Shoulder Joint Rheumatoid Arthritis : Symptoms, Treatment- Conservative, PT, Surgery

Rheumatoid arthritis of shoulder joint is an autoimmune inflammatory disease that mostly affects synovial membrane, capsule and articulating cartilage. Half the patients diagnosed of rheumatoid arthritis suffer with shoulder joint rheumatoid arthritis.¹ Shoulder joint rheumatoid arthritis is not a genetic or abnormal chromosomal disorder. Inflammation of synovium causes swelling or edema of the synovial membrane, hypertrophy of synovial fibrous tissue and excess secretion of synovial fluid within the joint. Later stage continuation of inflammation causes destruction of articular cartilage within the joint. Rheumatoid shoulder joint arthritis is a bilateral disease that affects both shoulder joint simultaneously unlike osteoarthritis. Disease often affects multiple joints simultaneously.

• Triggered by viral, bacterial or parasite infection in few individuals carrying certain gene types like PTPN22 and PAD14.
• Several epidemiological studies have indicated association between herpes virus infection and rheumatoid arthritis.

Several studies have suggested association between vitamin D deficiency and occurrence of rheumatoid arthritis.

• Rheumatoid arthritis is more common among smokers than non-smokers.
• Rheumatoid arthritis 3 times more common in patients with history of smoking than non-smoking.

More common in female than male (F/M: 2/1)

Middle age

• Mild to moderate pain- Initial stage of the disease.
• Severe to very severe pain- Later stage of the disease.
• Pain at rest- Mild to moderate in intensity.
• Pain with activities- Severe or very severe.
• Pain in the morning- Shoulder joint pain is worst in the morning at rest and with activities.
• Progressive pain- Pain becomes progressively severe and worse.
• Spread of pain- Pain is mostly felt in shoulder joint.

• History of weight loss.
• History of loss of appetite.

• History of fatigue.
• History of tiredness.
• Often unable to ambulate (move) because of pain and fatigue.
• Complaints of generalized weakness.

• History of fever.
• Fever is on and off.

• Patient initially complaints of difficulties in moving the shoulder joint.
• Shoulder joint movement is extremely painful.

• Shoulder joint movement is restricted because of severe pain.
• Patient complaints of severe pain while lifting upper arm or rotating the arm at shoulder joint, which restricts the joint activities.
• Passive and active shoulder joint movements are limited because of pain, joint stiffness and muscle spasm.

• Patient often complaints of Shoulder Joint Stiffness during shoulder joint movements.
• Joint stiffness is secondary to prolonged restricted joint movement and muscle spasm.
• Joint stiffness is also secondary to lack of flexibility of tendon, ligament and capsule of shoulder joint.

• Patients often complaints of shoulder joint muscles cramps caused by muscle spasm.
• Muscle cramps causes severe pain at rest and activities.

Examination and palpation of the joint causes severe pain.

Skin over the swollen joint often felt warm because of active inflammations of the capsule and synovial membrane.

• Swelling is soft in consistency.
• Swelling is secondary to excessive collection of synovial fluid in shoulder joint.
• Swelling causes joint deformity

• Joint stiffness is often observed in advanced stages.
• Stiffness is secondary to severe pain during joint movement, muscle spasm, lack of flexibility of ligaments and tendonitis.

Rheumatoid nodules are observed under skin mostly over arms.

• Deformities are observed in smaller joints like joints of fingers, hands and toes.
• Deformity is caused by excessive synovial fluid and joint subluxation.
• Smaller joint deformity causes deviations of fingers and toes.

• Shoulder joint arthritis caused by rheumatoid arthritis results in severe pain and restriction of joint movements.
• Shoulder joint muscles become stiff.
• Muscle stiffness follows muscle atrophy and weakness.
• Examination indicates loss of shoulder joint muscle mass.
• Disease is often bilateral. Shoulder joint muscle atrophy is often misdiagnosed since atrophy may be observed around both shoulder joint.

• Range of flexion, extension, abduction and rotation are often moderately restricted in late stage of disease.
• Patient is often unable to abduct (outward) the arm at shoulder joint.
• Extent of passive (assisted) and active (self-directed) range of motion is restricted.

• In few cases grinding sound is heard during passive or active movement of the shoulder joint.
• Grinding sound is secondary to subluxated bones grinding against each other.

• Excessive synovial fluid observed in shoulder joint.
• Joint space is narrowed suggesting deteriorating joint disease
• Joint space is often found wide if synovial fluid is excessive.
• Joint subluxation may be observed in advanced stages.

Findings are as follows-

• Uneven articulating cartilage.
• Joint space is wide and filled with synovial fluid.
• Joint subluxation or dislocation is rare but small joint in hand and feet may show subluxation and dislocation. Synovial membrane thickening are seen.

Findings are same as MRI findings.

• Rule out gout- Uric acid crystals are observed in gout,
• Rule out pseudogout- Calcium pyrophosphate crystals are found in joint synovial fluid.
• Septic arthritis- bacterial cells, red blood cells and pus cells are observed in septic arthritis.

