Do you wake up in the morning with a stiff and painful shoulder that takes a while to “warm-up”? It is sometimes so painful that you struggle to get dressed in the morning. Then you might be suffering from shoulder arthritis (one of the more common types of shoulder arthritis is also known as shoulder osteoarthritis). This means there is damage to the cartilage inside your ball and socket joint. It progressively gets worse as more layers are affected and your pain starts to limit you so much that you can’t do the most basic things.

Arthritis is one of the most common conditions we see and treat daily. It is a normal part of aging and can happen to anyone. As we age our joints gets worn out from the wear and tear, also known as degeneration. Much like the tires on a car, the surfaces inside your shoulder joint slide and glide over one another and they get worn out.

When it comes to shoulder arthritis you might have heard that “movement is the best medicine“, but this might not always be the case. This will depend on the severity and type of your shoulder arthritis you have. We want to help you find the correct balance between doing too much and too little.

Your shoulder is made up of three bones: Your upper arm bone (humerus), shoulder blade (scapula), and your collarbone (clavicle) come together to form your shoulder joint.

The top of your upper arm bone fits into a rounded socket in your shoulder blade. This is why they call it a ball and socket joint. This allows the arm to move in all sorts of directions. This socket is called the glenoid. A group of muscles called the rotator cuff and your tendons keeps your arm bone centered in your shoulder socket.

The three bones come together in two different places, to form what we call joints. Both of these joints can be affected by arthritis. The first joint is the acromio-clavicular (AC) joint, this is located where the clavicle meets the tip of the shoulder blade (acromion). Where the head of the humerus fits into the scapula is called the gleno-humeral (GH) joint.

Now that you understand the bones and joints in your shoulder that can be involved by shoulder osteoarthritis, let’s look at the other structures that can also be involved like the cartilage, ligaments and synovial fluid.

It’s not only a condition of the shoulder joint alone– it’s all the “in between” bits that change in your shoulder as well. Each structure has a role to play and should allow you to move. Let’s look at each of these structures:

Articular cartilage

The top part of the humeral head and the bottom of the glenoid is lined with a shiny white coating that we call the articular cartilage. This acts as a shock absorber in your shoulder and also gives us a smooth, frictionless motion when moving the shoulder. When you have shoulder arthritis symptoms, it is likely that your cartilage is affected and has worn down a bit.

Synovial Fluid

Inside your shoulder joint you have a gel-like substance that lubricates the joint called synovial fluid. This fluid also helps absorb shock in the shoulder during movement and is important in pain free shoulder movements. During shoulder arthritis this fluid is affected and thinned out due to the joint degeneration, leading to more friction and pain in your shoulder.

The Labrum

The labrum in your shoulder is like the rubber band around the top of the golf tee that stops the ball from falling off. This ring of fibrous cartilage offers stability around the glenoid.

Ligaments

Ligaments connect one bone to another bone and there are quite a few inside the shoulder joint. A ligament offers stability by limiting certain movements.

Bursae

A bursa is a pillow like sac filled with fluid, that absorbs shocks in the joint and allows smooth gliding movements in your shoulder. The bursa under your acromion is called the sub-acromial bursa.

Capsule

All of the structures mentioned above are kept in place by a strong, protective sleeve called a capsule.

Even though shoulder arthritis affects your shoulder joint mostly, all of the structures mentioned above may be involved, which makes it slightly more complicated. You will realize this makes your pain and stiffness worse. Therefore all of these structures should be addressed during your treatment session to decrease symptoms of shoulder arthritis.

Your shoulder joint connects your upper arm to your collar bone and shoulder blade. It is a very mobile joint because it can move in all directions, but also needs to handle excessive load when picking up stuff. You need all the movements in the shoulder to do the things you do every day and even sport: like hanging washing or playing golf.

• Flexion is forwards movement of your arm, like giving a friend a high five.
  Muscles responsible for this movement are anterior deltoid, pectoralis major and coracobrachialis.
• Extension is when your arm moves backwards, like tucking in your shirt at the back. This action is performed by the posterior deltoid, teres major and latissimus dorsi muscles.
• Abduction is movement away from the midline, like moving your arm out to the side to stretch. The muscles responsible for this movement are the deltoid, supraspinatus, trapezius and serratus anterior muscles.
• Adduction is movement towards the midline, like touching your opposite hip.
  Muscles that adduct the shoulder joint are pectoralis major, latissimus dorsi, teres major, triceps, and coracobrachialis.
• Internal rotation is a turning movement of your shoulder, turning your arm inwards.
  Internal rotators of the shoulder joint area subscapularis.
• External rotation is also a turning movement of your shoulder, but in this case your arm will turn outwards. This movement is performed by the infraspinatus and teres minor muscles.
• Shoulder arthritis affects the whole joint, ,meaning all of these movements will be affected.

