Shoulder osteoarthritis treatments and Shoulder replacement alternatives

Ross A. Hauser, MD., Danielle R. Steilen-Matias, PA-C.

Many times a patient will come into our office with advancing osteoarthritis of the shoulder. When they describe their shoulder pain they say things like:

• “My shoulder is barking at me today,” or
• “My shoulder is letting me know it is there.”

When we manipulate their shoulder to test for range of motion and we all hear the audible pops, clicking, and grinding, sometimes the patient tells us “My shoulder is talking.” Intuitively these people know that their shoulder is talking to them. Do they understand what their shoulder is saying? Do you?

In this article, we will explore options and alternatives to Shoulder Joint Replacement. We will also discuss the various non-surgical regenerative medicine injection techniques. Many people do very well with shoulder replacement surgery. These are not the people that we see in our practice. We see the people who are looking for answers who are not good surgical candidates, have been told that there is a good chance the surgery will not work for them or have already had the surgery with less than happy results. We also see the patient who is exploring their options, maybe the waiting list to get the surgery is long and the only treatments that can be offered at this time are cortisone and increased medications.

What will we be discussing in this article?

• You wake up in the morning, your shoulder is killing you.
• “I am leaning towards the shoulder replacement because I do not know what else to do.”
  • The last treatment available – shoulder replacement.
• Doctors aren’t helping you despite the medications and cortisone.
• The road to shoulder replacement.
  • Conservative Care followed by arthroscopic shoulder surgery
• A case history of a patient who came to Caring Medical following extensive shoulder surgery.
• Your rapidly degenerating shoulder is trying to function and survive. It swells up so it can function as best it can. Swelling holds the shoulder together. Your shoulder is trying to hold itself together.
• A heightened sense of shoulder pain is caused by runaway inflammation. Your shoulder hurts worse than it should because your shoulder is trying to get your attention.
• Your shoulder is under stress physical and emotional. Yes, your shoulder gets stressed out.
• The shoulder becomes highly inflamed.
• Now let’s talk shoulder replacement – Some doctors suggest shoulder replacement surgery is the only answer.
• Treatments in patients over 80 years old
• The research: When the shoulder is “too far gone.”
• No clear consensus on returning to activity or sport after reverse shoulder replacement.
• 70% return to sports – overhead sports remain problematic.
• Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.
  • Postoperative outcomes are disappointing, and the complication rate is high.
• Shoulder replacement works better for older patients…but complications, painkiller use, and complications are still a concern to surgeons.
• Complications leading to re-operation are often multiple and underestimated.
• Obesity is a complication concern in shoulder replacement.
• The realistic assessment of revision total shoulder replacement.
• Will your shoulder be stronger after shoulder replacement?
• Alternatives to shoulder replacement surgery.

You wake up in the morning, your shoulder is killing you

You wake up in the morning, your shoulder is killing you. No matter which way you turn, your shoulder hurts. You hardly slept because of your shoulder. You get up, you stand at the foot of your bed and you begin your morning trying to figure out how far you can lift your arms up. Then you start “loosening up,” and hoping you can get by today without a lot of help from medications. Hopefully going to the toilet, washing, and getting dressed will not be a big chore and you will not have to bother your spouse or other loved ones to help you do these simple tasks.

“I am leaning towards the shoulder replacement because I do not know what else to do.”

We see shoulder pain patients, and no matter how unique their story is, most have the same common problems and the same common medical history. They tell stories like this:

The last treatment available – shoulder replacement

I have had shoulder pain for a long time, my line of work is physically demanding. I have been to my doctors and specialists many times. I have been given varying doses of different pain medications, muscle relaxants, and anti-inflammatories. I have had cortisone twice. I have been sent to physical therapy, tried chiropractic and various electro-stimulation products. I am at the point now that my visits to the orthopedics are long discussions about surgical options.

I am here to explore other options. I do have a good range of motion in my shoulder though I cannot lift my arm over my head because of weakness. I can pick up objects and carry them, I just can’t leave them on a table or platform above my waist.

