Glenohumeral Arthritis

Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist
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Rx Musculoskeletal System (A - Z)

Arthritis of the glenohumeral joint is a common cause of debilitating shoulder pain, affecting up to one-third of patients older than 60 years. It is progressive in nature and characterized by irreversible destruction of the humeral head and glenoid articular surfaces.

Glenohumeral (shoulder) arthritis is a common source of pain and disability that affects up to 20% of the older population. Damage to the cartilage surfaces of the glenohumeral joint (the shoulder’s “ball-and-socket” structure) is the primary cause of shoulder arthritis. Replacing the whole shoulder with an artificial joint is usually done to treat arthritis of the glenohumeral joint. Replacement of the head of the humerus, or upper arm bone (hemiarthroplasty). This option, too, is used to treat arthritis of the glenohumeral joint.

Other Names

  • Shoulder Arthritis
  • Shoulder OA
  • Glenohumeral OA
  • Shoulder Osteoarthritis
  • Shoulder Arthropathy
  • Rotator Cuff Arthropathy

Background

  • This page describes osteoarthritis of the Glenohumeral Joint
  • Defined as degeneration of the articular surfaces of the humeral head and glenoid
  • Also includes a discussion of Rheumatoid Arthritis affecting the glenohumeral joint
  • Incidence increases with age (need citation)
  • Women > men (need citation)
  • Chondral injuries (early OA) are seen in 4-17% of patients undergoing routine arthroscopy
  • The third most common joint replaced after the hip and knee

Pathophysiology

Primary Osteoarthritis

  • Only 25-30% of the humeral head articulates with the glenoid fossa at any given time[3]
    • This facilitates increased range of motion at a cost of decreased stability
  • Irreversible loss of articular cartilage, hypertrophic subchondral bone
  • The humeral head undergoes flattening, osteophyte, and subchondral cyst formation, posterior subluxation
  • Glenoid is also worn down with subchondral cyst formation

Secondary Osteoarthritis

  • Rheumatoid Arthritis
    • Chronic synovial inflammation, degeneration of joint, medialization of the humeral head
    • Occurs in up to 90% of patients with RA (need citation)
    • Can also occur with Gout, Pseudogout
  • Post-traumatic
    • Commonly seen following proximal humerus fractures and shoulder dislocations
  • Septic Arthritis
  • Neuropathic
  • Osteonecrosis or Avascular Necrosis
    • Loss of blood supply with the subsequent collapse of subchondral bone and joint degeneration
  • Rotator cuff arthropathy
    • Rotator cuff tears lead to abnormal glenohumeral articulation

Associated Conditions

  • Rotator Cuff Tear

Pathoanatomy

  • Static Stabilizers
    • Negative intra-articular pressure[4]
    • The bony geometry of the glenoid surface of the Scapula and Humeral Head
    • Glenoid Labrum
    • Glenohumeral Joint Capsule
    • Glenohumeral Ligament Complex
    • Coracohumeral Ligament
  • Dynamic Stabilizers
    • Rotator Cuff
    • Pectoralis Major
    • Latissimus Dorsi
    • Deltoid
  • Rotator Cuff Tear
    • 5-10% of cases of OA and 25-50% of cases of RA (need citation)
  • Older age
  • Shoulder Dislocation