Stability

The shoulder is a very mobile joint, which is why it is often one of the more unstable joints in the body. However, when we look at the shoulder joint, it is the base structure of support for your entire arm. That’s why it’s so important that every muscle and ligament around your shoulder does its job to create stability around the joint. If some muscles are weak or tight it will affect the function of the whole arm, causing extra strain on the cartilage and ligaments. Over time this leads to degeneration – “wear & tear” – inside your shoulder joint eventually causing shoulder osteoarthritis.

The surfaces of all your bones in your body are covered with cartilage. Similar to Teflon on a ball bearing. Now much like shoulder arthritis, gradual wear and tear to this ball bearing causes run down of the Teflon (cartilage), it becomes rusty and struggle to move and glide like it used to. The longer you don’t use it, the worse it will get. If you do however use some oil and clean it, the movement can improve again. Your shoulder is exactly the same.

Your body has its own way of healing the injured and degenerated structures in your shoulder. This is called inflammation. During this process your body sends cells (named cytokines and chemokines) to the shoulder to assist with healing. These cells also activate the nerve cells in your shoulder joint responsible for carrying “danger” messages to your brain, leading to more pain.

Shoulder arthritis affects the cartilage inside your shoulder. The other structures in and around your shoulder joint like the bone, ligaments and capsule is also affected and causes thickening. Over time this leads to osteophyte formation – formation of extra bones in the shoulder to increase the stability inside your joint. This makes the movements in your shoulders less smooth, which is why you might feel pain and stiffness in your shoulder joint. This is the end result of years and years of normal use, not just a result from trauma or acute injury.

There are different types of arthritis that can affect your shoulder. Some of these include osteoarthritis, rheumatoid arthritis and juvenile arthritis. Regardless of which type of shoulder arthritis you might have, it is going to restrict your shoulder movement and cause you pain and stiffness in your shoulder. That is something we can help you with!

What causes shoulder arthritis?

There are 5 types of shoulder joint arthritis and each one is caused by a different reason:

1. Osteoarthritis – It occurs mostly in persons over 50 years due to normal wear and tear of your joints.

2. Rheumatoid Arthritis – Is due to an auto-immune disease (your immune system attacks your own tissues). This form of arthritis can therefore also affect other areas of your body like your eyes and ears and not only the joint itself.

3. Post traumatic arthritis – like a history of shoulder dislocation or fracture, this normally happens during sporting injuries in younger athletes.

4. Avascular necrosis – this happens when the blood cannot reach your shoulder joint, joint tissue will be destroyed and start to die leading to shoulder arthritis.

5. Rotator Cuff Tear arthropathy – the rotator cuff usually positions and stabilizes your shoulder, if this is torn off- damage will occur in the shoulder joint leading to arthritis.

Juvenile arthritis – this is another form of shoulder arthritis, it can manifest as any one of the five above mentioned types, the only difference is that it develops in patients before the age of 16 years.

Some risk factors that predispose you include:

• Bone defects
• Obesity
• Genetics
  
• Occupations that cause a lot of load and strain on your shoulder
• Age
• Gender: Women are more likely to develop shoulder osteoarthritis than men.
• Menopause
• Post-operative
• Inactive lifestyle

Shoulder arthritis symptoms doesn’t develop overnight. Your stiffness and pain gradually gets worse. Over time you notice more discomfort leading to pain while the stiffness takes longer to ease with movement. On the other hand too much motion will flare up your symptoms. As shoulder arthritis progresses you’ll feel pain more often and intense, it will last for longer periods of time and eventually your pain will be constant.

Pain will get worse with too much activity and relieved by rest, but complete rest will also cause more pain. Symptoms are worse in the mornings with stiffness in all directions, which takes about 30 minutes to ease. The longer it takes to ‘settle’ or ‘get moving’ the more advance your shoulder arthritis is.

As the condition gets worse you will find that you lose range of motion of your shoulder, like when you lift your arm up to hold your phone to your ear. The quicker you see your Physiotherapist, the quicker we can manage your pain and stiffness and start with to correct management and rehabilitation.

We can divide arthritis into four different stages of severity. What you experience in each of these stages might be different, depending on your type of arthritis, background and history. Stop hoping the pain will go away by itself, if you’ve been in pain for longer than 4 weeks, rather get it checked.