Doctors aren’t helping you despite the medications and cortisone

During the initial medical history review we have with our patients, they will tell us about the long list of treatment options that were recommended for their degenerative shoulder disease. These treatments do help some people. For some, perhaps like yourself, symptom relief was temporary. For others, the pain relief lasted hours or days if at all.

If you are reading this article it is more than likely you are in that group of patients who are still seeking answers despite years of these treatments and even a past history of “shoulder preserving arthroscopic surgery,” which at this point, does not appear to be successful in preserving your shoulder.

At your last follow-up visit with your orthopedic surgeon, a long discussion may have taken place over whether to continue with your conservative care options or pursue the shoulder replacement. Your concern with these “conservative care” treatments is that you will continue to have more pain, more grinding, more popping, and more clicking. You recognize that you are only being symptom managed and you need to fix it once and for all.

A February 2022 study in the Clinical orthopaedics and related research (15) asked the question, that despite the routine use of plain radiographs (MRIs) to assess and classify the severity of glenohumeral osteoarthritis, does the MRI actually show what is causing the patient’s pain and function?

To answer this question the researchers looked back at the records of 3133 patients. After further filtering through the outcomes of these cases, the study team wrote: “In patients with glenohumeral arthritis, no consistent clinically important differences in pain or function were discovered with respect to radiographic or demographic factors. Surgeons should understand that the pain levels of patients with glenohumeral arthritis may not parallel radiographic severity.” To reiterate that: The severity of ostoearthritis on the MRI did correlate to the amount of pain the patient suffered from. Surgeons should understand that the MRI may lead them down the wrong path.

The road to shoulder replacement Conservative Care followed by arthroscopic shoulder surgery

Conservative Care

• You may be on Anti-inflammatory medications. This is not something we recommend. Please see our article When NSAIDs make the pain worse.
• Stronger pain medications.  This particular recommendation has very little long-term appeal as it can make your situation worse. Please see our article, when Painkillers make the pain worse. 
• Corticosteroids/cortisone or steroid injection. This is also a treatment we do not recommend. Please see our article Alternative to cortisone shots

Arthroscopic shoulder surgery

• We frequently see patients who have had surgery for shoulder pain but are subsequently left with more chronic pain after surgery. The surgeries, such as arthroscopic surgery for glenoid labrum tears, Slap lesions of the shoulder, and of course for various degrees of rotator cuff tears and damage will sometimes lead to rapid shoulder deterioration. When these surgeries fail, shoulder replacement will be recommended.

The patient had extensive shoulder surgery.

The patient had extensive shoulder surgery. Seemingly, the surgeon tried to “fix” everything he thought was damaged enough to cause pain. The surgery went as planned, with no complications, and the surgeon accomplished everything he set out to do. Two years following the surgery the patient came to our office, still in pain. How could this be? Let’s look at exactly what was done.

The patient had an arthroscopic procedure for:

• partial-thickness rotator cuff tear, Type I (least severe),
• a shoulder labral tear,
• grade III to IV (nearly most or most severe) chondromalacia of glenohumeral joint and
• subacromial bursitis.

The labrum is a lip of cartilage that helps keep the end of the humerus in the shallow socket (glenoid). Chondromalacia is the degeneration of the cartilage inside the joint. Bursitis refers to the bursa, one of the fluid-filled sacks that provide cushioning in joints.

During the procedure, the surgeon debrided the labral tear and the rotator cuff tear. Then, where the chondromalacia was most severe, he performed a chondroplasty.  This consists of scraping the damaged cartilage which covers the surface of the bone in hopes of having healthy cartilage grow back. He scraped both the humeral head and the glenoid. He then performed a bursectomy, removing the inflamed bursa. This is fairly typical of what we see in an arthroscopy report of the shoulder.

The patient expressed a desire to return to tennis as a key to surgery outcome, and surgery did not help him with this, and he was left with chronic pain.

