New Advancements in the Treatment of Shoulder Arthritis

Deborah Howell
This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell. Welcome to the show. I'm Deborah Howell, and, you know, arthritis in the shoulder is extremely common. Today we'll ask what new advancements have there been in the treatment of shoulder arthritis? Our guest is Dr. Roger Sohn. And orthopedic surgeon and upper extremity specialist at MemorialCare, Saddleback Medical Center and Orthopedic Care Alliance. Welcome, Dr. Sohn.

Dr. Roger Sohn
Thank you. It's great to be on the show, Deborah.

Deborah Howell
A true pleasure. So what are the first signs of shoulder arthritis?

Dr. Roger Sohn
Oh, well, it's a it's an interesting question. Sometimes it's a very insidious onset, meaning that it's not like a sudden onset, but sometimes people will notice that something they could do previously, something with ease, they could do, for example, swinging a golf club or working in their garden, which didn't used to cause any issues, will start to cause some pain, pain that wasn't there before. So pain is usually the first hallmark of arthritis. The other thing is stiffness. People start to lose their motion gradually, but it usually is a progressive problem and it can interfere with a lot of activities that used to be painless.

Deborah Howell
Well, that's kind of a bummer, right? Like, you're wake up and you're like, that's new.

00;01;25;00 - 00;01;36;25
Dr. Roger Sohn
It is a bummer, in fact. But many patients do recognize that their shoulder is changing. It wasn't the way it used to be. And they can say, you know, as I'm getting older, my shoulder is starting to bother me more than it used to.

Deborah Howell
Right. Now, can joint problems affect people at any age and activity level?

Dr. Roger Sohn
Yes. The answer short answer is yes. It can affect anyone. Most of the time people start to have problems with their shoulder in their mid-forties, for example, with shoulder arthritis, it's usually in their mid 50s or 60s, but for example, I just had a patient I treated not too long ago. About a year ago, this young man was 39 years old and had severe arthritis of his shoulder. I mean, he's to the point where he couldn't pick up his young daughter. It was really causing him a lot of symptoms. And his problem was related to an injury you had when he was back in his teens or maybe early 20s. So sometimes injuries can also lead to problems such as shoulder arthritis.

Deborah Howell
Right injuries and surgeries in my case. So what are some common causes of shoulder arthritis?

Dr. Roger Sohn
You know we just briefly spoke about injuries. So for example, one of the common causes of arthritis as patients get older is a dislocation of the younger person. So for example, you have a person who's playing in either youth sports or in high school or college. They'll dislocate their shoulder, they'll dislocated once, dislocated twice. And as the shoulder dislocations continue, there's cartilage damage that happens. It may not bother them too much as a 20 or 30 something, but as they get into their older decades, the arthritis can really build up, causing severe pain and weakness and in many cases, stiffness. Other causes for arthritis, though, and the more common cause is just simply the cartilage starts to wear out. Now, we don't know exactly why, and I think there's $1 billion industry out there aimed at trying to preserve the cartilage in any way we can. And I think that's coming in the future. But for whatever reason, our cartilage loses its normal resilience. It loses its normal resilient cartilage, the brushy layer of the cartilage. That's the glycosaminoglycan layer. Sorry. It's a hard it's a mouthful, but the glycosaminoglycan layer, we're born with a certain amount of thickness of that cartilage. And as we get older that cartilage starts to thin out. And eventually you've probably heard the term bone on bone once the cartilage is gone. There's at least at the time of this recording, there's no real way to bring it back.

Deborah Howell
So I guess, what point should someone see an orthopedic specialist for shoulder pain?

Dr. Roger Sohn
Well, I think since arthritis, which is the subject matter, is such a slowly progressive problem, it's not like someone needs to go to the emergency room the first time they have a twinge in their shoulder, but there is a lot of evidence showing a couple of things. Number one, that shoulder arthritis can progress in a way that actually damages the bone socket and causes the options to be limited in the future. If the patient does elect to undergo a reconstructive type of surgery. So I don't think patients should wait years and years when they have shoulder pain. If you do have shoulder pain and it's persistent, it's a good idea to at least get some x rays and an early workup to see what your prognosis might be.

Deborah Howell
That's sensible. Now, are there any recent technology advances in shoulder arthritis treatments?