Stage 1

In the first stage of shoulder arthritis you will only have minor symptoms. There could be some osteophytes on X-rays, but you might feel more discomfort rather than pain. These symptoms come and go and don’t interfere with your daily routine. You can feel some stiffness in the morning when you get up, but this eases as soon as you start moving around. Pushing on the arm to get up or overhead activities makes you aware of slight discomfort. You are feeling these symptoms due to the inflammation in your joint.

During the disease process of Phase 1 rheumatoid arthritis you get the inflammation initially due to the body mistakenly attacking your own joint tissue (auto-immune disease). During osteoarthritis you will have inflammation in stage 1 due to the wear and tear in your joint irritating the synovium – it is your bodies own way to prevent further damage.

Stage 2

You will start to notice stiffness more often, like after a long drive or sitting at your desk for a couple of hours. You’re more aware of the shoulder on a cold day. Pain in your shoulder or neck at times, but you are still able to carry on with your daily routine. Reaching for something or picking up an object like grocery bags becomes sensitive. This is because the x-rays will now show osteophytes (bone growths) around the shoulder joint, but no narrowing of your joint space.

Stage 3

In the third stage of shoulder arthritis your symptoms will become more noticeable. You will find that your discomfort has changed to pain which can interfere with your daily activities. You might notice that you start avoiding certain movements or positions, like sleeping on your shoulder or getting dressed in the morning is a challenge. At this stage you will probably also struggle to lift up your arm and pain can start shooting down your arm. Other activities that cause pain are pushing on the arm, holding your steering wheel in the car and working for an hour brings on the stiffness. On X-rays this is confirmed by some damage to the cartilage inside your shoulder joint and we will see narrowing of your joint space.

If you have rheumatoid arthritis your joint can become crooked due to the formation of fibrous connective tissue during this stage, this is not the case in osteoarthritis.

Stage 4

At this point you will have constant, severe pain that wakes you up during the night. You will struggle to find a comfortable position to fall asleep in. Opening doors and getting dressed will be extremely painful and all movements of your shoulder will be limited. Your shoulder will be painful when you get out of bed in the morning and you could notice “locking” and “clicking” of your joint with most movements. On your X-rays there will be no visible joint space – which means that the cartilage is worn away – and a large number of osteophytes is present.

During the final stage of rheumatoid arthritis your joints will fuse together as one unit (called bony ankylosis), this will be visible on your x-ray. This is however not the case in stage 4 osteoarthritis.

Always remember that x-rays can tell us what your joint looks like on the inside, but this does not determine your pain levels. Pain and stiffness can be managed and you might even have days where you are PAIN FREE! We want to help you reach that phase, no matter the stage of arthritis you are in.

Since arthritis is a progressive disease the correct diagnosis is crucial for your recovery. Our physiotherapists are highly equipped to take a thorough history and perform a clinical assessment, to make an accurate diagnosis and determine which type of arthritis you have in your shoulder. We are able to lead you every step of the way.

Diagnosis of shoulder arthritis begins with thorough history taking and is followed by a physical exam. During the history taking your physiotherapist will collect all the details needed to confirm your diagnosis and other contributing factors that might affect your shoulder arthritis symptoms (like your age, weight, pain, previous joint injury etc). Your physiotherapist will be looking at various different components in your physical exam. Some of those include:

• Active and passive movements in your shoulder
• Your shoulder joint movements
• Nerve mobility and gliding
• Muscle length and strength

X-rays show us the bones (not the soft tissue). Therefore it is the image of choice to diagnose osteoarthritis of the shoulder. We will be able to see any bone spurs, joint space, alignment and the quality of the bone. On the x-ray decrease joint space between the bones, bone cysts and bone spurs might be present, which is an indication of shoulder osteoarthritis.

Your physiotherapist will refer you to get x-rays taken if shoulder arthritis is suspected.

Sonar (Diagnostic Ultrasound) show soft tissue (muscles, ligaments and nerves) and is therefore not the best diagnostic tool if we suspect osteoarthritis or other forms of arthritis in the shoulder joint. However, depending on your symptoms this can rule out soft tissue conditions like tendonitis or shoulder bursitis. Your Physiotherapist will refer you for a Sonar if a different diagnosis is suspected.

An MRI is a very expensive scan which can only be ordered by a specialist (like your orthopedic surgeon). An MRI will show us all the soft tissue and bone of the shoulder joint and what exactly is going on inside the joint. This makes it the most effective tool to diagnose your shoulder joint arthritis.

Your physiotherapist can refer you to the right specialist to get the right scans, if necessary.

