Shoulder Osteoarthritis (advanced)

Condition: Shoulder Osteoarthritis (advanced)

Shoulder osteoarthritis (OA) involves progressive degeneration of cartilage at the glenohumeral joint. 1
This condition may be classified as either primary (unknown cause) or secondary (identified cause or
instigating factor).3 Potential causes of secondary shoulder OA include shoulder trauma, chronic rotator
cuff tear or dislocations, congenital malformations, or infection.8 Other contributing factors include
age, sex, genetics, weight, history of shoulder surgery, rheumatoid arthritis, and shoulder overuse. 8, 11
Shoulder OA progresses gradually, with increasing symptoms of abnormal joint function, catching or
crepitus with movement, pain, swelling, and loss of joint strength and ROM. 2, 8 As a progressive
condition, treatment aims to mitigate pain, slow progression, and prevent development of debilitating
symptoms.6, 12

Scenario:
A 57-year-old female recalls experiencing a pop in her right shoulder 2 years ago when swinging for a
tennis ball. She has since noticed increasing shoulder pain, tenderness, and stiffness, and a dull ache
that keeps her awake at night. Recently, her shoulder has begun to catch frequently, such as when
raising a watering can to water hanging baskets or when putting dishes away in cupboards. She is
concerned about losing strength in her right shoulder as she is gradually using her dominant arm less.
She is a physical education teacher and enjoys gardening with her husband, walking her puppy, and
holding her 9-month-old grandchild. Two weeks ago, her orthopedic doctor diagnosed her with
advanced right shoulder OA.

Standard In a resting posture, the ideal alignment
Posture of the shoulders begins with the
positioning of the pelvis in anterior pelvic
tilt. Ascending from the pelvis, the
lumbar, thoracic, and cervical spine
should be in slight extension. This
alignment allows the shoulders to rest in
adduction at the sides of the body; neutral
rotation of the shoulder is indicated by
the neutral positioning of the hands, with
the palms slightly internally rotated from
anatomical position.
In the lateral view, the line of stability
follows a plumb line (along the
frontal/coronal plane) that bisects the
lobe of the ear, descends through the
glenohumeral joint with less than 1/3 of
the humeral head anterior to the line, and
passes through the lateral epicondyle of
the elbow.
In the anterior view, both right and left
shoulders rest at the same height,
demonstrating neither elevation nor
depression relative to the other.

As a ball-and-socket joint with a shallow

socket (the glenoid fossa), the shoulder
moves around 3 axes of motion resulting
in flexion/extension, internal/external
rotation, and adduction/abduction. These
movements rely upon scapular stability
and movement. During activities
involving shoulder movement,