Differential Diagnosis

  • Fractures
    • Proximal Humerus Fracture
    • Humeral Shaft Fracture
    • Clavicle Fracture
    • Scapula Fracture
    • First Rib Fracture (traumatic or atraumatic)
  • Dislocations & Separations
    • Acromioclavicular Joint Separation
    • Glenohumeral Dislocation (Acute)
    • Sternoclavicular Joint Dislocation
    • Glenohumeral Instability (Chronic)
  • Arthropathies
    • Glenohumeral Arthritis
    • Acromioclavicular Joint Arthritis
  • Muscle & Tendon Injuries
    • Pectoralis Major Injuries
    • Pectoralis Minor Injuries
    • Proximal Biceps Tendon Injuries
    • Scapular Dyskinesis
  • Rotator Cuff
    • Rotator Cuff Tear
    • Rotator Cuff Tendonitis
    • Calcific Tendinitis of the Rotator Cuff
    • Subcoracoid Impingement Syndrome
  • Bursopathies
    • Subacromial Bursitis
    • Scapulothoracic Bursitis
  • Ligament Injuries
    • Glenoid Labral Tears
  • Neuropathies
    • Suprascapular Nerve Injury
    • Parsonage-Turner Syndrome
    • Quadrilateral Space Syndrome
    • Winged Scapula
  • Other
    • Adhesive Capsulitis
    • Paget-Schroetter Syndrome
  • Pediatrics
    • Coracoid Avulsion Fracture
    • Humeral Head Epiphysiolysis (Little League Shoulder)

Diagnosis

  • General: Physical Exam Shoulder
  • History
    • Patients endorse pain, decreased function, and/or loss of motion
    • Pain often is vague and nonspecific
    • Most often patients will endorse chronic, progress symptoms
    • There may be a history of remote trauma or surgery
    • Pain often worse at night or with activity
    • Patients may also endorse catching, locking, or popping
  • Physical
    • May be relatively normal in the setting of mild or moderate symptoms
    • Patients may experience loss of range of motion
    • Mechanical signs include grinding, popping
    • Atrophy of rotator cuff muscles may be observed
  • Special Tests
    • Passive Compression Test: Apply axial compression while passively internally and externally rotating

Radiographs

  • Standard Radiographs Shoulder
  • Arthritis findings: Joint space narrowing, osteophytes, subchondral sclerosis, Cyst
  • High riding humeral head suggests cuff arthropathy

CT

  • Study of choice to evaluate osseous anatomy
  • Consider arthrogram

MRI

  • Better for evaluating soft tissue structures
  • May demonstrate subchomdral edema in OA
  • Helpful for surgical planning and decision making, especially integrity of rotator cuff

Diagnostic Injection

  • See: Glenohumeral Joint Injection
  • Diagnostic injection can help clarify etiology of shoulder pain
  • This can be done as a separate procedure OR during arthrogram for CT/MRI
  • This should be performed under fluoroscopy or ultrasound guidance

Classification

Walch Classification of Glenoid Wear

  • Type A[5]
    • Concentric wear, no subluxation of HH, well centered
    • A1: no or minor central erosion
    • A2: deeper central erosion, line connects anterior/posterior glenoid rims and transects humeral head (HH)
  • Type B
    • Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly
    • B0: pre-osteoarthritic posterior subluxation of HH
    • B1: posterior joint narrowing (no posterior bone loss), osteophytes, subchondral sclerosis
    • B2: posterior rim erosion, retroverted glenoid
    • B3: monoconcave, posterior wear, at least HH subluxation >70% OR retroversion >15%
  • Type C
    • C1: Glenoid retroversion >25 degrees, regardless of erosion
    • C2: Biconcave, posterior bone loss, posterior translation of HH
  • Type D
    • Glenoid anteversion or anterior HH subluxation (HH subluxation <40%)

Treatment

Nonoperative

  • Generally considered first-line management
  • Treatment options
    • Relative rest
    • Activity modification
    • Physical Therapy
    • Medications including NSAIDs, Acetaminophen
    • Intra-articular Corticosteroid Injection under ultrasound or fluoroscopy guidance
      • See: Glenohumeral Joint Injection
    • Viscosupplementation is an off-label option
    • Regenerative Medicine has mixed and limited evidence
    • Heat
    • Ice
    • Supplements: Glucosamine, Chondroitin
  • Acute arthritis “flare” can consider
    • Brief period of immobilization in Shoulder Sling

Operative

  • Indications
    • Failure of nonoperative management
  • Technique
    • Total shoulder arthroplasty (TSA) if rotator cuff intact
    • Hemiarthroplasty
    • Reverse shoulder arthroplasty (RSA) if large or irreparable rotator cuff tear
    • Arthroscopy
    • Arthrodesis

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