Interviewer: What could be causing that pain in your shoulder? Today we're going to focus on a prevalent, yet often overlooked condition when it comes to shoulder pain — arthritis.
We're joined by Dr. Chris Joyce, an orthopedic specialist from University of Utah Health. Now, Dr. Joyce, can you kind of explain to me, just as a layperson, what exactly is arthritis and how it shows up in the shoulder?
Shoulder Pain and Arthritis
Dr. Joyce: The general gist of what arthritis is, is the breakdown of cartilage in a joint. So if you've ever looked at the end of a chicken drumstick or something like that, there's that really smooth, shiny surface. That's what cartilage is, and we have that in all of our joints. And what arthritis is, is for a couple of different reasons that cartilage can wear down and break down and start to disappear. And when that happens, you get to the point that you have arthritis. And some people hear of something called bone-on-bone arthritis. That basically means, when all of the cartilage is gone or worn away, then you have bone-on-bone arthritis, and it causes a lot of pain.
Causes of Arthritis: Trauma, Wear and Tear, and Genetics
There are a couple of different ways that you can get arthritis. You can get it from an injury if you break your shoulder or dislocate your shoulder. These are things that can damage the cartilage in the shoulder and cause you to go on to have arthritis. Actually, we've seen that people who have had a shoulder dislocation have somewhere 10 to 20 times the rate of getting arthritis in their shoulder as opposed to people who have not had a dislocation. Then there's also just a normal kind of wear and tear arthritis. That's called osteoarthritis. And that's kind of what we see for the vast majority of people who get arthritis in the shoulder as well as other joints in the body.
Then there are other kinds of less common things, such as inflammatory arthritis or rheumatoid arthritis. People who have rheumatoid arthritis are predisposed to getting arthritis in many different joints in the body as well.
Arthritis Signs and Symptoms
Interviewer: How can we recognize that the pain that we're feeling in that joint in our shoulder is arthritis versus anything else?
Dr. Joyce: Sometimes it's not as easy to diagnose as you would think, at least just by clinical symptoms. Generally speaking, if you have arthritis or as arthritis starts to progress, the number one symptom by far is pain. So if you start to have more pain in your shoulder, it doesn't necessarily mean that you have arthritis, but if you have arthritis, generally you have pain in the shoulder.
Another thing is you start to get stiff, and this is true in the shoulder, but it's true in other joints as well. As the arthritis gets worse in your shoulder, the lining of the shoulder joint starts to get thickened and inflamed, and you start to develop bone spurs in the joint as well. And those two symptoms start to tighten the shoulder joint. So what people commonly say is that they lose the internal rotation, which is reaching behind your back. Whereas when you're in your twenties and thirties, you can reach up and scratch the middle of your back. As you start to get older and arthritis sets in, all of a sudden you can't do that anymore.
Those are usually the two main symptoms of arthritis, pain and decreased motion in the joint. But from my perspective, when somebody comes in with shoulder pain, I will almost always get an X-ray of their shoulder. An X-ray is really the gold standard for diagnosing arthritis because there are a couple of other things that can cause pain and stiffness in the shoulder that are not necessarily arthritis. We use that X-ray to help determine if it's arthritis or is it something else.
Can Arthritis Get Better?
Interviewer: Does the pain, do some of these symptoms of like a lack of inward mobility and stuff get worse over time with arthritis? Is that something? Because I know some people, at least myself included, it's something where you can kind of like, "Eh my shoulder is just kind of achy," or "Ah, I'm just getting older." Or, "It was an old injury," whatever that is. Is there something that, you know, a sign or a worsening of symptoms that means you really should have it looked at?
Dr. Joyce: Unfortunately, at least with the technology that we have now, arthritis is a one-way street. You know, it doesn't generally get better with time. It generally just gets worse. The joints, once they start to degrade a little bit, will continue to go on that path. But that can get worse over a couple of months. That could get worse over a couple of decades. And we don't really know which type of person is going to be a rapid progressive arthritis and a slower progressive arthritis. So the general progression is that things do get worse over time.
But just because you have some pain in your shoulder, it doesn't mean that you have to run in and get an X-ray to take a closer look at that. If it's been going on for a couple of weeks, you can usually start with some stretching exercises, physical therapy, and some stuff like that. If it starts getting worse over time, that's when you should go in to see a provider to take a closer look.
Risk Factors for Developing Shoulder Arthritis
Interviewer: Who is the person who is the most at risk for developing shoulder arthritis? I know we've talked about a couple of different types that could, you know, affect the joint, but is there a certain group that it affects more than others?
Dr. Joyce: Yes. So probably the biggest factor is really genetics. You know, so arthritis does run in families. Or if you have arthritis in one shoulder, you're more likely to get it in the other shoulder. Or if you have arthritis in your knee, you're more likely to get it in your shoulder sort of thing. And that just has to do with how we're built and what our genes are. That you can't really change too much.
But other than just genetics, there are a few things that can predispose you to arthritis. So there is something called post-traumatic arthritis, which I kind of alluded to earlier. So if you've had a dislocation in your shoulder or you've broken a bone in your shoulder or you've just had a really hard hit in a football game or something like that, you could go on to get post-traumatic arthritis, which means after a trauma or an injury, the cartilage gets damaged somehow and then that starts the progression towards arthritis.
