Clinical Presentation and Evaluation of Glenohumeral Arthritis.
Last updated Thursday, January 27, 2005
Rheumatoid and other types of inflammatory arthrit
Rheumatoid arthritis is a systemic disease with highly variable
clinical manifestations. It may be isolated to the glenohumeral joint
or may affect most of the tissues in the body.Effects of arthritis In rheumatoid and many other types of inflammatory arthritis, the
cartilage is characteristically destroyed evenly across all joint
surfaces. The glenoid is eroded medially (see figure 5) rather than
posteriorly as in degenerative joint disease (see figure 6). The
condition is often bilaterally symmetrical. The arthritic process
erodes not only the cartilage, but also the subchondral bone and
renders it osteopenic. The glenohumeral, acromioclavicular,
sternoclavicular, elbow, wrist and hand articulations may all be
affected, greatly amplifying the resulting functional losses. Soft
tissues, including the rotator cuff, may likewise be swollen,
contracted, weakened or torn.
In a clinical and arthrographic study of 200 painful shoulders in
patients with rheumatoid arthritis, Ennevarra found only 26 per cent of
patients had full-thickness rotator cuff defects. (Ennevaara, 1967) In
two series of patients with rheumatoid arthritis that required total
shoulder arthroplasty, the rotator cuff had full-thickness tearing in
29 of 69 shoulders (42%) and in 18 of 66 shoulders (27%). (Cofield,
1983b; Neer and Kirby, 1982)
Even the skin may be fragile and subject to compromise in wound
healing. The fragility of the patient with rheumatoid arthritis is
frequently compounded by long term use of steroids and other
antimetabolic medication. Because the condition itself involves the
immune system, because the patient is often on immunosuppressive
medication and because the clinical manifestations of rheumatoid
arthritis are similar to those of infectious arthritis, the physician
must be aware of the possible coexistence of joint infection.
Petersson (Petersson, 1986a) pointed to the prevalence and
progression of rheumatoid involvement of the shoulder. Winalski and
Shapiro(Winalski and Shapiro, 1991) and Mulliaji et al (Mullaji, Beddow
and Lamb, 1994) used computerized tomography to characterize the
rheumatoid involvement of the sternoclavicular and glenohumeral joints.
Alasaarela and Alasaarela (Alasaarela and Alasaarela, 1994) have used
ultrasonography to define the soft tissue changes associated with
rheumatoid arthritis of the shoulder. Other conditions Other conditions may produce shoulder findings quite similar to
those of rheumatoid arthritis. Included in the list are localized
processes, such as pigmented villonodular synovitis (Dorwart, Genant,
Johnston, et al., 1984a; Dorwart, Genant, Johnston, et al., 1984b)
synovial chondrometaplasia (Hjelkrem and Stanish, 1988) and pseudogout.
(Hughes, Biundo, Scheib, et al., 1990) The shoulder may be a site of
manifestation of systemic disorders such hemophilia and
hemachromatosis, (Epps, 1983; Rand and Sim, 1981) primary
hyperparathyroidism, (Nussbaum and Doppman, 1982) acromegaly,
(Podgorski, Robinson, Weissberger, et al., 1988) amyloid arthropathy,
(Curran, Ellman and Brown, 1983) gout, (Ellman and Curran, 1988)
chondrocalcinosis, (Cosendai, Gerster, Vischer, et al., 1976)
ankylosing spondylitis, (Fournie, Railhac, Monod, 1987; Marks, Barnett
and Calin, 1983) psoriasis,(Fournie, Railhac and Monod, 1987) and Lyme
arthritis. (Curran, Ellman and Brown, 1983) Recently, Sethi et al
(Sethi, Naunton-Morgan, Brown, et al., 1990) have reported a "dialysis
arthropathy" which affects multiple joints, including the shoulder, in
individuals on long term dialysis.
Because of the fragility of the skin and other soft tissues, the
osteopenia, and the severe bony erosion common with this condition, the
patient with substantial involvement from rheumatoid or similar types
of arthritis needs to be treated with extreme gentleness, thoroughness
and care. These admonitions are referred to as "rheumatoid rules."
In a recent review, Sneppen et al (Sneppen, Fruensgaard, Johannsen,
et al., 1996) pointed to the challenges of arthroplasty in rheumatoid
disease. In their series of Neer arthroplasties, at 92 month followup,
55% showed proximal migration of the humerus relative to the glenoid,
40% showed progressive loosening of the glenoid component, 5 of 12
press fit humeral components showed progressively loosening (but none
in 50 cemented humeral components). In spite of these problems, 89% of
the patients demonstrated good pain relief. Boyd et al (Boyd, Aliabadi,
Thornhill, 1991) found that of 111 Neer total shoulders with an average
followup of 55 months, progressive proximal migration occurred in 22%
of patients (29 shoulders).
Individuals with rheumatoid arthritis characteristically have
substantially lower self-assessed vitality and overall physical
function than the other causes of glenohumeral arthritis. The
compromised general health and strength of individuals with rheumatoid
arthritis must be considered in their management as has been emphasized
by a recent comparison study of RA and DJD conducted by Smith et al.
(Matsen, Smith, DeBartolo, et al., 1996)
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