Dr. Roger SohnYes, there are quite a few, actually. If you go back to my residency and fellowship training, the implants we used to use were these big, gigantic implants that reminded me of hip replacements. Now shoulder is a small joint, and as such, the implants we use now are much more sophisticated. We use smaller, for example, stemless implants on the arm side, on the humerus side and on the socket that's, I think, the area where a lot of people have been working. A lot of companies have been working to improve the longevity, because we've got a small little socket that's made out of plastic that is a polyethylene implant. And we always worry about that wearing out for two reasons. Number one, the thickness can get worn down just through repetitive cycles of moving the joint throughout the years. And secondly, because of a condition called the rocking horse phenomenon, the shoulder is an inherently unstable joint. So as the shoulder moves back and forth and side to side and rotates, the plastic component or the polyethylene component has a tendency to rock back and forth. And if that happens enough times, it can get loose. So a lot of attention has been focused on improving that longevity. One of the exciting changes that we've seen is there's a technology called an inset glenoid, where the glenoid component or the socket component is now placed inside the bone with a thin rim of a bone, the patient's native bone surrounding it, completely surrounding the implant. So if you can kind of picture it, it looks a little bit like a hockey puck, which has a circular pocket in the bone and the puck sits inside the pocket. In such a way, this may seem like a no brainer, but it's actually novel. It is held there, and it's supported by this supportive rim of bone around its entire circumference. So they've shown in both biomechanical studies and in clinical studies that the glenoid loosening can be something like in the biomechanics studies it's like ten times less cycling and loosening. And in the actual clinical data, it shows that there was a 0% loosening. In Dr. Gunther's study that was published with eight year follow up, there was no loosening whatsoever. So I think this is an exciting advance forward because typically we tend to see a lot higher numbers as far as loosening and rocking horse phenomenon, and that may be something that has some real promise. This insight type of glenoid.

Deborah Howell
And is this component useful in a more active patient?

Dr. Roger Sohn
Absolutely. And I told you about that patient at the beginning, who was a young 39 year old gentleman, and he had been told by many doctors that he just wasn't a good candidate. He would have to wait until he was 50 or 60, and that just wasn't a realistic option for him because he could not move his shoulder, or the bone spurs around his joint were so large he couldn't live like that. And so for him, it gave him a whole new lease on life. I mean, I just saw him back at the one year mark and he's got a great big smile on his face, and he tells me how he's lifting up his daughter, throwing her in the air. He doesn't think about the shoulder as a damaged shoulder anymore. He doesn't have any significant pain. And the reason we were able to give him this new lease on life is because of the promise that we have with these types of new technology advances that may give longer lasting performance from the implants.

00;07;44;03 - 00;07;49;24
Deborah Howell
That's just wonderful. Now, what are some preliminary non-surgical treatment options for shoulder arthritis?

Dr. Roger Sohn
We do focus a lot on surgery and doing surgery as well, but I think the majority of my patients don't receive surgery for this for when they have arthritis of the shoulder. So we do try several things, including trying to focus on things that will maintain their activity. So having good posture, having good scapular strength, having good mobility and just educating patients. This is a damaged joint. You can get a lot more longevity out of it if you treated gently and trying to educate patients on what sort of activities, sort of the high impact repetitive motions, sort of like tennis and those type of activities, those can definitely cause the joint to wear out faster. So focusing on things that are more smooth, like yoga, Pilates and those types of activities can help to make the joint last longer. And those are the main strategies we use in some patients where they're having a bad flare up. You know, arthritis tends to follow up a flare up than a calm down sort of pattern. And if they're having a big flare up, selective use of cortisone injections can be helpful. But they don't usually cure the problem. They can just kind of get patients back down to where they were before the flare up occurred.

Deborah Howell
You talk about tennis as being, you know, a little bit harmful. I've recently taken up pickleball, and I've noticed there's a lot of seniors on the court because it's a much lighter ball. It's a wiffle ball, and maybe not so much strain on the shoulder as a tennis ball.

Dr. Roger Sohn
You absolutely. And I think it was funny. Covid accelerated the adoption of pickleball. I think a lot of people picked up pickleball and it's a great sport. It's great because it's outdoors and it's very active. But of course I have seen an increase of patients come in complaining about pain from their pickleball activities. So yes, it's not a totally harmless type of activity, but thankfully you're right, it is a little bit less impact. It's less moving and running. It's also less the weight of the ball. So if someone is considering that as an alternative to tennis, I think it's definitely a great idea.

Deborah Howell
All right, two thumbs up. Just don't take it too hard and too manic like I do. Okay. No.

00;09;48;06 - 00;09;49;12
Dr. Roger Sohn
Yes.

Deborah Howell
Here's something a lot of people wonder about. Are cortisone injections bad for the shoulder joint?

