cold for temporary pain relief 1, 2

• Consider manual therapy (manipulation and stretching) combined with supervised exercise for additional benefit 1, 2

• Assess need for assistive devices to help with activities of daily living, particularly overhead tasks 2

Critical Safety Monitoring During Conservative Treatment

• Joint pain lasting more than 1 hour after exercise indicates excessive activity and requires immediate modification 1, 2

• Joint swelling after exercise signals overexertion; adjust intensity, volume, or type of exercise 1, 2

• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing oral NSAIDs in this age group 2, 3

• Never exceed 4000 mg daily of acetaminophen, and strongly consider 3000 mg limit in patients over 60 to prevent hepatotoxicity 2, 3

Surgical Referral Criteria

Refer for total shoulder arthroplasty when:

• Joint symptoms (pain, stiffness, reduced function) substantially affect quality of life and are refractory to at least 3-6 months of conservative treatment 1, 2

• The patient's inability to sleep and perform overhead activities persists despite optimal conservative management 2

• Referral should occur before there is prolonged and established functional limitation and severe pain 1

• Age, sex, smoking, obesity, and comorbidities should not be barriers to referral for joint replacement surgery 1

Surgical Procedure Selection

Total shoulder arthroplasty is moderately recommended over hemiarthroplasty for glenohumeral osteoarthritis, as it provides superior functional outcomes on the American Shoulder and Elbow Surgeons Shoulder Scale (10-point improvement, 95% CI 1.13-18.97) with no significant differences in pain scores, quality of life, or adverse events 1, 4

• Hemiarthroplasty showed a non-statistically significant trend toward higher revision rates (Risk ratio 6.18,95% CI 0.77-49.52, P=0.09) 4

• Total shoulder arthroplasty should not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear (consensus recommendation) 1

• Use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients (consensus recommendation) 1

• Surgeons performing fewer than two shoulder arthroplasties per year should be avoided to reduce the risk of immediate postoperative complications 1

Surgical Options NOT Recommended

• Arthroscopic lavage and debridement should not be routinely offered as part of treatment for osteoarthritis 1

• While comprehensive arthroscopic management (debridement, capsular release, osteoplasty) has shown short-term promising results in younger patients with demanding activities 5, this approach is not appropriate for a patient over 60 with severe disease and functional impairment requiring definitive treatment

• Injectable viscosupplementation is only a weak recommendation with limited evidence 1

Common Pitfalls to Avoid

• Do not delay surgical referral until there is prolonged and established functional limitation, as outcomes are better with earlier intervention 1, 2

• Do not prescribe oral NSAIDs without gastroprotection (proton pump inhibitor) in this age group 2, 3

• Avoid prolonged high-dose NSAID use in older patients due to serious adverse event risks including GI bleeding, renal insufficiency, and cardiovascular complications 2, 3

• Do not allow inflamed joints to be dynamically strengthened; use only isometric exercises with few repetitions and no resistance during acute inflammation 1, 2

• Do not substitute pharmacologic therapy for core non-pharmacologic treatments; exercise and structured rehabilitation are mandatory first-line interventions 1, 2, 3