Your rapidly degenerating shoulder is trying to function and survive. It swells up so it can function as best it can. Swelling holds the shoulder together. Your shoulder is trying to hold itself together.

When your shoulder swells up. It is talking to you. It is saying “I am not stable, I have instability. I am going to swell up to hold myself together.”  If you are reading this article, this may be happening to you all the time. Here is the science of what your shoulder is doing. When you understand what your shoulder is doing, you can understand what may be the best treatment for you.

This is research published in the Journal of Shoulder and Elbow Surgery. (1)

Here are the highlights:

• Shoulder osteoarthritis is a gradual wearing of the articular cartilage accompanied by degenerative rotator cuff tears. This pathologic (disease) disorder is related to inflammation, oxidative stress, and angiogenesis.
  • What does this mean? What is your shoulder saying?
  • Angiogenesis is the formation of new blood vessels. In degenerative shoulder disease, new blood vessels can be beneficial as they bring healing and growth factors to the site of injury or they can be harmful as they open new highways for chronic inflammation (chronic swelling) which eventually erodes joints.
  • So your shoulder is telling you that it is creating more blood vessels to bring more inflammation to it.
• Degenerative alterations in the shoulder may prompt the production of cytokines and angiogenesis-related proteins, evoking rotator cuff diseases.
  • What does this mean? What is your shoulder saying? 
  • Cytokines are small proteins that cells secrete when they want to communicate with each other. Cytokines, while beneficial in acute injury to help heal damage, become detrimental in chronic pain situations. They sustain chronic inflammation and create more pain. How? We are going to briefly discuss a 2007 paper that researchers have heavily cited for its understanding of Cytokines that appeared in the journal International anesthesiology clinics. Here we will see that your shoulder is no longer talking but yelling at you!

A heightened sense of shoulder pain is caused by runaway inflammation. Your shoulder hurts worse than it should because your shoulder is trying to get your attention.

• In this paper from the University of Cincinnati, (2) doctors say:
  • “There is significant evidence showing that certain cytokines/chemokines (part of the cytokines family of inflammation) are involved in not only the initiation but also the persistence of pathologic pain by directly activating nociceptive sensory neurons. (Simply excessive messages sent to nerve cells that something is hurting), but also certain inflammatory cytokines are also involved in nerve-injury/inflammation-induced central sensitization and are related to the development of contralateral hyperalgesia/allodynia. (A heightened sense of pain caused by runaway inflammation).

What all this means is that your shoulder hurts worse than it should because your shoulder is trying to get your attention. What is your shoulder trying to get you to do? It wants you to stop doing what you are doing to make it hurt.

Your shoulder is under stress physical and emotional. Yes, your shoulder gets stressed out.

For someone in chronic pain, if you told them that shoulder is stressed out, burnt out, ready to give up. They will probably not argue with you. Because that is the way they feel some days. Stressed, tired, ready to talk about shoulder replacement. Let’s recap what we discussed to this point:

1. Your shoulder is unstable. The ball and shoulder socket are banging against each other because your rotator cuff tendons, muscles, labrum, and shoulder ligaments are damaged and not holding your shoulder together.
2. Your shoulder is asking your immune/repair system for more inflammation to bring swelling to act as a “cast,” to hold the ball and shoulder socket in proper alignment.
3. But the shoulder knows it cannot stay in a constant state of swelling. Chronic inflammation is toxic. It burns out and erodes the joint. Your shoulder is hurting more because it is trying to send you more pain signals that this situation is on the verge of joint “death,” – your shoulder will not survive prolonged chronic inflammation and will need to be replaced.

