What is shoulder arthritis?

Shoulder osteoarthritis (OA), or more commonly called arthritis, is a condition that occurs when the cartilage that lines the sides of the shoulder joint is worn or torn away. It may be caused by injury or dislocation of the shoulder, or “wear and tear” of the shoulder over time. Shoulder OA develops most often in people in their 50s and beyond. As people misuse or overuse their joints over time, more cases are seen with each advancing decade of life. However, shoulder OA can also develop in younger people after trauma or surgery to a joint. The condition occurs more frequently in women than men. Physical therapists treat shoulder OA with hands-on therapy and individualized exercise programs.

What are common causes of shoulder arthritis?

Shoulder osteoarthritis (OA) occurs when the cartilage that lines the opposite sides of the shoulder joint becomes worn or torn. In the early stages of the condition, small pits develop in the smooth cartilage that lines each side of the joint. Eventually, small protrusions of bone, or “bone spurs” develop at the edges of the joint surfaces. Joint fluid may also accumulate under the cartilage, forming cysts, which can put pressure on the bone and may contribute to pain. In the late stages of the condition, the cartilage can wear away completely, allowing bone-to-bone contact.

Two bones make up the shoulder joint. The bone at the top of the arm, the humerus, has a round, ball-shaped head, covered in cartilage. The bone on the body side of the joint is the scapula, or shoulder blade. The flat, cartilage-covered surface on the scapula that makes the other half of the shoulder joint is called the glenoid. The 2 sides of the shoulder joint are surrounded and connected by ligaments that control motion in the joint. The ligaments at the front of the shoulder become tightened as OA progresses. In addition, the four main muscles that surround the shoulder, known as the rotator cuff, may be over-used, weaken, or even tear. Rotator cuff conditions occur in about 90% of people with shoulder OA.

Where does it hurt?

In most cases of a shoulder arthritis, patients report a dull diffused ache inside the shoulder with intermittent sharp pain with certain motions. Shoulder impingement can also cause similar symptoms. Understanding the root cause of your pain is fundamental to treating your pain in the long run and will decrease your dependence on painkillers or treatment that only addresses the symptoms.

What are common symptoms of shoulder arthritis?

Shoulder OA may cause you to experience:

• Pain with activities that relieves with rest
• Decreased shoulder movement (range of motion), especially when reaching back as if grabbing a seat belt
• Weakness
• Stiffness and eventual difficulty using the affected arm
• Pain at rest and difficulty sleeping as the condition worsens

Can shoulder arthritis be treated?

Yes, shoulder arthritis pain can be treated and with great results. Even better, many times it can be treated conservatively without needing injections, pain medications, or surgeries if you catch it early enough. The key to treatment is to solve the root cause of your pain so you can get the best results and a long term outcome.

Some root causes of shoulder arthritis pain can be:

• Forward head posture
• Rounded shoulders with impingement
• Weak mid back and shoulder blade muscles
• Overload to the shoulder joint with active motions
• Tight neck and mid back
• Poor biomechanics
• Decreased mid back rotation
• Tight rotator cuff muscles

If you have failed multiple treatment approaches already, your clinician missed the real root cause of your pain and was just chasing the symptoms. The pain or symptom is the effect, not the cause. What do I mean by this? Say your fire alarm goes off in your house. Its purpose is to protect you and make you aware that something is wrong, i.e., that there is a fire in your house. The “alarm” is like your pain (your body’s way of telling your something is wrong) and the “fire” is the root cause. When the fire alarm goes off, you don’t run upstairs and just turn it off, right? You run through the house with the fire extinguisher, trying to find the room where the fire is at. You try to find out what caused the alarm to go off so you can put it out. Once the fire is out, then the fire alarm can go off. Solve the “root” cause of your pain, and then the pain (“the effect”) eventually goes away.

Additionally, there is a common root cause which many clinicians misdiagnose. They treat the shoulder pain with a cookie cutter approach, hoping it will work, and treat it as a simple muscle problem. They tend to rely on stretching, ultrasound, massage, and focus treatment directly on the shoulder joint. However, often the root cause is missed and the symptoms return.  If you can normalize shoulder range of motion and biomechanics, you should be able to decrease your pain and increase range of motion. So many healthcare clinicians treat pain like this and thus show poor treatment outcomes which results in the pain coming back. Why? They missed the root cause of your shoulder pain. This is also the case when patients turn to injections, nerve blocks and other surgeries which are still not effective because the actual problem still is not solved, their treatment was just chasing the pain.

The first step in treatment is to identify the root cause of your pain. A specific and individualized treatment approach for your type of pain can lead to a successful outcome for you and resolve your symptoms for the long term. This is why you can’t rely on a standard cookie cutter approach; you need a customized and individualized treatment approach specifically for your type of shoulder arthritis pain.