Other things that can kind of predispose you to arthritis, and a lot of this hasn't been completely proven, but generally heavy weightlifting, especially pressing exercises, such as bench press or overhead military press, seemed to have a link with a certain type of arthritis in the shoulder joint as well that we only see in that kind of individual. That being said, I never tell people they should stop working out, or stop staying active because staying active is very important. But some of those really heavy loads can certainly put you at higher risk for that as well.
Treatment Options for Shoulder Arthritis
Interviewer: If someone gets diagnosed with arthritis in the shoulder by a professional, what kind of treatment options are available?
Dr. Joyce: Yeah, so there are lots of different treatment options, and, you know, this is a discussion I have every day with patients that come into the office. So arthritis, there's nothing urgent about it. So you can do something about it now. If it's not bothering you too much, you can certainly just wait and see if things get better or worse over time. As I said before, generally they don't tend to get much better. But you can have an acute flare-up of some of the arthritis, and sometimes we can do something to get that flare-up calmed down. And there are a couple of ways that you can do that.
Physical Therapy for Arthritis
So one is physical therapy, and I will say that physical therapy for shoulder arthritis is a little bit controversial. Generally speaking, I think physical therapy is pretty much all-around good for your body. When you have bad arthritis, especially in the shoulder, it seems like a lot of the physical therapy exercises that we typically do can actually aggravate the pain to some degree. So what I'll usually tell people, if you're going to do physical therapy or some exercises to work on arthritis in your shoulder, really primarily focus on stretching exercises. So you're kind of stretching out that tight capsule in the joint. Don't worry about heavy lifting and strengthening stuff. Really just focus on the stretching and give it a couple of weeks. If you're not making much progress over three to four weeks, it's probably not worth continuing with physical therapy for shoulder arthritis specifically. That's a little bit different than some of the other shoulder pathology that we see.
Other things that you can do that I actually, especially in an acute flare-up, you know, one of the things about shoulder arthritis that really bugs people is it keeps them up at night and they have difficulty sleeping. A lot of times the daytime is actually not too bad and nighttime is pretty bad. And an injection actually can be really helpful for that, specifically like a . . . What we usually start with is a cortisone or a steroid injection. For arthritis, I typically will have one of my colleagues use an ultrasound machine, put the needle in the joint, and inject the steroid. And that'll help calm down the inflammation that you have from arthritis. It's not a fix. It doesn't make it go away, but it can calm things down sometimes for 6 to 12 months. So a lot of times we'll start with that as well.
When you kind of have tried a lot of these different things, injections, physical therapy, and the pain is still there, we kind of get to a point where you either can live with it or if it's really bad, talk about surgery and there are a couple different surgical options for it as well.
Non-Surgical Management for Daily Living
Interviewer: So say a patient is not in a place where maybe they don't want to do that surgical option, what are some of the kinds of day-to-day management that they can do with arthritis? Are there medications? Is it, you know, occasional injections? Like what are some of the options they have for living with shoulder arthritis?
Dr. Joyce: Yeah, as I mentioned, doing some daily stretches, an injection. If you're going to do an injection, we usually don't recommend you do an injection more often than every three to four months.
So there are other things that you can do as well, as you mentioned. So medications can be helpful. We obviously, in this day and age, really try to avoid doing really strong like narcotic type medications. The best medications for arthritis really throughout the body are anti-inflammatories. So anti-inflammatories would be like ibuprofen, naproxen, Advil, or Aleve. Anyways, these are all in a category called non-steroidal anti-inflammatories or NSAIDs. Those can be very helpful, and they're generally pretty well tolerated. Obviously, people don't want to be taking medication for the rest of their lives, but if it's that versus doing a big surgery, sometimes it's reasonable to try those. A lot of those anti-inflammatory medications do have some side effects, you know, stomach issues, stomach upsets. They can affect your kidneys. So as you start to get over about 60, 65, maybe 70, you have to be a little careful about taking those on a daily basis. So some people can't really tolerate them as well.
Outcomes and Quality of Life Expectations of Shoulder Arthritis
Interviewer: So say that there's a patient that has come into your exam room, they're complaining of arthritis in their shoulder. Like, what kind of outcomes can they expect? What is kind of their outlook for quality of life and, you know, relief from pain?
Dr. Joyce: So one of the beauties of being a shoulder specialist, as I am, is that you don't walk on your shoulders.
Dr. Joyce: So, you know, from a functional standpoint, people can really do pretty well without having to have surgery in their shoulder and tolerate a lot of arthritis. So what I like to tell people is, at the end of the day, it's your shoulder. You know, it's not your heart or your lungs. It's not going to kill you. It may feel like it's killing you sometimes, but it's not. If you can function well and the pain level is reasonable, then we can try some injections, you can live with it, that sort of thing.
But if you get to that point where you've already tried all of that stuff and it's still bothering you a lot, the surgical options for shoulder arthritis are very, very good. You know, people do really well. Obviously, it's surgery, and the recovery is a couple of months.
But generally speaking, there are a lot of people who don't even remember how their shoulder felt before they had all of that pain. And then the pain goes away with some of these options, and people are very, very happy. So, you know, whatever route you end up going down, whether it's home exercises or physical therapy or injections or surgery, generally we have the tools to make people pain-free or very close to pain-free with shoulder arthritis.
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