Shoulder osteoarthritis is a degenerative disease affecting the structures in and around your shoulder joint. Nobody can change what has already happened in your shoulder. But we can help you slow down the disease progress. We would like you to understand what is happening in your shoulder.

Pain flare-ups are a normal symptom of shoulder arthritis. Cold weather, doing too much activity the day before or even doing too little. It is very important to find the balance between your activities and rest, to minimize pain and manage your flare-ups. We are here to guide you through every step of the way.

Morning stiffness is very common with osteoarthritis. This is caused by the inflammation within the joint. Movement and activity actually improves the circulation to and within the joint and eases the stiffness. It usually lasts approximately 30 minutes.

Pain and stiffness are common symptoms of shoulder arthritis, this encourages you to use your arm & shoulder even less. This causes more stiffness and less circulation in your shoulder joint (this means you will experience more pain when you do decide to move your arm). It is a vicious cycle! We can help you break this cycle and find the balance between movement and rest. So you will be able to play golf and walk your dog without worry.

• Mismanagement of your shoulder arthritis. Because the shoulder joint is so complicated there are lots of different conditions that cause shoulder pain and these different areas must be evaluated properly during an assessment to make the correct diagnosis. If the wrong structures are treated you may have temporary relief without the long-term benefits.
• Lack of education and advice. Shoulder arthritis cannot just be “fixed” as it is a degenerative condition. Educating you about your condition and how to manage flare-ups is a crucial part for the treatment of your shoulder osteoarthritis symptoms.
• Chiropractic manipulation of your shoulder joint or the neck can aggravate your arthritis symptoms due to the bony changes that is present inside your shoulder joint.
• Wearing a sling for the shoulder will only offer temporary relief. You might experience more pain, stiffness, muscle weakness in your shoulder or even neck pain when wearing the sling for prolonged periods.
• Overuse of medication is another big problem with shoulder joint arthritis. As your pain gets worse over time you will need more and more medication to get relief. This becomes quite expensive over time and makes you vulnerable to side effects.
• Resting too much leaves you weaker than before. Moving too much causes extra pain and inflammation in the joint. Finding the balance between resting and doing safe movements is key! Let us help you find that balance.

We are here to help you get the right treatment for your shoulder arthritis symptoms and stop it from progressively getting worse.

Unfortunately we cannot reverse the cartilage damage and changes in your shoulder joint. However, we can relieve a great deal of your your shoulder joint pain. In doing things differently you can slow down the degeneration process and limit painful episodes. The best strategy to manage your shoulder arthritis is having a good understanding of what is going on inside your shoulder joint, which type of arthritis you have and knowing when to rest or exercise your shoulder.

Treatment of shoulder osteoarthritis and other forms of arthritis should start with non-surgical treatments like physiotherapy, medication, exercise, advice and resting. Some of the specific Physiotherapy treatments will include:

• electrotherapy, including laser and ultrasound, to help with pain relief
• myofascial release and dry needling to get rid of muscle spasm and tightness
• joint mobilisation to improve or restore the movement of the joints
• nerve mobilisations to restore the normal gliding movements of the nerves
• taping/strapping to support the area
• exercises to strengthen the stabilizing muscles around your shoulder, so you can have confidence and start lifting weights again
• how to start with pain free activities like working in your garden with no limitations
• advice and education to help you to understand your condition and know what you can change to be in control of your symptoms

All types of arthritis are progressive, so we cannot reverse or heal the damage that has already been done to your shoulder joint. However, we can make a huge difference in your pain and quality of life. Our treatment plan and how often we need to see you will depend on the severity of your condition and your current pain. We want to get you back to doing all the things you love.

In the beginning we will see you twice a week, to start with your pain management or rehabilitation process, depending on your condition and shoulder arthritis symptoms. Thereafter we will make an appointment once a week to maintain the joint movement we have gained and to increase the intensity of your exercises. As your exercises get progressively harder the time between treatments will increase to two weeks and later a month to check on your progress and adapt your exercises as necessary. You could have a flare-up sometime during the course of treatment if there is a sudden increase in your activity, but this will settle down after one or two treatments, because you have already started the rehabilitation process. Your journey to recovery will not be smooth, there will be ups and downs. But your Physiotherapist will guide you through these flare-ups.

Without any treatment or if you do not finish your rehabilitation, the pain and stiffness will always return and get worse over time. At some point you will find that you have constant discomfort or pain that isn’t relieved by rest. The best way to combat this is to work hand in hand with your physiotherapist to ensure that this doesn’t happen to you.

