Treating shoulder arthritis without surgery - non-operative management

Arthritis is a chronic condition - there is usually no rush in pursuing a surgical approach. The quality of life of a person with shoulder arthritis can often be improved by optimizing the person's overall health:
  1. regular aerobic exercise for an hour a day (walking, running, cycling, treadmill, stationary cycling, elliptical, swimming, etc).
  2. stopping smoking and alcohol consumption
  3. eliminating narcotic and sleeping medications
  4. healthy diet
  5. positive social interactions (dancing, volunteer work, church)
  6. getting outdoors (hiking, fishing)
  7. keeping the BMI under 25

In addition to these general health measures, there are some shoulder-specific therapies

A. Exercises
   1. Range of motion - In that stiffness is a prominent feature of arthritis, gentle range of motion exercises may be helpful in improving comfort and function. Each stretch needs to be held with gentle pressure for a full two minutes while the patient focuses on relaxation. How to stretch and how not to stretch
      a. Flexion
         i. Supine stretch
         ii. Pulley
         iii. Forward lean
      b. External rotation
      c. Cross body adduction
      d. Internal rotation
         i. Sleeper stretch
         ii. Up the back

2. Strengthening exercises – In that weakness from disuse may compromise the comfort and function of the shoulder, gentle progressive strengthening exercises may be helpful as long as they do not cause increased discomfort. A useful guideline is the ‘rule of 20’ i.e. exercises are likely to be helpful if they can be repeated comfortably for 20 repetitions. This performance level should be achieved before advancing the resistance of the exercises.
         i. Supine press
         ii. Latissimus pull
         iii. Rowing

B. Medications –Acetaminophen and non-steroidal anti-inflammatory medications may offer some symptomatic relief. However, these medications can have serious side-effects and patients need to be advised to follow the manufacturer’s dosing instructions on the bottle and to be made aware of potential hepatic, renal, marrow, cardiac and gastrointestinal complications. Here's a post about drugs for arthritis. Here are two posts about non-steroidal antiinflammatory medications (NSAIDS1)(NSAIDS2).

C. Injections
         i. Steroids + local anesthetic – these injections may be used to achieve temporary relief of symptoms. In some studies these injections have not been more effective than injection with saline alone. Repeated injection may damage cartilage and rotator cuff tendons.
         ii. Hyaluronic acid – while there have been some reports that these injections provide substantial relief; most data suggest they are no more effective than saline.

D. Arthroscopy
         Arthroscopy may be helpful in the management of early arthritis. See also here.
     
For more on things to be considered in the management of arthritis, click on this link.

When is the right time for shoulder joint replacement arthroplasty? Click on this link.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link)

Scapular spine and acromial fractures after reverse total shoulder - which ones might best be left alone?

Nonoperative Treatment of Acromial Fractures Following Reverse Shoulder Arthroplasty: Clinical and Radiographic Outcomes

These authors reported on clinical and radiographic outcomes of nonoperative treatment of acromial and scapular spine fractures (ASF) after reverse total shoulder arthroplasty. 

44 patients diagnosed with ASF following RSA were matched 1:3 to a control group based upon gender, age, and preoperative function. 

ASF were identified at a median of 2 months and were followed for a median of 37 months. All ASF patients were treated nonoperatively.

Overall, patients with ASF had inferior clinical outcomes with a higher rate of dissatisfaction when compared to controls. 

Lateral fracture subtypes (I and IIA) were similar to controls and had little impact on outcomes. 

Medial fracture subtypes (Type-IIB, IIC, and III) demonstrated inferior outcomes when compared to controls, with Type-III fracture patients demonstrating no improvement from baseline. 

The overall non-union rate was 61.4%, with high rates of scapular rotation and osteolysis in medial fracture subtypes. Nonunion was associated with a higher incidence of secondary radiographic findings, including scapular rotation, progressive notching, and osteolysis.

The authors concluded that fractures which occur at or medial to the glenoid face demonstrated high rates of unsatisfactory results and worse clinical outcomes as well as increased rates of scapular tilt, progressive scapular notching and osteolysis

Comment: For good reason, there has been substantial interest in the prevention, diagnosis and treatment of acromial and spine fractures after reverse total shoulder arthroplasty. It seems that the symptoms from these fractures are related both to the location of the fracture and the amount of displacement.

Here's a case: a middle aged man had a reverse total shoulder after multiple failed cuff repairs of the left shoulder. At the six week checkup, all was well clinically and radiographically.

He started gentle assisted flexion exercises. Two days after the office visit while reaching up he had sudden pain in the shoulder and heard a 'crack'. He returned to the office at which time tenderness was noted at the posterior acromion. The AP view was not remarkable.

However, the axillary view showed a non-displaced crack in the acromion.

