AP radiograph of the left shoulder demonstrating osteoarthritis with joint space narrowing, subchondral sclerosis and humeral osteophyte formation
11.3.2.2 MRI and CT
T2 weighted coronal MRI scan demonstrating features of osteoarthritis
T2 weighted axial MRI scan demonstrating osteoarthritis with posterior humeral translation and almost complete chondral loss
3D CT reconstruction demonstrating circumferential humeral osteophyte formation
11.4 Management Options
The principles and goals of managing the athlete with glenohumeral arthritis are understandably different from those of the general patient population. The competing professional athlete generally aims to maintain a career at the highest level for as long as possible. The recreational athlete may have slightly different priorities, and is often content to continue to participate in their chosen sport albeit at a lower level. Thus a solid understanding and appropriate management of the patient’s aims, goals and expectations is critical to achieving a positive outcome in degenerative conditions such as arthritis that have a natural history of gradual deterioration. The athlete must be educated as to their condition, taught to interpret symptoms and contribute to their treatment plan so they can assume some responsibility and control over its implementation. They should understand the aims of each treatment in the context of the overall prognosis of their condition, so they can adjust their expectations and in many cases, consider their career direction and planning for the future [1].
Treatments for degenerative joint disease have traditionally been divided into palliative, reparative, restorative and reconstructive options [9]. However, as this chapter focuses on the management of athletes, particularly those involved in professional or higher level recreational pursuits, we have categorised each treatment modality in the context of the athlete’s ability to meet the functional demands required to continue their career.
11.4.1 Career Maintaining
The following are all appropriate treatment options for the athlete with early or moderate stage arthritis who is aiming to continue to perform at the highest possible level. The objective is to mitigate against symptoms that may limit some aspects of higher level function. This group of treatments will be the most commonly utilised in athletes as they are less invasive with lower associated morbidity. Successful outcomes in the short term can often be achieved, however the natural history of deterioration of arthritis will generally determine the longer-term effect on the athlete’s career. In professional sport, it is essential that the treating team liaise closely with the relevant governing body to ensure that all medications and injections used comply with the World Anti-Doping Agency (WADA) code, and if necessary a therapeutic use exemption obtained.
11.4.1.1 Oral NSAIDS and Analgesics
As function is paramount in the athlete, a key aim of treating their arthritis is to effectively manage pain during activity, as pain itself is a significant contributor to impaired function. Oral analgesics including paracetamol should be used as part of a regular tailored analgesic regime, whilst medications containing codeine are most appropriate for use at night. Intermittent use of non-steroidal anti-inflammatory medications (NSAIDS), particularly around high intensity training sessions or on game day can be helpful, though care must be taken due to the risk of gastrointestinal, renal and possible cardiovascular side effects with prolonged use [30].
11.4.1.2 Nutritional Supplements
Glucosamine and chondroitin sulphate are components of the extracellular matrix of articular cartilage. The former is derived from crustacean exoskeletons, whilst the latter is extracted from animal cartilage [31]. A seminal paper based on a high-quality randomised controlled trial published in The Lancet in 2001 concluded that the use of glucosamine in patients with knee osteoarthritis could alter the natural history of the disease [32]. Since this time, the use of complementary medicines including glucosamine and chondroitin to treat arthritis has continued to rise. The largest multicentre, double-blinded trial published in the New England Journal of Medicine, however, concluded that the use of combined glucosamine/chondroitin had no overall effect on knee pain in a large cohort of patients, though there was a small benefit for the subgroup with moderate to severe pain [33]. Although their efficacy is uncertain, particularly in the shoulder, these supplements are approved for use in sport, and are safe with minimal side effects. This suggests that a trial of use in the athlete with painful glenohumeral arthritis is appropriate [31].
11.4.1.3 Corticosteroid Injections
The use of corticosteroid injections in sport is widespread, and often utilised in conjunction with long-acting local anaesthetics. Local anaesthetic is a helpful diagnostic tool while providing very short-term pain relief. A Cochrane review suggested that intra-articular steroid injections were superior to physiotherapy alone in providing pain relief in the short term. However, many studies are confounded by variability in injection type and site, associated medications and physiotherapy and differing activity levels. Hence assessing the true efficacy of injections in patients with arthritis has limitations [34].
The treating team should provide an environment that ensures the safest and most effective use of injections. The injection should be performed under sterile conditions with fluoroscopic guidance to ensure correct intra-articular position. It is critical that injections are not used as short-term solutions to ‘get an athlete through a game.’ This approach can have devastating consequences and accelerate chondral degeneration due to the loss of the protective mechanism of pain. Furthermore, corticosteroids suppress collagen synthesis and may affect the integrity of the remaining cartilage. The objective should be to provide temporary dampening of the synovitis and pain associated with arthritis and to allow for a structured strengthening and rehabilitation programme. The athlete should not be expected to play or train at full intensity during this time. Therefore, injections should be used judiciously and ideally not more than twice per joint per year [1].
11.4.1.4 Hyaluronic Acid Injections
The intra-articular injection of various hyaluronic acid formulations has been utilised most commonly in the knee. There are some positive clinical outcomes reported as a pain reliever and a low side effect profile, particularly when compared to NSAIDS [35, 36]. There is less evidence regarding treatment of glenohumeral arthritis, likely in part due to regulatory approval in many countries (though not the European Union) being limited to the knee. There are two well designed randomised studies that show significantly improved pain for 6 months or more in patients receiving 3–5 weekly hyaluronic acid injections, with particular benefit in those without other concomitant shoulder pathology [37, 38].
