Treatment of GH Osteoarthritis

treatment of glenohumeral osteoarthritis

introduction

Degenerative changes of the glenohumeral (GH) joint are found in up to 17% of patients with shoulder pain, a patient group that has tripled in the last 40 years [1].  The glenohumeral joint is the third most common large joint affected, following the knee and hip [2].  It will be a condition that will present in any sports medicine clinic and providers should be comfortable with the management options and state of the evidence with the options. 

Pain and functional impairment can affect physical as well as psychological well-being, causing limitations in occupational and leisure activities in younger individuals and threatening physical independence in the elderly [3].  It is not uncommon for the osteoarthritis to advance and the individual is unable to lift their arm less than ninety degrees.  Furthermore, Kerr et al [4] reported a 20% incidence of idiopathic glenohumeral joint osteoarthritis in patients older than 60 years who presented for shoulder symptoms. Although the true incidence and prevalence of glenohumeral joint osteoarthritis cannot be estimated currently, it is important to recognize it is common.

In 1974, Neer described primary glenohumeral OA as a limitation in shoulder movement, loss of joint space, the presence of humeral head osteophytes, and the absence of rotator cuff tear [5].  It remains important to differentiate OA from rotator cuff arthropathy. Pain from OA is often localized posteriorly and deep within the joint. It is typically associated with night pain, stiffness, and functional limitations [6].  Patients with a history of trauma to the shoulder or systemic inflammatory disease may have an earlier onset of disease.

Physical examination should exclude etiologies of pain outside the shoulder and attempt to identify other pathology within the shoulder, such as tendinosis and bursitis. Neck pain, pain radiating down the arm, and pain with provocative maneuvers such as Spurling’s test suggest a cervical source of pain. A thorough neck and neurovascular examination should always be performed. Pain at the greater tuberosity, weakness, or lag signs suggest rotator cuff disease. Impingement and OA are not mutually exclusive diagnoses, but impingement should be identified nonetheless [7].  Active and passive range of motion of the shoulder should be assessed and compared. Maneuvers such as Neer’s impingement sign, cross-body adduction, and the Hawkins-Kennedy sign should be included in a physical exam.  These were covered in last week’s post.

Radiographs are the keystone to diagnosing and staging glenohumeral OA. As already described, joint space narrowing and posterior glenoid wear are common findings. The presence of subchondral sclerosis and osteophytes from the humeral head, often described as a “goat’s beard”, is an anticipated finding as well [8].  Advanced imaging is rarely necessary for diagnosis but can provide useful information for staging, identification of concomitant labral or rotator cuff pathology, and preoperative planning.

Goat's beard Gh OA

Image 1: Glenohumeral osteoarthrtis with “goat’s beard.”  Right image showing lateral axillary view. Adopted from [30].

management

Initial management is similar to knee and hip osteoarthritis and many times begins with attempts at nonoperative management.  Lifestyle changes, activity modification, and adoption of joint hygiene measures comprise the first actions which the patients have to take. If possible, activities that involve weight bearing or impact on the joint should be avoided. Information on the disease, potential treatments, and prognosis should be provided. The patient should also be sensitized to the need for adherence to an exercise program, prescribed in an individualized manner [9].  Programs that have proven beneficial for patients with OAGH last at least 12 weeks. It is recommended that patients incorporate therapeutic exercise as part of their lifestyle [9].  

Acetaminophen and non-steroid anti-inflammatory medications have been shown to be effective in reducing pain [10,11].  Topical formulations of these medications have not been well studied. Topical capsaicin, a transient receptor vanilloid-1 receptor antagonist, has been evaluated in treatment of OA of the knee and hand and found to be more effective than placebo with minimal side effects [12].  Its role in management of glenohumeral OA has not been studied.

There are no recommendations for the use of glucosamine, chondroitin sulfate, or a combination of both, as well as of vitamin supplements, soybean and avocado unsaponifiables, or diacerein due to the lack of good quality evidence. There is scarce evidence concerning their use at this site, although evidence exists of their use in other sites (knees and hips) as an adjuvant for pain management, but not as cartilage structure modifiers [13].

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Ultrasound guided steroid injection.
Ultrasound guided hydrodilation.
shoulder stability brace
Stability Brace
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Shoulder Sling
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shoulder sling with pillow

Shoulder Immobilizer

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heated shoulder brace

Heated Brace

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injectates

Intra-articular medication administration can be performed in cases of persistent pain for patients who were unresponsive to oral therapy.  Of particular interest are the roles of corticosteroids and hyaluronic acid, for which there are multiple formulations.  The use of hyaluronic acid has been approved in Europe since 2007, but the FDA has still only approved this for use in knees. 

Merolla et al compared intra-articular methylprednisolone to Hylan G-F 20 in 83 patients and found that though both groups had significant improvement in pain at 1 month; only the hyaluronic acid had sustained pain relief at 6 months [14]. Blaine et al. evaluated 660 patients with glenohumeral OA and found a threefold decrease in pain in a group receiving Hyalgan compared to placebo at 26-weeks [15].  A second trial of 300 patients with chronic shoulder pain found a statistically insignificant decrease in pain. However, in a subgroup of patients with glenohumeral OA as the source of shoulder pain, intra-articular hyaluronic acid was found to be superior [16].