This case reveals the potential of fracture of an acromion that is not used to being loaded.

Here's another case:
An 85 year old lady presented with severe cuff tear arthropathy as shown below.

She had a reverse total shoulder in early 2012. Two years after surgery she had excellent comfort and function. An axillary x-ray at that point is shown below.

Three and a half years after her procedure she developed the atraumatic onset of posterior shoulder pain. Her axillary x-ray shows a fatigue fracture of the scapular spine (to the left of the red line).

These minimally displaced fractures healed with non operative management.

Research is ongoing to determine the effect of prosthesis type and position that influence the risk of these fractures.

However, the type of patient at greatest risk is becoming clearer:

Patient risk factors for acromial stress fractures after reverse shoulder arthroplasty: a multicenter study

These authors investigated the incidence of acromial stress fractures (ASFs) after reverse total shoulder and and sought to identify preoperative patient characteristics associated with their occurrence.

They identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). 

Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex, rheumatoid arthritis, osteoporosis, a diagnosis of degenerative joint disease with rotator cuff tear, and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P < .05).

This is an interesting study, although the followup time is short. Many acromial fractures occur more than 3 months after surgery.

The article below dives a bit deeper into the local changes in scapular bone density associated with age and sex.

Changes in Scapular Bone Density Vary by Region and are Associated with Age and Sex

They studied 97 three-dimensional models of the scapula that were segmented from routine clinical computed tomography (CT) scans, and obtained detailed calibrated bone density measurements for each bone model. The effects of age and sex on cortical and trabecular bone density were assessed for the entire scapula.

They found that cortical bone loss averaged to 1.0 mg/cc and 0.3 mg/cc per year. 

Trabecular bone loss was 1.6 mg/cc and 1.2 mg/cc for female and males respectively. 

Areas that were significantly affected by age included the acromion, the scapular spine, the base of the coracoid, the inferior glenoid neck as well as the glenoid vault. 

Areas that were significantly affected by sex were the scapular spine and body. These findings are consistent with the risk factors for acromial and scapular spine fractures after reverse total shoulder.

Here are some other links relating to acromial and scapular spine fractures after reverse total shoulder: link 1, link 2, link 3, link 4, link 5 and this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Rotator cuff tears - repair versus non-operative treatment

Rotator cuff repair versus nonoperative treatment: a systematic review with metaanalysis

These authors conducted a systematic review to analyze randomized controlled trials (RCTs) comparing rotator cuff repair to non-operative treatment for patients with any type of RC tear.

Six RCTs met the inclusion criteria. 

At 6 months, pooled results showed improvement in favor of the repair group with respect to the Constant score (mean difference 1.26 [CI 95% -2.34 to 4.85, p=0.49) and pain perception  (0.59 [95% CI -0.84 to -0.33, p< 0.00001).

At 12 months pooled results showed improvement in favor of the repair group with respect to the Constant score (mean difference 5.25 [CI 22 95% 1.55 to 8.95, p= 0.005) and pain perception(mean difference -0.41 [CI 95% -0.70 to -0.12,  p=0.006]).

At 24 months pooled results showed improvement in favor of the repair group with respect to the Constant score  (mean difference 5.57 [CI 95% 1.86 to 9.29 p= 0.003] and for pain perception (mean difference -0.92 [CI 95% -1.31 to -0.52 p<0.00001]).

However, these differences did not reach the minimum clinically important difference for the Constant score (10.4) or the VAS pain score (2.17). 

The certainty of evidence ranged from low to moderate due to imprecision in the studies included. The authors question whether these statistically significant effects are clinically significant.

The authors concluded that this systematic review with meta-analysis on repair versus conservative treatment for patients with rotator cuff tears showed statistically, but not clinically, meaningful difference between repair and conservative treatment in terms of improvement in pain and Constant score.

Comment: These findings can be compared to the 2019 Evidence Based Practice Guidelines from the American Academy of Orthpaedic Surgeons 

In which there are two strong recommendations:

and a moderate recommendation:

Rotator cuff failure is the most commonly treated shoulder disorder. More data are needed directly comparing the outcomes of operative and non-operative management for different types of cuff defects in different types of patients.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Does the patient over the age of 55 benefit from attempting a repair of small atraumatic cuff tears?

OPERATIVE VS. CONSERVATIVE TREATMENT OF SMALL NON-TRAUMATIC SUPRASPINATUS TEARS IN PATIENTS OVER 55 YEARS: OVER 5-YEAR FOLLOW-UP OF A RANDOMIZED CONTROLLED TRIAL

A previous post (see this link) discussed the management of traumatic rotator cuff tears in individuals with an average age of 60 years. By contrast this study discusses the management of atraumatic rotator cuff tears in individuals with an average age of 71.