“Dr. Ron Miller is the best! Several months ago I developed shoulder pain that was limiting my physical activity, computer work, and even sleep. One week after the first treatment I was playing tennis with much more strength in my serve and groundstrokes. After just three sessions we’re done!“

Lily P.
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What happens if it goes untreated?

Minor case – If it is a minor case of shoulder arthritis pain, research shows that many acute cases of pain may spontaneously go away in 4-8 weeks. But who wants to wait 8 weeks to get pain free? In minor cases, the arthritis may be a false positive and it was there before your current episode of pain. Let’s try to solve the root cause of your pain in 2-3 weeks and address all of the risk factors present (so it never returns!) and get you back to your favorite activities faster! We still recommend that you get it checked out by a one of our board-certified physical therapists to ensure that it is just a minor case, to solve all risk factors, and to get the optimal outcome in the fewest visits needed. Most minor cases resolve on their own in time, or get better with some stretching and strengthening. But, the sooner you take action, the sooner you are pain free. (And research supports this!)

Severe case – If it’s more of a severe and chronic case shoulder arthritis pain, your pain will probably start to worsen and increase because the root cause of the pain is not being treated. Many people turn to pain medication at this time but this only blocks the pain for short term. You may not feel the pain when taking pain medications, but the underlying problem is still there. Many people say after the pain medication is stopped, then usually the pain returns and sometimes it returns even worse. This is when you may experience chronic muscle pain, radiating pain into you neck, shoulder blade, or shoulder. The shoulder will start to get really achy and you may notice a decrease in range of motion. Sometimes in severe cases, you will notice a severe decrease in range of motion in all planes and it gets very painful with movement. Even though it’s more chronic now, we can still help. Once the root cause is addressed, then we can start decreasing your pain, regardless of how chronic and severe the pain is. This is the crucial first step. It just may take more time to recover from a chronic case. Usually with chronic and severe cases, the longer you have your pain and injury, the longer it takes to resolve.

What outcome can you expect from treatment?

As we’ve discussed, the first step is to solve the root cause of your shoulder arthritis pain. This is the most essential step to plan a treatment specialized for you and your unique type of pain. Your root cause will guide your treatment and dictate what is the best way to treat your pain. This, along with identifying risk factors that may be predisposing you to have your pain and injury, will allow you to start getting pain free again. The next step is to start decreasing pain, modifying activities, and start addressing all of the impairments causing your pain which we discovered during your evaluation. With each session, pain should start to decrease and you should start to regain range of motion with less pain and symptoms. Any radicular and referred pain should resolve fast as well. At this point, we begin light and basic strengthening only if it does not increase pain. Treatment will consist of a lot of manual therapy and light exercises.

The next step is to achieve full range of motion, (which should correlate to being pain-free) and now we can start progressive strengthening. Strengthening the muscles is crucial and research shows that this gives you the best long-term outcome! As you start to get stronger and maintain your mobility, your pain will continue to decrease if it is not already gone. Your increased strength will allow you to perform more activities and prevent flare ups. This usually does take up to 4 weeks. As you clear our goals, then we can start easing you back into sport, golf, running, and whatever your favorite activities are. This is when we start winding down treatments and getting you back into functional strengthening, sport specific training, return to run programs, golfing, and whatever your goals are. At the end, we reassess everything, making sure we achieved all of our goals, your goals, that all risk factors are gone, and finalize your long term home exercise program. There are many factors which can influence your outcome, but 85-90% of our patients respond well to our treatment approach and achieve a successful outcome when completing their plan of care.

How is it diagnosed?

Your doctor may order an x-ray to determine the amount of change in the joint. As the cartilage wears down, it decreases the space between the bones visible on these images. Bone spurs or cysts may also be present. Apparent damage often does not directly correlate with your pain. If there is suspected loss of bone, a CAT scan (computerized topography) may be ordered to get a clearer picture of the area.

Your physical therapist will ask questions about how the shoulder problem is affecting your life, and what activities are now difficult for you. Describing your pain will help determine the best plan for your treatment. Your physical therapist will evaluate how far the shoulder can move, both as you move your arm and as he or she moves it for you. The examination will include evaluating the strength of the muscles of the rotator cuff and those that support the shoulder blade. The physical therapist may look at your posture and how you perform certain activities and movements to see how they affect your shoulder.

Do you need an X-ray and MRI imaging for shoulder arthritis pain?