Glenohumeral intra articular corticosteroid injections are one of the most commonly used conservative treatment modalities for symptomatic glenohumeral OA, but there is a paucity of information in the current literature regarding the efficacy of these injections.  In 2012, Patel et al. compared the accuracy of the US-guided posterior approach with the glenohumeral joint with the blind technique on 80 shoulder specimens. The accuracy rate was significantly higher with US guidance compared with blind administration (92.5% vs 72.5%) [17].  One study with thirty patients showed a significant improvement in pain and function scores at 4 months in thirty patients with glenohumeral osteoarthritis [18].  There is a strong need for randomized controlled trials to further evaluate the effectiveness of corticosteroid injections for glenohumeral osteoarthritis.

Kim et al. found that 37.3% of shoulders that had received a glenohumeral intra articular corticosteroid injection for primary glenohumeral OA went on to shoulder arthroplasty within 3 to 8 years of the injection. When considering the percentage of shoulders that received a surgical procedure other than arthroplasty (4.5%), approximately 42% of patients went on to a surgical procedure [19].  This is useful information when discussing these injections with patients in a sports medicine office.

Advanced GH OA

Image 2: Advanced OA of the humearal head.  Adopted from [30].

Clinical studies evaluating the use of PRP injections to treat GH osteoarthritis are also scarce and are mostly case studies. One randomized trial in seventy patients showed significant improvements in SPADI, ASES, and NRS pain scores at 1 and two months, regardless of osteoarthritis severity.  This was shown to be similar for both hyaluronic acid and a single injection of leukocyte-poor PRP [20].  In 2013, Freitag and Barnard described a case report in which 3 intra-articular PRP injections one week apart were administered to a 62-year-old woman under ultrasound guidance. The patient experienced a reduction in the VAS (visual analogue scale) from 6 to 1, which lasted for the full follow-up period of 42 weeks [21].

BMAC (bone marrow aspirate concentrate stem cells) have also shown to improve pain in function in thirty four patients with glenohumeral OA [22].  Striano et al. conducted a study to evaluate eighteen patients with osteoarthritis and refractory shoulder pain who were treated with microfragmented adipose tissue [23]. Significant improvement was observed at the 1-year follow-up in the NPS and the ASES scores.

Botulinum toxin injections were compared to corticosteroid injections in a 2018 study and showed that both botulinum toxin and corticosteroid resulted in a reduction in pain and increased motion in patients with glenohumeral OA.  Botulinum toxin was shown to have longer lasting effects and more pain reduction at 12 weeks [24]. 

Surgical management

Arthroscopic procedures are frequently used prior to an arthroplasty. These include arthroscopic exposure, capsule release, or removal of intra-articular fragments, as well as cartilage repair techniques such as microfracture, chondroplasty, or labral repair [25,26]. Chondrocyte transplants are used for isolated injuries but not for glenohumeral OA. Although the AAOS has not found conclusive evidence on their usefulness, these joint preserving techniques without the use of arthroplasty are commonly employed in young subjects or in those with incipient stages of the pathology.[27]

Total arthroplasty or hemiarthroplasty provides significant pain relief and functional improvement, especially in senior populations. These joint replacements are indicated in patients with temporary or inadequate response to conservative treatment, with important functional limitation, and with severe lesions such as massive rotator cuff tears or osteonecrosis [28].

Total shoulder arthroplasty is indicated in patients with moderate to severe glenohumeral OA with complete loss of humeral and glenoid cartilage and an intact rotator cuff or reparable rotator cuff tears. Patients with irreparable tears or with rotator cuff tear arthropathy may be treated with reverse shoulder replacement. In younger adult patients, active in heavy physical labor or high impact sporting activities, hemiarthroplasty may be indicated over total shoulder replacement to prevent early loosening of the glenoid component replacement. In patients with intact glenoid cartilage, a significant humeral head cartilage loss or collapse from avascular necrosis a hemiartroplasty is also preferred [29]. 

Functional results are adequate in the majority of patients. While due to access and costs, surgery should be considered completely elective, the decision should be based on an informed estimation of the benefits of the surgical treatment relative to the impact of the OA on the well-being, functionality, and general health of the patient and the risks associated with the surgical procedure [29].

Summary

In summary, glenohumeral osteoarthritis is the third most common large joint affected by osteoarthritis and its prevalence is increasing.  There is paucity of evidence in regards to optimal management and many guidelines are based on consensus or on the basis of studies involving the hip and knee.  Nonoperative management is attempted for most individuals and evidence surrounding injections has been shown to be limited.  Some patients eventually elect to have a shoulder arthroplasty or arthroscopy depending on many factors.

– More Shoulder Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/shoulder/

– Read More @ Wiki Sports Medicine: https://wikism.org/Glenohumeral_Arthritis

References

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