Skeletal Skeletal Anatomy (primary/secondary)
Imbalance Degeneration of both the labrum and the
articular cartilage on the humeral head
result in bone-on-bone grinding between
the humeral head and the glenoid fossa.9
The presence of osteophytes (bone spurs)
may develop around the glenoid fossa or
the humeral head.9 Subsequent pain,
stiffness, and inflammation results in
protective posturing – adduction and
internal rotation of humerus, anterior tilt
and protraction/abduction of scapula.
During movement, pain and/or the
presence of osteophytes may result in
loss of ROM due to diminishing ability of
the humeral head to glide smoothly in the
glenoid cavity.9
Muscle Structures
Imbalance Ligaments
 Glenohumeral ligament (middle,
inferior) and coracohumeral ligament
– laxity due to protective posturing
and decreased use of affected UE
 Glenohumeral capsule– thickening1
Muscles
 Supraspinatus – weakness due to
decreased active ROM (decreased
abduction)
 Infraspinatus, teres minor and
rhomboids – weakness due to
protective posturing
 Subscapularis and latissimus dorsi –
shortening/tightness due to protective
posturing (internal rotation,
adduction)
 Posterior deltoid – weakness due to
decreased active ROM (decreased
extension and external rotation)
 Anterior deltoid and pectoralis minor
– tightness due to protective
individuals should not demonstrate trunk
compensation.
Lateral View
From the lateral perspective, the humeral
head may be observed in internal rotation
and forward posturing.
Frontal View 11
From the frontal perspective, the
diminished joint space between the
glenoid fossa and the humeral head can
be observed. Osteophyte development
may also be observed surrounding the rim
of the glenoid fossa and the humeral head
in a curved pattern known as a “goat’s
beard.” 9
Progression:
In mild stages of OA, periarticular
muscles (rotator cuff muscles) begin to
decline in strength due to gradual
decreased use of affected UE.
In severe stages of OA, the increasing
limitations for ROM and increasing
protective posturing result in increasing
weakness of the muscles that perform
shoulder external rotation, abduction,
flexion, and extension.12 Simultaneously,
the muscles that elicit adduction and
internal rotation become increasingly
tight and shortened.
Adaptive Shortening:
This mostly occurs in the muscles
responsible for internal rotation and
adduction as induced by increasing
degrees of protective posturing.
 posturing (internal rotation,
adduction)
 Biceps brachii, coracobrachialis –
weakness due to decreased use of
affected arm in tasks
Compensation Postural Changes Anatomic description
 Protective posturing to minimize pain During task performance, shoulder pain
results in shoulder internal rotation, causes changes in movement patterns,
adduction, and forward positioning (i.e. exaggerated forward trunk flexion
 During task performance, observed when lying granddaughter down on
fixed arm pattern movements changing table), as well as protective
(patterns that cause least amount of posturing that results in increased
pain)5 shoulder elevation (i.e. shoulder hiking
Proximal when reaching to put away dishes).
 Increased trunk movement5 During motion, the shoulder and elbow
 Increased center of mass excursion5 position is more rigid and guarded (i.e.
 Fixed arm position5 while gardening, holding the right arm in
 Increased shoulder elevation4 an adducted position and relying mostly
on the left hand for tool manipulation).
 Decreased shoulder abduction4
During reaching tasks with the affected
 Increased reliance on unaffected
arm, fatigue of weakened muscles
shoulder/UE
(induced by disuse) may elicit lateral
Distal
leaning towards unaffected, non-reaching
 Decreased elbow movement arm (i.e. leaning towards left arm while
 Decreased use of hand on affected reaching with right arm to place glass on
side shelf).4
 Increased use of hand on unaffected
side
Primary /Secondary Pathology
 Pain and decreased degrees of
freedom (due to decreased joint
space) results in increasing stiffness
and self-restricted decreases in
shoulder ROM, necessitating
compensatory movements of the
trunk during task performance
 Decreased use of affected UE also
results in loss of strength and
increasing stiffness (cyclic effect)
Occupations ADLs, iADls, work, leisure, sleep/rest Affected
 ADLs: Washing/styling/brushing
hair, brushing teeth, donning shirt
 iADLs: Walking puppy, holding
granddaughter, accessing high
cupboards in kitchen
 Work: Setting up supplies for P.E.
activities, demonstrating activities
(i.e. setting up volleyball nets,
swinging overhead for volleyball)
  Leisure: watering hanging baskets,
gardening
 Sleep/rest: restless nights of sleep due
to continual re-positioning