The shoulder becomes highly inflamed

Back to the research, we cited above (1):

• In the two groups of patients examined and divided by less severe and more severe osteoarthritis and rotator cuff tear, measurements of the patients:
  • Cytokines (a way to determine the number of pain signals and messages going back and forth in your shoulder between cells),
  • growth factors (healing chemicals that your body is sending to the shoulder)
  • and angiogenic biomarkers to determine if and how much blood vessel making activity was happening
• Findings: Well-known inflammatory factors such as interleukin 8, tumor necrosis factor α, and interleukin 1β were considerably elevated in synovial fluids of the patients.
  • (The whole joint was highly inflamed and in a state of erosion).
• The joint inflammation highly enhanced insulin-like growth factor 1 and transforming growth factor β1 (TGF-β1) in the synovial fluids and serum.
  • (The inflammation was more destructive,  potent, and lethal to cells.)
• The toxic situation is shown by upregulated inflammatory factors that have created oxidative stress throughout the shoulder).

Now let’s talk shoulder replacement – Some doctors suggest shoulder replacement surgery is the only answer

You may be wrestling with the idea of shoulder replacement because you are a worker who needs to work. Shoulder replacement brings with it possible hope, but it also brings with it, the risk of surgery, possibility of complications,  surgical recovery, and rehab time. For some, the problem with the surgery is not the surgery itself, it is the rehabilitation and the downtime away from exercise, physical activity, and sports involvement. For others, it is time away from work. For these workers, some consider shoulder replacement as a means of “forced retirement,” or “disability.” At what price do you have the surgery? At the cost of your job? At the cost of maintaining a fitness lifestyle? Is replacement surgery the only way?

Here is a sample email from someone asking about shoulder replacement options:

My MRI report says I have advanced narrowing of the glenohumeral joint space. Bone spurs. Subchondral cystic change (Bone cysts). Mild Acromioclavicular Joint degeneration. I already had a shoulder replacement in my left shoulder and I do not want to go through another surgery. I have a great deal of pain from my shoulder that radiates into my arm. I am getting physical therapy and while this is helping my range of motion, it is not helping with the pain. Is surgery the only way for me?

Often we will see a patient who says, “I went to two reputable orthopedists, both said surgery was the only way.” Below we are going to show you research that surgery is not the only way for many people. Surgery is usually the only way when the shoulder bones are fractured or there is a gross anatomical failure, bone spurs, complete or near loss of range of motion, no cartilage at all.

The research: When the shoulder is “too far gone.”

Some doctors suggest shoulder replacement surgery is the only answer:  This is from the journal Arthritis Research and Therapy: (3)“While research in cartilage regeneration has not yet been translated clinically, the field of shoulder arthroplasty has advanced to the point that joint replacement is an excellent and viable option.”

Why? Because of poor tendon healing and irreversible changes associated with rotator cuff inflammation.

• In other words, the shoulder is “too far gone.”
• But the same researchers also say: “Future treatment types involving biologics and tissue engineering (stem cells) hold further promise to improve outcomes for patients suffering from shoulder pathologies.”
  • Stem cells used during the course of surgery – Many of you reading this article may have already had a consultation for shoulder surgery. The surgeons may have advised you that they were able to bring stem cells into the surgery to facilitate healing. We address this in our article My surgeon wants to use Platelet Rich Plasma and Stem Cell Therapy during surgery.

Return to work after shoulder replacement

A September 2022 paper in the World journal of orthopedics (4) assessed the outcomes of patients being able to return to work following a shoulder replacement. The researchers here made similar observations to patients we see. The patients looking into getting a shoulder replacement are younger and are prioritizing the need for the surgery as a means to get themselves back to work. Outcomes for return to work were measured in patients who had total shoulder replacement, reverse total shoulder replacement, and shoulder hemiarthroplasty.

Results: The majority of patients undergoing total shoulder replacement, reverse total shoulder replacement, or shoulder hemiarthroplasty were able to return to work between one to four months, depending on work (the extent of the physical demand of the job).

While sedentary or light demand jobs generally have higher rates of return to work, moderate or heavy demand jobs tend to have poorer rates of return. The rates of return to work  following total shoulder replacement (71%-93%) were consistently higher than those reported for shoulder hemiarthroplasty (69%-82%) and reverse total shoulder replacement (56%-65%).