For most common orthopedic cases, imaging is not needed and the diagnosis can be made with a simple physical therapy evaluation. No need to waste thousands of dollars on unwarranted diagnostic imaging. We also have clinical tests which we can perform to help rule in and rule out pathologies that correlate to MRI findings (which is WAY cheaper than an MRI!). An expensive MRI may just tell us what we already know. Also, often times the positive findings found on x-rays, MRIs, and EMGs may not actually be the root cause of your pain. What does that mean? Many positive findings on an MRI are also found in asymptomatic (pain-free) individuals, so diagnostic imaging may not be able to tell us what is actually causing your pain. For example many people have a herniated disc in their low back but do not have any low back pain. So if herniated discs can cause no pain, just because someone with low back pain has a herniated disc does not mean that is what’s causing their pain. The key is to find out if your clinical evaluation findings during your evaluation at Pursuit match the MRI findings. If so, then we can decide what is the best way to treat it.

How can a Physical Therapist treat it?

Without Surgery
When someone develops shoulder pain, the first recommended treatment is physical therapy. The following treatments can help decrease pain, improve movement, and allow increased use of your shoulder for daily activities. They may prolong the time until surgery is needed, or help you avoid it altogether.

• Improving tolerance of daily activities. Your physical therapist will work with you to help you get back to performing your daily tasks. Just changing your posture can reduce the pressure and forces at the joint and help reduce your pain. He or she may recommend the use of physical therapy “modalities” such as heat and cold, teach you about proper movement, and help you modify your activities to control your pain.
• Improving shoulder mobility. Your physical therapist can recommend ways to restore shoulder movement (range of motion). Stretching can lengthen tight muscles and ligaments, improving your posture and movement. Shoulder-joint mobilization may help improve movement and ease your pain. Your physical therapist may gently move your shoulder (manual therapy), to stretch the ligaments in ways normal stretching or arm motions do not.
• Improving the strength of your muscles. Strengthening the rotator cuff muscles can reduce the friction caused by the rough arthritic surfaces of the shoulder joint rubbing together. Support from the muscles that maintain your posture can help reduce forces on the shoulder joint.

Other options for treatment may include medications such as steroids or nonsteroidal anti-inflammatory drugs (NSAIDs). Injections of steroid or anesthetic medications may also help.

Following Surgery
There are several surgical options for treating shoulder OA, depending on the degree of damage at the joint and its surrounding structures, and your age, activity level, and occupation.

Palliative Options: The goal of this surgery is to resolve symptoms; it does not restore or reconstruct the arthritic area. This option is best for people under the age of 65 with minimal cartilage problems, or people in their 20s to 40s with many active years ahead.

Reparative, Restorative, and Reconstructive Options: Over the last several years, surgeons have developed new “biologic resurfacing” techniques for younger people who have shoulder OA who are not yet ready for total shoulder replacement. Your doctor and physical therapist can describe them in detail for you.

Total Shoulder Arthroplasty (TSA): Total shoulder arthroplasty is the medical term for a shoulder replacement. This is the best surgical technique for older patients with advanced OA who have good quality of bone at the shoulder joint and intact rotator cuff muscles. This procedure is best for people who do not plan to do high-level activities (overhead work at a job, overhead sports, or significant amounts of heavy lifting).

Shoulder Hemiarthroplasty: Shoulder hemiarthroplasty is a partial replacement of the joint. It is an option if the muscles that make up the rotator cuff of the shoulder are too weak or damaged to properly support and move the joint.

Reverse (Inverse) Total Shoulder Arthroplasty (rTSA): This surgery is also an option when the muscles that make up the rotator cuff of the shoulder have failed or are irreparable, or a complex fracture is present.
Arthroscopy: Many shoulder surgeries can be done via arthroscopy, a less invasive surgery by which the surgeon makes small incisions in the skin and inserts pencil-sized instruments (with a camera) into the joint to repair damage.

Postsurgical physical therapy varies based on the procedure performed. It may include:

• Ensuring your safety as you heal. Your surgeon and physical therapist work together as a team to return your shoulder to health. After the surgeon completes his or her work, your work begins. You will perform specific activities and exercises at the correct time to allow for optimal healing. All surgical procedures modify your shoulder joint and surrounding tissues. Restorative and reconstructive options may take several months to heal, with longer precautions.
• Aiding motion of the shoulder. After surgery, your shoulder will be sore and swollen, and you may not feel like moving your arm. However, gentle motion is often recommended. Your physical therapist may move your arm or assist you in moving your arm to begin to gently restore movement. After some surgeries, movement is restricted during healing; your physical therapist and surgeon will choose the best options for recovery and guide you through the process.
• Strengthening the shoulder. Due to prior disuse or postoperative pain, your muscles may not be as strong as normal. If the muscle was repaired during surgery, you will have to let it heal for a period of time, and your physical therapist can let you know what activity is safe to help the healing along.
• Relieving your pain. Using manual (hands-on) therapies and other modalities, your physical therapist can help reduce your pain during exercise and daily activities.
• Getting back to work and activities of daily living. Returning to work and daily activities may be slow, and your physical therapist will guide you through the process to achieve the best results.