11.4.1.5 Physiotherapy
The key aim of physiotherapy in these patients is to maximise range of motion and strength within the limitations rendered by the arthritic joint. This may focus on maintaining range of motion rather than attempting to increase it. Arthritic shoulders will often cause scapular dyskinesia, and a tailored programme focusing on scapular stabilisation and regaining excellent scapulohumeral rhythm throughout range of motion is paramount to maximising function. This should be associated with isometric strengthening and passive stretching to maintain range and function. Hydrotherapy should play a key role in the rehabilitative process, as water provides buoyancy and resistance that aids strengthening, while minimising the stress on the joint [1]. Training regimes should be modified, in particular to avoid high load and repetitive impact activities.
11.4.1.6 Arthroscopy
Full thickness humeral chondral defect seen at arthroscopy
However, the therapeutic role of arthroscopy in patients with arthritis of any joint is controversial. The literature suggests that up to 80% of patients report good to excellent results over the short term following arthroscopy, however, many of these larger studies involve lower demand pre-arthroplasty patients who have a mean age of 50–60 years and are, therefore, a different cohort to the athletic population [39, 40]. The most convincing results of arthroscopic debridement and chondroplasty in young patients are found in those with isolated, symptomatic chondral lesions. The aim is to remove any unstable chondral flaps that are likely pain generators and may cause propagation of the defect. The benefit is greater in those patients with a congruent joint, minimal osteophyte or cyst formation and shallower lesions on only one side of the joint measuring <2 cm2 [39].
Loose body retrieved during arthroscopy
Other pain generators are appropriately addressed at the time of surgery. As the disease progresses, the anterior capsule in particular contracts leading to decreased external rotation and increased load on chondral surfaces due to abnormal motion [1]. Patients with more advanced disease may benefit from a more comprehensive procedure that includes a full capsular release, subacromial decompression, glenohumeral chondroplasty, AC joint excision, humeral osteoplasty and osteophyte resection plus a biceps tenodesis and axillary nerve neurolysis. Promising results have been described, with 85% of patients delaying arthroplasty by 2 years [40].
11.4.2 Career Salvaging
These options are indicated in the athlete with more severe or symptomatic degenerative disease. The athlete is likely to have already undertaken multiple treatments in the career-maintaining group with diminishing success. Although high-impact activity is possible after these modalities, their overall success rates are circumspect, particularly in a high-load environment. Therefore, the athlete’s expectations must be managed: they must be aware that although these procedures are an attempt to prolong a career, they may not recover sufficient function or symptom control to return to their desired level of activity or performance.
11.4.2.1 Microfracture
Due to the poor vascularity and cellular structure of articular cartilage, the ability for chondral defects to heal is poor [43]. The principle behind microfracture is to first create a favourable healing environment, followed by penetration of the subchondral plate and marrow underlying the defect to stimulate the body’s injury response. This leads to a stimulation and proliferation of mesenchymal stem cells as part of an organising fibrin clot, and in conjunction with growth factors and platelets the formation of granulation tissue and eventually fibrocartilage [44]. The procedure is generally performed arthroscopically, however, crucial to its success is meticulous surgical technique and a slow, tailored rehabilitation programme [45]. Although microfracture treatment of full-thickness chondral defects have been utilised successfully in the knee and to a lesser extent the ankle, there is minimal literature regarding its use and efficacy in the shoulder [26]. The small series that have been published in the shoulder have found the best outcomes in isolated humeral-sided lesions, with promising improvement in pain, ability to work and play sport in young, active patients. Microfracture does not appear to compromise future reconstructive options, however, this is tempered by a failure rate of up to 20% [43, 46]. These results suggest that microfracture is a reasonable escalation of treatment in the symptomatic athlete, however, appropriate counselling must emphasise that a significant percentage of patients will not respond to this treatment resulting in likely premature retirement.
11.4.2.2 Chondral/Osteochondral Grafting
Replacing an area of damaged or missing cartilage with normal or near normal chondral tissue is the ideal endpoint for managing a focal chondral lesion. Though difficult to achieve successfully, modalities include osteochondral transplant using allograft, primary grafting using autograft transfer (OATS), staged autologous chondrocyte implantation (ACI) or use of a synthetic scaffold.
Osteochondral grafting (OATS) into a humeral head defect has theoretical advantages including the healing potential of bone and use of autograft. However, there is also significant potential morbidity with open surgery required at both the shoulder and the donor site–normally the knee. The largest series, albeit in only 8 patients, shows good results with congruent joint lines and no further surgery at nine years following the index procedure [47]. For larger, uncontained defects, size and contour matched allograft from a glenoid or humeral head is a preferable option, though is limited by availability of fresh or fresh frozen grafts in some centres [5, 9]. Although ACI in the knee has shown promising results [48, 49] it remains unproven in the shoulder, with only two studies covering five patients in the literature [50]. This includes a case report in a teenage athlete who maintained a full range of motion and preserved function at one year after grafting [5, 51, 52].
11.4.2.3 Biological Resurfacing
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