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Normal Shoulder Xray
The glenohumeral joint of the shoulder lives where the ball at the top of the arm bone (the humeral head) meets the socket of the shoulder blade (the glenoid). As you can see in this normal xray, the ball is well centered on the socket which means that the rotator cuff is doing its job of keeping the ball centered on the socket. You can also see a nice healthy space between the ball and the socket, which means that they still have some cartilage on them, cushioning the contact between them so that they can glide smoothly against each other. It is possible for there to be some rotator cuff damage or cartilage damage that is not seen on the xray.
Glenohumeral Joint Arthritis
Here the cartilage has worn out completely and the ball of the humeral head is grinding into the glenoid socket. Having bone on bone arthritis does not necessarily mean that you need surgery. Since cartilage wears away gradually over time, if you are able to modify you activities so that the shoulder is good enough for you, then if you can live with it, I can live with it. If you still have pain after taking a long acting NSAID or if you are not allowed to take NSAIDs, we can discuss doing an ultrasound guided cortisone injection into the joint. The goal of the NSAIDs and the cortisone is not to reverse the arthritis but to settle down the inflammation enough to give you pain relief that makes it easier to do daily activities and sleep through the night without pain. Some patients even report improvement in their ability to move the arm, which can happen if the limitation in their range of motion was because of inflammation related pain.
Cuff Tear Arthropathy
When someone has had a rotator cuff tear for a long time, it is possible that this can result in breakdown of the cartilage. That is why you can see in this xray that not only is the cartilage worn out but the ball is also not centered on the socket. In this case we are dealing with two problems - the worn out cartilage and the rotator cuff tear. The conservative management with NSAIDs and cortisone injections is the same, but if the patient does end up needing a shoulder replacement, it is important to recognize that it is not just enough to replace the ball with metal and the socket with plastic like in a standard shoulder replacement.
Types of Shoulder Replacements
If someone has failed conservative management and they continue to have significant pain that affects their daily activities and their sleep at night, we can discuss the possibility of doing a shoulder replacement. If someone has isolated glenohumeral joint arthritis with a normal rotator cuff, the standard shoulder replacement works well because it relies on the rotator cuff to keep the metal ball centered on the plastic socket. As you can see in the xray, the small area of contact between the ball and the socket is similar to the normal shoulder xray above, maintaining the "unconstrained mechanics" of the normal shoulder. If a patient has cuff tear arthropathy, the preferred operation is a reverse replacement, in which the ball is replaced with a socket and a ball is screwed into where the socket used to be, resulting in "constrained mechanics" that keep the joint centered even without a rotator cuff.
Frequently Asked Questions
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How do we know we are making the right decision? We are always making decisions with imperfect information, so we have to do our best to make the best possible decision based on your values and my experience. Once we make a decision, we move forward together with confidence that we made the best possible decision with the information we had.
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Will my shoulder replacement surgery be successful? For patients who have lived with shoulder arthritis for many years, they are often so happy with their result that they wish that they had their shoulder replacement sooner. We are in the process of looking back at our results over the last few years to see if people say they are glad they did the surgery, and to see how much they improved by comparing what percent of normal they rated their shoulder before an after surgery. So far, it looks like more than 98% of people are glad they did the surgery and the average change is about 70 percentage points, meaning that on average people reported their shoulders to be 10% of normal before surgery and this improved to about 80% of normal on average.
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When is it time to come see you for my shoulder arthritis? I am happy to see you any day and any time. You should never feel like if you come see me that we have to end up doing something for treatment. If you just want to talk about your shoulder and get some more information this is a perfectly good reason to see me in the office or virtually through our telemedicine portal. Based on our conversation you may choose to do nothing, go on a course of NSAIDs, get an ultrasound guided cortisone injection, or book your shoulder replacement surgery. Click here to get an idea of how to prepare for your shoulder replacement surgery and see the instructions you will be given on the day of surgery.