Treatments in patients over 80 years old: “Surgical treatment of Glenohumeral osteoarthritis is reserved for patients who do not respond to conservative management or who suffer from debilitating symptoms that severely impair their quality of life”

A February 2022 study in the journal Druga and Aging (5) examined treatment options for patients over 80 years old. The researchers here cite the “prevalence (of shoulder osteoarthritis) is estimated to be between 85 and 94% in men and women over the age of 80 years.”

Looking at the shoulder joint, the ball and socket that forms the Glenohumeral joint the researchers wrote: “Glenohumeral osteoarthritis is a common cause of shoulder pain and is characterized by articular cartilage thinning, glenoid bone loss and deformity, osteophytosis (bone spurs) , and other associated changes.” These are the treatments options typically presented to patients:

“Non-pharmacological treatment options may serve as adjuvants to other therapies and should be incorporated for a more holistic approach to management. Pharmacological treatments include oral agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids and antidepressants. . . . (United Kingdom guidelines, this paper comes from Canada) recommend NSAIDS as the first-line drugs for osteoarthritis; topical forms of some of these agents can also be used.

Intra-articular injections such as platelet-rich plasma, cortisone, and hyaluronic acid are usually used to control symptoms in moderate to advanced arthritis or in non-surgical candidates. Other non-surgical treatment options include suprascapular nerve block and radiofrequency ablation, and these options have been studied on different levels of evidence. Furthermore, all these treatments have their own indications, contraindications, and adverse effects profiles. Surgical treatment of Glenohumeral osteoarthritis is reserved for patients who do not respond to conservative management or who suffer from debilitating symptoms that severely impair their quality of life.”

No clear consensus on returning to activity or sport after reverse shoulder replacement

A July 2019 study published in the journal Shoulder & Elbow (6) states clearly that “Reverse total shoulder arthroplasty is now the most frequently performed form of shoulder replacement. There is currently no consensus on recommended levels of activity and sport following Reverse total shoulder arthroplasty.”

However, these researchers do suggest that “Return to sport is tolerated following Reverse total shoulder arthroplasty; however, studies are short to medium term only and although the reported complication rate is low, the studies did not include a radiographic evaluation. Longer-term studies with subgroup analysis evaluating common recreational activities after reverse total shoulder arthroplasty are required, particularly in the younger population, in order to establish clear post-operative guidelines.”

70% return to sports – overhead sports remain problematic

A June 2021 study in the Orthopaedic journal of sports medicine (7) led by the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota offers this opinion: “Patients who had undergone primary uni (one-sided)- or bilateral (both-sided) reverse shoulder replacement reported a 70.1% rate of return to sports with the maintenance of the same level of intensity, duration, and frequency of preoperative sport participation. Rates of return to high-demand sports were lower than low- and medium-demand sports. Patients also had difficulty returning to overhead sports.”

In this report, none of the patients returned to these “high-demand sports”:

• Badminton
• Basketball
• Racquetball/handball
• Tennis
• Volleyball

Alternatives to shoulder replacement surgery. PRP and Prolotherapy

In this section, we will discuss the realistic treatment options to shoulder replacement surgery. We will focus on Prolotherapy and PRP injections.

• PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
• Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
• The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
• Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on extensive research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.

Caring Medical Research:

In the same manner, we present research on shoulder replacement surgery, we would like to present information on regenerative medicine injections. Our focus is on simple dextrose Prolotherapy as the first course of action. In more problematic cases, we may rely on Platelet-rich Plasma injections or bone marrow concentrate commonly referred to as stem cell therapy.

Hauser RA, Hauser MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;1(4):205-216. The article in its entirety can be downloaded as a PDF

What are we seeing in this image?

A shoulder x-ray showed a large bone spur. This is an x-ray of a patient who was only in their ’30s. The patient suffered from significant shoulder pain and limited range of motion. In this image, the shoulder cartilage is fairly well preserved but the large osteophyte or bone spur is present. This is a situation where Prolotherapy can be helpful with the elimination of the patient’s pain, the bone spur causing restricted movement may require surgery.

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.