Adaptation
(client adaptations in attempting to
minimize pain and maximize function)
 ADLs: uses right arm during
overhead activities until pain/fatigue
sets in, then relies on left arm while
using the right for supporting /
stabilizing items; threads right arm
first when donning shirt
 iADLs: holds granddaughter with left
arm; uses step-stool to access high
cupboards
 Work: uses right arm for all activities
until pain/fatigue sets in, then relies
more on left arm and occasionally
asks students to help move supplies
and to perform demonstrations
 Leisure: uses left arm to water
hanging baskets; often forgets to use
left hand to hold puppy’s leash until
her dog tries to bolt and jars her arm
 Sleep/rest: used to sleep on right
shoulder, currently trying to learn to
sleep on her back
Assessments Impairment Based Evidence to support
 Imaging  X-ray – joint space narrowing
(deterioration: central, posterior,
superior), osteophytes, cysts,
subchondral sclerosis8
 MRI – cartilage degeneration8
 Goniometry PROM and AROM – normal values:
 Flexion: 0-180°
 Extension: 0-60°
 Abduction: 0-180°
 External rotation: 0-90°
 Pain assessment  Palpation to assess for tenderness
along joint line and to rule out other
shoulder pathologies (i.e. bursitis,
rotator cuff disease, biceps
tendinitis)8
 Visual Analog Scale
 Manual Muscle Test Measure for flexion, extension,
abduction, external rotation (avoid
eliciting pain)
  Grind test
 Postural assessment
Performance Based
 Observation of performance
Self-Report Outcome Measure
 Disability of Arm, Shoulder, Hand
 Upper Limb Functional Index
 American Shoulder and Elbow
Surgeons Standardized Shoulder
Assessment Form, self-report
section7
Therapy Occupation-based interventions Phases:
Interventions The client is in a combination of
restriction and augmentation phases.
Initially, many interventions should be
developed according to a restriction
phase in order to protect the right
shoulder from further aggravation and to
allow for pain and edema reduction.
Because shoulder OA is progressive,
however, many interventions should also
be developed according to an
augmentation phase in order to teach her
techniques for how to prevent eliciting
pain or causing damage while
maximizing independence in her daily
occupations.
 Crepitus with ROM8
 At rest and during activity
performance
 ADL6 – overhead grooming tasks
 iADL – simulating holding infant,
accessing high cupboards
 Work – picking up, carrying, and
setting up, and providing
demonstration with sports equipment
 Leisure – simulating watering
hanging baskets
 Self-report measure indicating degree
of disability during occupations due
to shoulder restrictions
 Self-report measure indicating degree
of functional ability during
occupations
 Condition-specific scale involving
pain rating and rating of ability to
perform various activities (0 =
unable; 1 = very difficult to do; 2 =
somewhat difficult; 3 = not difficult)
-General education to
 avoid activities that elicit pain,
 improve posture
 alter posture during activities to
appropriately limit shoulder ROM
without performing harmful
compensatory movement patterns
(i.e. over-reliance on left shoulder)
 prevent shoulder aggravation during
ADLs and iADLs (i.e. modified
technique for dressing, grooming,
bathing)
 use adaptive equipment during
ADLs/iADLs as necessary to
maximize independence (i.e. reacher)
-Provision of a sling and wearing
schedule, to be worn during the following
activities: while at work as a physical
education teacher to remind her to ask for
help setting up activities, while walking
her puppy to prevent her from holding the
leash in her right hand and risking sudden
jerking movements, and potentially while
gardening depending on client’s
compliance with restricted movements.
 -Education to suggest postural changes,
such as sleeping on her back or left side
with a pillow in front of her chest to
drape her right arm over, thereby
minimizing strain on right shoulder.
-Suggest using left arm to lower hanging
baskets prior to watering them, using
right arm only to stabilize basket and
watering can; may also suggest investing
in a lightweight, expandable garden hose
in order to increase ease of task
-Suggest altering setup of kitchen, storing
items at or below shoulder level (i.e. pull-
down shelves for high cupboards,
reconfiguring what is stored where, etc.)
-Suggest holding her granddaughter while
seated in an arm chair, with her left arm
supported on the armrest.
-Practice pain-free shoulder movements
embedded in meaningful occupations (i.e.
gardening activities, pet care, sports-
related activities)

Therapeutic Intervention -Ice/heat/ultrasound and/or TENS to

 Pain and edema reduction reduce pain and edema10
 ROM -Gentle stretches to increase pain-free
 Strength shoulder ROM3 (i.e. doorway stretch and
supine passive external rotation and
abduction over edge of bed to lengthen
subscapularis and latissimus dorsi)
-Isometric strengthening exercises
targeting rotator cuff muscles (isometric
external rotation against towel roll on
wall), and scapulothoracic muscles
(supine or seated shoulder blade
squeezes)3

References
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