“After at least three years of doctor-hopping […] looking for someone to alleviate my constant dizziness and neck pain, I finally found Dr. Miller. I have more energy and less pain, and have halved my dependence on painkillers. He shouldn’t be the last stop on your road to recovery, he should be the first.”

Lisa Bywater
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How long does it take for recovery?

Recovery time for shoulder arthritis depends on multiple factors:

• The severity and chronicity of your pain
• Whether your pain is an easy or complex case
• If the root cause of your pain was solved or if it was missed (this is the key to getting a great recovery!)
• How long you have been in pain for and when you need to be pain-free by
• Other therapies and treatments you have tried
• Which medical professional(s) you saw prior to seeing us
• How active you are in trying to resolve your pain
• Which treatment approach is chosen and if it is proven to work for your pain

There are many factors that influence your recovery time and every patient’s recovery time is different. If you do nothing and don’t pursue treatment, it could gradually get better on its own, you could continue to have the same pain persist, or it could continue to get worse. As stated earlier, most acute cases may or may not resolve in 4-8 weeks. If you get expert treatment that solves the root cause of your pain, some cases resolve in 1-3 weeks! Then you can get back to sports, exercise, and your favorite activities without flare-ups and recurrences. Some of our patients are pain-free in 1-3 visits and back to 100% in 2 weeks!

If it is a complex case with chronic pain, your recovery may take longer, but you can still get a good outcome. Some chronic cases can resolve as fast as 2 months but can take as long as 4-6 months. It varies with every patient because every case of shoulder arthritis pain is different. Every patient’s recovery varies depending on the factors listed above. After a thorough evaluation here at Pursuit Physical Therapy, you will know your exact timeline of recovery, your prognosis, and when you should reach your goals.

How much does it cost?

The average cost of care for a case of spine pain in the US is $1800-$6600. This high price is due to many factors: the over-inflated cost of healthcare, the over expensive cost of unwarranted imaging (x-rays, CT scans, and MRIs) that is not needed, over-utilization of care (which increases the number of visits needed to be treated, requiring multiple visits to different doctors and physical therapists for the same diagnosis), and getting billed for unnecessary and unproven treatments that you don’t even need. All of these factors increase cost and this is why healthcare is so expensive. We strive to end that unnecessary, expensive cycle. In fact, we are currently publishing our first-year data with the University of Central Florida that shows the cost-effectiveness of our treatment approach.

This year, the average cost of our care was shown to be $814-$1141. Some of our patients get even as low as $315 for the full treatment! So if you have a deductible of $3,000-$10,000 and you have to pay out of pocket for your treatment, we can save you lots of money.

Remember, every case of pain is different and not all shoulder arthritis pain is the same. It is hard to predict exactly how much your treatment is going to cost you. But after a thorough evaluation, we can tell you exactly what is causing your pain, how long it is going to take, what the best way to treat it will be, and exactly how much it is going to cost. We have no hidden fees, no co-pays, and no miscellaneous bills that you will be surprised by 3 months after you receive treatment. Your pain, your diagnosis, your goals, and what is best for you dictate your treatment and how much it will cost, and while it varies for every patient, treatment at Pursuit is still much more affordable than standard healthcare.

How long are sessions?

Our evaluations are always one-on-one with one of our board-certified specialists and 60-90 minutes long. We like to perform thorough evaluations so we can solve the root cause of your pain, identify all risk factors, and make sure that we do it right. After the evaluation, you will know your diagnosis, the root cause of why you have your pain and symptoms, your prognosis, an expected timeline of when you should see results, what the best way to treat your pain is, how much it will cost, and your expected recovery outcome. We want you to fully understand everything about your pain and injury. What is best for you and will get you the best outcome is what will dictate your care and treatment. There will be plenty of time for you to ask questions so we can make sure you fully understand why you have your pain and what the best way to treat it will be. After the evaluation is completed, all treatment sessions are 60 minutes going forward and still one-on-one with your physical therapist. You and your physical therapist will design a customized treatment plan that works for you and that will achieve your goals.

How can it be prevented?

There is no way to prevent shoulder OA. You may reduce your risk by staying moderately active, keeping the shoulder strong, and keeping the shoulder muscles the appropriate length with stretching. Your physical therapist can help you determine what exercises will keep your shoulder healthy. Eating healthy and exercising will help you manage a healthy weight and healthy joints. Avoiding injuries to the shoulder joint will help reduce your risk of OA as well.

What are the next steps?

Getting started is simple. The first step, and the key to getting you pain free again, is to solve the root cause or your case of pain. Remember, not all pain is the same. Your pain is different than someone else’s pain, even though it may be in the same area. If you’re ready to get pain free, give us a call at (407) 494-8835 or fill out the form below. The next step is to schedule your evaluation so we can solve the root cause for you. We’re happy to answer any questions you may have and we would love the opportunity to help you.