180 shoulders with symptomatic, non-traumatic supraspinatus tears were randomly assigned to one of the three treatment groups: physiotherapy (Group 1), acromioplasty and physiotherapy (Group 2) and rotator cuff repair,  acromioplasty and physiotherapy (Group 3). 

150 shoulders (mean age 71) were available for analysis after a mean follow-up of 6.2 years. 

The mean sagittal tear size of the supraspinatus tendon tear was at baseline 10 mm in all groups.

Eight shoulders in Group 1 and two shoulders in Group 2 crossed over to rotator cuff repair during the follow-up. 

There were no significant differences in the mean change of the Constant score.

There were also no statistically significant differences in the change of visual analog scale for pain and patient satisfaction. 

Preoperatively there was no or mild radiographic evidence of osteoarthritis  At follow-up moderate or severe osteoarthritis was detected in 7 (19%), 14 (40%), and 13 (35%) shoulders in Groups 1, 2, and 3 respectively (p=0.124). Despite non-significant between group differences, there was a statistically significant mean progression in the grading of osteoarthritis from baseline to follow-up in the overall study group.

From this study, the authors concluded that 

(1) operative treatment was not better than non-operative treatment of small non-traumatic single tendon supraspinatus tears in patients over 55 years of age. 

(2) operative treatment did not protect against degeneration of the glenohumeral joint or cuff tear arthropathy. 

(3) non-operative treatment is a reasonable option for the primary initial treatment for these tears.

Readers may be interested in a recent Cochrane analysis, Does repair of torn rotator cuff tendons work?, that concluded, "As compared with non-operative treatment, moderate-certainty evidence (downgraded due to risk of bias) indicates that surgery (rotator cuff repair with or without subacromial decompression) probably provides little or no benefit in pain and low-certainty evidence indicates that it may provide little or no improvement in function, participant-rated global treatment success or overall quality of life (downgraded due to bias and imprecision) in people with rotator cuff tears." The AAOS practice guidelines for the management of cuff tears can be found at this link.

Comment: Rotator cuff repair is a surgical procedure that can be associated with increased costs,  substantial postoperative discomfort and a prolonged "down time" to protect the repair during the time of anticipated healing. In this light, surgical repair should be reserved for cases in which the procedure offers a definite benefit to the patient in comparison to non-operative treatment.

An example of "right sizing" treatment is shown in the case below of a degenerative supraspinatus cuff tear.

With a simple stretching and strengthening rehabilitation program (see this link), durable full, comfortable function was achieved.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Chronic, massive, irreparable rotator cuff tears - improvement without surgery.

Nonoperative Treatment of Chronic, Massive Irreparable Rotator Cuff Tears: A Systematic Review with Synthesis of a Standardized Rehabilitation Protocol

These authors conducted a comprehensive review of studies involving clinical outcomes of nonoperative treatment of massive, irreparable rotator cuff tears.

Multiple studies showed significant improvement exceeding the MCID for functional outcome scores following treatment. Several studies demonstrated significant improvements in strength and range of motion. Success of nonoperative treatment ranged from 32-96%. 

Comment: Many options exist for the management of chronic massive irreparable cuff tears.  

By definition, these chronic tears are long standing, so there is no rush to the operating room. 

As this article points out, stiffness is often an important feature of the affected shoulder. This can usually be addressed by gentle progressive home stretching exercises. Here are some of the most effective:

Supine stretch (link)

Table slide (link)

Pulley (link)

Abduction stretch (link)

Cross body (link)

Up the back (link)

Sleeper stretch (link).

These stretches should be carried out multiple times per day with the stretch being held for a slow count of 10. 

Once full comfortable assisted motion has been achieved with the six exercises described above, it's time to work on strengthening, using a simple press-up exercise (link). It is important that the angle of inclination is progressed slowly, assuring that the exercise can be repeated at least 20 times before the angle is increased. 

This simple home program has been successful in restoring substantial shoulder comfort and function for many shoulders that have been referred to us for reconstructive surgery or for a shoulder replacement. 

Finally, it has been demonstrated that the patient's optimism about the success of the non-operative program is a major predictor of its success.

See also this related post: Rotator cuff tears - getting better without surgery.

To support our research to improve outcomes for patients with shoulder problems, click here.To subscribe to this blog, enter your email in the box to your right that looks like the below

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator cuff tears - why not try non-operative treatment?

What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears 

These authors examined the 5-year outcomes in a prospective cohort of patients aged 40-85 years referred to shoulder surgeons because of chronically symptomatic  (>3 months), full-thickness rotator cuff tears of the supraspinatus or infraspinatus, confirmed on ultrasound or magnetic resonance imaging.

These patients were initially managed with a comprehensive, nonoperative, home-based treatment program. 