• Rule out hematoma or bleeding of the joint
• Excessive synovial fluid is observed in Rheumatoid Shoulder Joint Arthritis.
• Rule out shoulder joint subluxation.

• RF is a protein molecule known as antibodies.
• Seventy to ninety percent of patients suffering with rheumatoid arthritis show presence of RF.
• RF test is often non-specific test, since RF is also present in patients suffering with other type of autoimmune disorders.
• Symptoms of rheumatoid arthritis are less severe when RF is absent.

• Specific antibodies produced in rheumatoid disease prior to symptoms and during symptoms binds to Citrulline.
• The test is specific. Test is always positive in rheumatoid shoulder joint arthritis in spite of RF being absent. Anti-CCP predicts severity of rheumatoid arthritis and disease (RD) and also subclinical RD.

• Cytokins and related protein factors are elevated in early stages of rheumatoid disease.
• Cytokine factors are used as a marker to diagnose early stage of rheumatoid arthritis.

• ESR is non-specific test and increased in Rheumatoid Arthritis.
• ESR and Anti-CCP test are used to monitor the disease and prognosis.
• Erythrocyte sedimentation rate (ESR) is increased during active inflammation. Increased ESR suggests inflammatory joint disease and prognosis of the disease.
• ESR is elevated in rheumatoid shoulder joint disease, osteoarthritis of shoulder joint and psoriatic shoulder joint arthritis.

• ANA is a non-specific antibody test.
• Results are positive in all autoimmune disease.

Test is positive in inflammatory joint diseases like Psoriatic Hip Joint Disease, Ankylosing Spondylitis and Reiter’s Syndrome.

• ANCA is an abnormal antibody seen in-patient with history of hip joint pain caused by Wegener’s granuloma.
• Blood examination for ANCA level is performed to rule out Wegener’s granuloma as a cause of hip joint pain.

• Thin tubular camera is inserted after sedation in shoulder joint through tiny skin incision.
• Joint structures are observed over television screen.
• Cartilages, tendon, ligaments and synovial membrane structures are observed for any abnormalities or inflammation.
• Findings of Shoulder Joint Rheumatoid Arthritis-
  1. Thickening of inflamed synovial membrane and capsule
  2. Cartilage thinning and inflammation
  3. Excessive synovial fluid.

• Restricted shoulder joint activities are advised.
• Restriction is beneficial during early stages and aggressive treatment with medications.
• Shoulder joint braces are prescribed to immobilize joint for short period of time.

• Improve joint movement during early stage.
• Prevent muscle weakness and atrophy during later stages.
• Exercise recommended during early phase of the disease.
• Exercises advised are swimming, yoga therapy and stretching.

• Heating pad
• Moist heat

• Therapeutic for pain and inflammation.
• Pack of ice or cold pad is applied over shoulder joint for 20 to 30 minutes two or three times a day.

Assisted device are prescribed if pain is severe and intolerable with activities. Following devices are often prescribed-

• Cane
• Walker
• Wheelchair

Therapeutic value of following medications is not supported by any research or scientific evidence.

• Glucosamine
• Chondroitin sulfate

Physical therapy is advised during initial phase of the disease or after surgery. Physical therapy and anti-inflammatory medications often are adequate to treat early symptoms.¹ Physical therapy involves exercise under supervision by physical therapist. Physical therapy exercises are often combined with massage therapy, heat treatment, ultrasound therapy and cold therapy.

Objectives Of Physical Therapy To Treat Shoulder Joint Rheumatoid Arthritis Are As Follows-

• Prevent muscle weakness
• Prevent muscle stiffness and atrophy
• Prevent muscle spasm
• Improve range of joint movement and
• Prevent Joint Stiffness

Prescribed for

• Joint Inflammation
• Soft tissue inflammation
• As a non-opioid analgesics

Side Effects-

• Stomach Pain
• Gastric Ulcer
• Bleeding Disorder

Most Common NSAIDs Prescribed are as Follows-

• Motrin
• Naproxen
• Daypro
• Celebrex

Prescribed for

• Chronic pain not responding to NSAIDs
• Post surgical pain

Side Effects-

• Nausea
• Vomiting
• Constipation
• Dependence
• Addiction

Most Common Opioids Prescribed is as Follows-

Short Acting- Acts for 3 to 4 hours

• Hydrocodone, (Vicodin, Lortab and Norco)
• Oxycodone (OxyIR)
• Morphine (MS IR)

Long Acting- Acts for 12 to 24 hours.

• Oxycodone (Oxycontin)
• Morphine (MS Contin)
• Avinza and
• Methadone

Prescribe for –

• Muscle cramps
• Continuous muscle spasm

Side Effects of Muscle Relaxants:

• Drowsiness
• Dizziness
• When prescribed with opioids dual effect may cause sleep apnea (unable to breath normal).

