Patient information: Shoulder osteoarthritis treatment

SHOULDER ARTHRITIS OVERVIEW

Arthritis of the shoulder (the ball-and-socket joint) is an uncommon problem. In almost every case, the shoulder has been injured months or years earlier, leading to an abnormal wearing down of the cartilage. Injuries include bony fracture, dislocation, or heavy blow to the outer shoulder.

Fortunately, arthritis of the shoulder progresses slowly. Treatment focuses on reducing inflammation, physical therapy stretching exercises to preserve motion, and avoidance of activities to prevent further wear and arthritic flare-ups.

SHOULDER ARTHRITIS TREATMENT

Limit activities — Avoiding painful activities in general will alleviate strain on the injured area. Restrict lifting, overhead reaching and reaching behind (eg, reaching into the backseat) as much as possible during the early recover period. It is safest to keep the arm down and in front of and close to the body.

Some general rules to decrease shoulder strain with activities include:

• Lift objects close to the body
• Only lift light weights and limit lifting to below shoulder level
• Do sidestroke or breaststroke when swimming
• Throw balls underhand or sidearm
• Avoid pushing exercises at the gym (eg, pushups, bench press, flys, shoulder press)
• Do not serve overhand in tennis or volleyball
• Maintain good posture with writing, assembly work, and other tasks by keeping the shoulder blades down and back

Pain relief — If needed, a pain medication such as acetaminophen (Tylenol®) can be taken; the usual dose of acetaminophen is two 375 mg tablets every four to six hours as needed. No more than 4000 mg of acetaminophen is recommended per day, and anyone with liver disease or who drinks alcohol regularly should speak with their healthcare provider before using acetaminophen.

A nonsteroidal antiinflammatory drug (NSAID), such as ibuprofen (eg, Advil®, Motrin®) or naproxen (eg, Aleve®) can also be used for pain. The dose of these NSAIDs is available in table 1 (table 1). (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)".)

SHOULDER AERTHRITIS STRETCHING EXERCISES

Heat — Heat helps prepare the tissues for stretching and should be performed prior to exercise sessions. The preferable method of heating is in a warm shower or bath for 10 to 15 minutes. Local heat (for example with a moist heating pad or a towel warmed in a microwave) is an alternative, but generally is not as effective.

Weighted pendulum stretching exercise — These exercises are intended to help maintain joint mobility and flexibility of the muscles and tendons in the shoulder. Range of motion/flexibility exercises should not cause more than a mild level of pain; patients who feel sharp or tearing pain while stretching should stop exercising immediately and consult with their healthcare provider.

This exercise should be performed once or twice per day, after the shoulder is warmed with cardiovascular exercise or a warm pack.

The exercise is performed as follows (figure 1):

• Relax your shoulder muscles
• While standing or sitting, keep your arm vertical and close to your body (bending over too far may pinch the rotator cuff tendons)
• Allow your arm to swing forward to back, then side to side, then in small circles in each direction (no greater than 1 foot in any direction). Only minimal pain should be felt.
• Stretch the arm only (without added weight) for three to seven days. Progress this exercise by adding 1 to 2 lbs (0.5 to 1 kg) per week and gradually increasing the diameter of the movements (not to exceed 18 to 24 inches or 45 to 60 cm)
• After a few weeks this exercise should be supplemented or replaced by other exercises to target specific areas of tightness/restriction. The pendulum stretch may be recommended as a warm up for more localized flexibility exercises and/or strengthening exercises.

When performed correctly the pendulum exercise should not result in more than mild discomfort. If more pain is felt, consult a healthcare provider for instructions.

Passive stretching exercises — Passive stretches are performed after the pendulum stretch exercise (picture 1A-C). These exercises, performed once or twice a day for several months, should further loosen the tightened shoulder lining and restore normal range of motion. Sets of 10 to 20 of the following three exercises are performed daily:

• Armpit stretch — Use your good arm to lift the affected arm onto a shelf, dresser, or any object about breast high. Gently bend at the knees, opening up the arm pit. Try to push the arm up a little farther with each stretch.
• Finger walk — Face a wall about three quarters of an arm length away. Using only your fingers (not your shoulder muscles) raise your arm up to shoulder level.
• Towel stretch — Take a three foot long towel, grasp it with both hands, and hold it at a 45 degree angle. Use the upper, good arm to pull the arm toward the lower back. This can be repeated with the towel in the horizontal position.

The goal of these exercises is to stretch the shoulder to the point of tension, but not pain.

SHOULDER STRENTGTHENING EXERCISES

Muscle toning exercises should be performed after your initial pain has resolved. These exercises are necessary to restore any lost muscle strength.

The joint should always be heated and stretched (as outline above) prior to beginning toning exercises. Following a two or three minute rest, perform sets of 15 to 20 exercises daily, each held for five seconds. Flexible rubber tubing, bungee cords, or large rubber bands are used for each exercise (figure 2).

Outward rotation exercise — Hold your elbows at 90 degrees, close to your sides. Grasp the rubber band with your hands and rotate your forearms outward only two or three inches, holding for five seconds (picture 2).

Inward rotation exercise — Hold your elbow at 90 degrees, close to your side. Hook the rubber band onto a door handle and grasp with only one hand. Rotate your forearm inward two or three inches and hold for five seconds. The forearm swings like a door (picture 3).

Lifting exercise — Bend your elbow to 90 degrees. Place the rubber band near the elbows and lift your arms up four or five inches away from the body, holding for five seconds (picture 4).

Mild soreness should be expected with these exercises. Sharp or severe pain may indicate a flare of the underlying problem; stop these exercises for a few days if this occurs.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)

Professional Level Information:
Acromioclavicular injuries
Biceps tendinopathy and tendon rupture
Brachial plexus syndromes
Evaluation of the patient with shoulder complaints
Frozen shoulder (adhesive capsulitis)
Glenohumeral osteoarthritis
Multidirectional instability of the shoulder
Presentation and diagnosis of rotator cuff tears
Rotator cuff tendinopathy
Shoulder impingement syndrome

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Physical Therapy Association

      (www.apta.org)