After 3 months, the outcome in these patients was defined as “successful” if they were essentially asymptomatic and as "failed" if they were symptomatic and consented to undergo surgical repair. 

At 5 or more years, all patients were contacted for follow-up; the response rate was 84%.

Approximately 75% of patients remained successfully treated with nonoperative treatment at 5 years and reported a mean rotator cuff quality-of-life index score of 83 of 100. 

Those in whom nonoperative treatment had failed and who underwent surgical repair had a mean rotator cuff quality-of-life index score of 89  at 5-year follow-up. 

The operative and nonoperative groups were not significantly different at 5-year follow-up  (P = .11).

The authors concluded that nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. 

Comment: It is recognized that most patients with chronic rotator cuff tears are minimally symptomatic. A small subset of all patients with chronic rotator cuff tears present to surgeons because of symptoms of pain, weakness or crepitus. 

This study suggests a cost-effective approach to these patients: start with a 3 month non operative program and reserve surgery for those who do not improve.

The results of this study are consistent with those of

Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results.

Those authors compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (sd 14.2), 77.2 (sd 13.0) and 77.9 (sd 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34).

These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.


See also: Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Rotator cuff tears - surgery or non-operative treatment?

Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis

These authors analyzed level I and II research comparing operative versus nonoperative management of full-thickness rotator cuff tears. The inclusion criteria were as follows: randomized controlled trial, full-thickness rotator cuff tear, and age 18 years or old. The exclusion criteria included any history of rotator cuff surgery and a follow-up period of less than 1 year.

After a review of 1013 articles only 3 qualified for inclusion representing 269 patients aged 59-65 years with 1-year follow-up.

While statistically significant differences favoring surgery were found in both Constant and VAS scores after 1 year, with mean differences of 5.64 (95% confidence interval, 2.06 to 9.21; P = .002) and −1.08 (95% confidence interval, −1.56 to −0.59; P < .0001), respectively, the differences were small and of questionable clinical significance.

The differences in both Constant and VAS scores were small and did not meet the minimal difference considered clinically significant. 

Comment: Cuff repair is more costly than non-operative management and the recovery period (down time) can be protracted. Better evidence is necessary to determine which patients with rotator cuff tear will realize substantial benefit from this procedure.

====
The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

What happens if a rotator cuff tear is not repaired?

The natural course of nonoperatively treated rotator cuff tears: an 8.8-year follow-up of tear anatomy and clinical outcome in 49 patients

From May 2001 through November 2006, 1 orthopedic surgeon referred to physiotherapy 89 consecutive patients who were diagnosed sonographically and by MRI with an isolated full-thickness tear of the rotator cuff with a tear size of no more than 3 cm, no involvement of the subscapularis tendon, a negative tangent sign for muscle atrophy and a fatty degeneration of no more than stage 2 according to Goutallier.

It is unclear why surgery was not performed on these shoulders and what percent of similar tears were operated on by this surgeon during the same time period? Were these patients too ill (of note 11 could not participate in followup because of serious medical conditions unrelated to the shoulder and 4 had died)? Were they poor candidates for surgery for other reasons? Did they decline surgery because of minimal symptomatology? Or was this surgeon very conservative with the indications for surgery?

Twenty-three had surgical treatment later on but we do not know if this surgery improved the function of these shoulders.  The remaining 49 still unrepaired tears were re- examined after 8.8 (8.2-11.0) years with sonography.

The mean tear size increased by 8.3 mm in the anterior-posterior plane (P = .001) and by 4.5 mm in the medial-lateral plane (P = .001). Increase of tear size was −5 to +9.9 mm in 33 patients, 10 to 19.9 mm in 8 patients, and ≥20 mm in 8 patients. The Constant Score was 81 points for tear increases <20 mm and 58.5 points for increases ≥20 mm (P = .008). Muscle atrophy and fatty degeneration progressed in 18 and 15 of the 37 patients, respectively. In tears with no progression of atrophy, the CS was 82 points compared with 75.5 points in tears with progression (P = .04). 

Comment: This study again demonstrates the uncertain indictions for the different types of management for the different types of cuff tears. 

It is surely of interest that the average Constant scores improved with non operative management

A key question is the relationship of cuff integrity to shoulder function. In that light, it would have been interesting to see a plot of the final Constant score as a function of final tear size and to see a plot of the change in Constant score as a function of change in tear size.

While it may be tempting to use these results as justification for surgical intervention in an attempt to prevent tear enlargement, we do not have evidence that the anatomic or functional outcomes would have been better had these shoulders been operated on.

The bottom line is that, even in spite of some tear enlargement with time, the shoulder comfort and function for these shoulders as reflected by the Constant Score improved over 9 years with non operative management (p<.0001).

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.