Most Common Muscle Relaxants Prescribed are as Follows-

• Baclofen
• Flexeril
• Skelaxin
• Robaxin

Prescribed for

• Neuropathic pain
• Pain not responding to NSAIDs
• Replace opioids when opioid side effects contraindicates opioid therapy.

Side Effects of Anti-epileptic Analgesics are:

• Drowsiness
• Dizziness
• Hypotension
• When prescribed with opioids dual effect may cause sleep apnea (unable to breath normal).

Most Common Anti-epileptic Prescribed as Analgesics are:

• Neurontin
• Lyrica

Prescribed for

• Neuropathic pain
• Pain not responding to NSAIDs
• Replace opioids when opioid side effects contraindicates opioid therapy
• Chronic pain associated with depression

Side Effects of Anti-depressant Analgesics are:

• Drowsiness
• Dizziness
• Hypotension

Most common antiepileptic prescribed as analgesics are:

• Cymbalta
• Elavil

• DMARDs are used to slow the progress of the disease.
• DMARD prevents permanent damage of the synovial membrane of the joint and ligaments.

Following medications are often used as DMARDs-

• Methotrexate (Trexall)
• Leflunomide (Arava)
• Hdroxychloroquine (Plaquenil)
• Sulfasalazine (Azulfidine).

• Rheumatoid disease is associated with exaggerated immune activities.
• Following medications are used to suppress hyperactivities of immune system-
  1. Azathioprine (Imuran, Azasan) and
  2. Cyclosporine (Neoral, Sandimmune, Gengraf).

• Rheumatoid arthritis causes increased secretion of Tumor Necrosis Factor-Alpha (TNF-alpha) within hip joint.
• Tumor Necrosis Factor-Alpha triggers inflammation.
• Inflammation induced by TNF-alpha factor causes pain, joint stiffness and joint swelling.
• Medications known as TNF-alpha inhibitors reduces production of TNF-alpha factor and provides symptomatic relief from pain, joint swelling and joint stiffness.
• Following medications are used to inhibit secretions of TNF- alpha factors-
  1. Etanercept (Enbrel)
  2. Infliximab (Remicade)
  3. Adalimumab (Humira)
  4. Golimumab (Simponi)

• Decreases inflammation of synovial membrane and tendon
• Cortisone reduces pain by decreasing secretion of prostaglandin and other pain inducing chemicals.
• Most common cortisone injection used for shoulder joint osteoarthritis are as follows-
  1. DepoMedrol
  2. Kenalog
  3. Decadron

Following Nerve Blocks Are Useful For Shoulder Joint Rheumatoid Arthritis-

• Cervical Plexus Nerve Block
• Brachial Plexus Nerve Block and
• Field Block of Shoulder Joint

Following Local Anesthetic Medications Are Used For Nerve Block

• Lidocaine
• Bupivacaine

Reason For Nerve Block

• Severe intractable pain not responding to oral pain medications including opioids
• Assist physical therapy
• Diagnostic block to evaluate cause of pain
• Improve joint movements

Advised when all other treatment has failed and chronic intense pain is not responding to oral pain medications including opioids.

• Arthroscopy- Arthroscopy procedure is performed for diagnosis and also for treatment.
• Procedure- Procedure involves insertion of tubular camera and surgical instruments in shoulder joint following small incision under anesthesia.
• Camera and surgical Instruments are inserted through small incision in to shoulder joint. Small Incisions are made under sedation or anesthesia. Prior to incision local anesthesia is injected to numb skin and tissue over shoulder joint.
• Surgical instruments are advanced under camera (arthroscope) guidance.
• Instrument is directed to the diseased section of the joint.
• Necrotic tissue, fragments of soft tissue and cartilages are removed (debridement) by special equipment under direct vision while using arthroscope (camera).
• Tendon or ligamental tear and joint subluxation are treated using arthroscopic surgery.

• Diseased articulating cartilages covering humerus and glenoid socket is removed with proximal end of humerus.
• Surgery involves removal of head of humerus and inner surface of glenoid cavity.
• Proximal end of humerus is replaced with metal or plastic ball.
• Glenoid cavity cartilages are replaced with plastic or metal prosthesis.

• Anatomical position of ball and socket is reversed.
• The socket is placed over humerus and plastic or metal ball is placed over scapula to replaces glenoid cavity.
• Surgery helps to prevent deterioration of rotator cuff.
• Surgery is recommended to prevent symptoms caused by non-functioning rotator cuff.

• Glenoid cavity, articulating cartilage of glenoid cavity and glenoid socket of scapula is in normal functional shape.
• Head of humerus and cartilage covering head of humerus is degenerated and deteriorated.
• Surgery involves replacement of head of humerus with artificial metal or plastic head.

• Bleeding.
• Infection.
• Blood clots.
• Nerve Injury.

Also Read:

• What is Shoulder Joint Arthritis: Types, Signs, Symptoms, Treatment, Surgery, Recovery
• Shoulder Joint Osteoarthritis: Symptoms, Treatment- Conservative, PT, Surgery

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