Dr. Roger Sohn
Great question. I know it's an awkward question because I get asked this question a lot as I'm offering patients the cortisone injection. You know, I've heard that the cortisone shots aren't good for you or that they can cause the joint to have problems in the future or ruptures of tendons. It's all true. I think in the olden days, patients or doctors, in fact, didn't know that that was the case, that these cortisone injections could have some negative effects. So they gave them freely. And in fact, this was before my generation of doctors. But I think they learned the hard way that cortisone is basically a manmade derivative of what your body normally makes, called cortisol. It's a powerful anti-inflammatory. So we think that, you know, putting it in the joint isn't the worst thing that you could do because your body makes it. But the truth is, we're putting in a pretty concentrated amount and it can weaken the cartilage, the bones, the tendons, the ligaments, and it can make people prone to having tears of all those structures, such as a rotator cuff tear. That's possible. We also think knowing from the knee literature that as patients get multiple injections over the course of several years, that the cartilage can break down faster. They did a study in patients who had bilateral knee arthritis. That means both knees were arthritic and in one knee they gave injections, the other knee they didn't. And lo and behold, the knee that got the cortisone injections had a faster radiographic appearance, meaning on x rays they could see the progression of arthritis happening faster. So, you know, is that because of the cortisone or is it because patients feel some relief of the pain. And so they use the joint more and it wears down faster? I don't really know the answer to that, but we do know that in shoulders, particularly if you get a cortisone injection, the chances of having a complication later with a surgery. For example, if the patient does choose to have a eventual shoulder replacement, that they are at a higher risk. It's very slight, but it's a slightly higher risk of an infection in that joint, and it may be because some bacteria is deposited into the joint at the time of the cortisone shot. So no, you know the answer. That's the long answer. But the short answer is still yes. Cortisone shots aren't the best, but sometimes people are either not very healthy or they're not really able to consider having a shoulder replacement surgery. And I think sometimes just having a management type of strategy, a cortisone injection, maybe twice a year, it's a reasonable option just to help manage the pain.

Deborah Howell
Okay. Now when should surgery for shoulder arthritis be considered?

Dr. Roger Sohn
Well, I think anytime a patient starts to lose or give up functions, you know, with arthritis it's usually a gradual type of thing. Around here we see a lot of surfers, for example, and some surfers are X surfers that comes in and say, you know, I haven't been in the water for nine months, and the last time I went, I just had so much pain afterwards, I just it took me like three weeks to feel like the shoulder wasn't bothering me anymore. And I think it's always the best to have a conversation with a surgeon who has some experience with shoulder replacement. But many times, if you're having to give up things that you love, things that you enjoy, activities, and I think that's a good time to consider the surgical option, because we actually have very good results to show the improvements in patient related outcomes. If you look at a disability score such as the dash score, the drastic improvement, the statistically significant improvement, even at the three-month mark really shows that we're making a positive difference in patients lives. So I think on the one hand, it's not something we offer willy nilly, but at the same time, I wouldn't wait too long because many times patients give up sports and they can never return to them because they become deconditioned and weaker.

Deborah Howell
Exactly. So, can a person do all of their normal activities after a shoulder replacement?

00;13;29;28 - 00;14;03;02
Dr. Roger Sohn
I would give that a cautious yes for the most part, we do the replacement with the intention of letting patients return to their normal life, their normal activities. Now, in some cases because of bone loss or the particular type of surgery we do, we do give some patients some restrictions, but in general, we let patients return to their normal life and their normal activities. Sometimes we have them wait a little bit of time also to let some of the muscles and tissues adapt to the new implant. But at the end of that waiting period, we generally tell patients to go back to all of their activities.

Deborah Howell
Great. And are there alternatives to surgery for joint pain, depending on how severe someone's problem may be?

Dr. Roger Sohn
Certainly. You know, I think we briefly touched on some of the injections and the activity modifications. I think that's our mainstay. A lot of times if we tell patients just arming them with information about their condition, saying, hey, this type of impact, your activity you're doing is really not good for the joint. So long term, you may want to choose the time that you do activity X. And I think in the future there may be other things with biologics such as stem cells and things of that nature. It's really not ready for prime time at this point.

Deborah Howell
I do have one final question for this podcast is there anything people can do to prevent shoulder arthritis?

Dr. Roger Sohn
You know, that's the million dollar question. I think there's a lot of attention placed on supplements such as glucosamine, chondroitin, and MSM. There haven't been in actually studies that I've seen that have actually proved that they work. And I think there's also a lot of attention on the type of diets folks eat such as anti-inflammatory diets. Time will tell whether these are fads or whether they're going to stand the test of time, but I personally have looked at some of them, and I think that in general, they involve eating healthy. And I think that's a good thing no matter what.

Deborah Howell
Exactly. And Doctor, where can people go to learn more?

00;15;16;07 - 00;15;22;28
Dr. Roger Sohn
They can go to the website MemorialCare.org/SBjoints. That's like SB as in Saddleback.

Deborah Howell
Great MemorialCare.org/SBjoint. Thank you so much Dr. Sohn for your time and expertise today. We really enjoyed having you on the show.

00;15;30;29 - 00;15;31;21
Dr. Roger Sohn
Thank you Deborah.

Deborah Howell
And for more info or to listen to a podcast of this show, please visit MemorialCare.org/podcasts. That's MemorialCare.org/podcasts. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.