Also remember that even if your doctor has suggested surgery, you don’t have to wait until after your procedure to start physiotherapy treatment. Prehabilitation ensures that you are strong before surgery and can dramatically shorten your recovery after surgery.

• Your GP can prescribe medications like cortisone and anti-inflammatory medication to relieve your symptoms during an acute flare up of shoulder arthritis. Remember these medications will give temporary relief to the pain and stiffness that you are experiencing. However, it will not be the solution to your problem.
• Lifestyle modifications – Exercising regularly and eating healthy can help with some of your shoulder arthritis symptoms. A dietician can help you with dietary adjustments if you are overweight.
• Biokineticist – After completing your treatment with a physiotherapist a biokineticist can help you with a long-term exercise program.
• Cortisone injections – In the earlier phases of shoulder arthritis a cortisone injection can suppress the inflammation and help with pain relief. However, this doesn’t take away the degeneration, so it will only be temporary pain relief.
• Orthopedic surgeon – Surgery should not be your first option when dealing with pain. Physiotherapy offers you a non-surgical solution before you decide to go for surgery. However, your Physiotherapist can help you determine when surgery is needed and refer you to a specialist.
• Wearing a sling or brace – It may make your shoulder feel more stable, but in the long run wearing the sling will make the muscles around your shoulder lazy. You might also experience severe stiffness after prolonged periods of wearing the sling, because the shoulder is essentially not moving.
• Intra articular gel injections – (hyaluronic acid) helps with joint lubrication and can give pain relief for a few months. This is however not a long term solution.
• Rheumatologist – your Rheumatologist can help you manage the symptoms and slow down progression with a tailored treatment plan specific to your needs. This is specifically to slow down and manage the disease progression for Rheumatoid Arthritis.

Surgical options depend on your age, the degree and type of your arthritis. Your physiotherapist can help and advice you on non-surgical and possible surgical managements.

The shoulder can be “cleaned out” with surgical tools and a small camera they insert into the joint (Arthroscopic Shoulder Debridement). This is only indicated if your shoulder arthritis is not as severe. This is not a permanent solution as it does not change the presence of the disease in the shoulder and might only offer temporary relief.

The most common procedure offered for severe shoulder joint pain is a total shoulder replacement, which replaces the ball and the socket parts of the shoulder joint with artificial parts. Depending on your age, previous surgical interventions and your surgeon’s preference, a partial replacement may be considered (where only certain parts of the joint are replaced).

Even though you technically get a brand new shoulder, it still won’t be as good as the shoulder you had in your twenties, unfortunately. And even this is not a quick fix. It takes months of rehabilitation to make the surgery worth while. We can help you through this decision and with your rehabilitation. Please remember that the stronger you go into your surgery, the easier your recovery will be. So you can start “prehabilitaion” before you even have the date of your procedure.

After the surgery the hard work starts. You might have to wear a sling after surgery for a few weeks and avoid sleeping on the shoulder. You will have to start with Physiotherapy as soon as possible to gain your movement and strength back; otherwise it would have all been for nothing. Disciplined rehabilitation will get you the results you want. This can take up to 9 months after the surgery, depending on your goals. We are here to guide you every step of the way, from before surgery right to the end.

Remember your physiotherapist can refer you to an orthopaedic specialist for your shoulder, if surgery is indicated.

• Shoulder Bursitis: Bursitis in the shoulder is the inflammation of the small, fluid-filled sac in the shoulder joint. The result can be pain, tenderness and swelling of the affected area, particularly with movement.
• Shoulder labrum injuries: Pain in the shoulder that includes ‘clicking’ or ‘popping’ noises or your shoulder feeling stuck in one position
• Rotator Cuff Injury: An injury to the muscles around your shoulder. Usually due to overuse, lifting something too heavy or forceful throwing
• Bicep tendinitis: Inflammation of the bicep muscle attachment to the front of the shoulder can influence the tendon’s integrity and lead to small tears of the musculotendinous junction.
• Shoulder dislocation: Dislocation/subluxation can result from traumatic injuries to the shoulder joint. The humerus moves out of its normal location in the gleno-humeral joint and you might feel pain and inability to move the shoulder.
• Frozen shoulder: Or adhesive capsulitis is a self-limiting pathology (it occurs and heals spontaneously) where the capsule tightens and limits movement progressively and quite aggressively. Your daily activities and movements become stiff and severely painful.

• Shoulder arthritis
• Rheumatoid Arthritis
• Arthritis of the shoulder
• Shoulder joint degeneration
• Shoulder joint osteoarthritis
• Juvenile Arthritis
• Degenerative shoulder disease