Arthritis in the Young Athlete
Glenohumeral osteoarthritis is a rare but potentially debilitating condition in young athletes. At present there are a number of treatment options available to the young arthritic sportsperson. In this article I discuss the common aetiologies and presentation of osteoarthritis and evaluate the treatment options available. Contributing reasons for the treatment chosen include; surgeon's experience, patient factors (chiefly age and activity level) and pathological features i.e. the type of arthritic disorder and the amount of bone affected. Treatment follows a common pattern; initially a period of unsuccessful conservative therapy followed by subsequent need for surgery of which there are many options: arthroscopy, biological resurfacing of the glenoid, humeral head resurfacing, arthrodesis, hemiarthroplasty, and total shoulder arthroplasty. Humeral head resurfacing has shown good initial results although future long term study of its outcomes in comparison to alternative surgical options is required. From the literature reviewed I have therefore concluded that currently the most effective treatment is to evaluate each case individually.
The term osteoarthritis is derived from the three Greek words meaning bone, joint and inflammation. Traditionally thought of as a disease of progressive 'wear and tear', its key pathological changes of local loss of cartilage, bone remodeling and osteophyte formation instead support the view that it is a dynamic repair process (1) gone wrong (see figure 1). These structural changes can significantly affect a patient's quality of life. The common picture of arthritis of the shoulder is one of pain and stiffness and so of decreased capacity.
Osteoarthritis of the glenohumeral joint is an uncommon yet debilitating problem for any young athlete. Its diagnosis and treatment in such an individual presents a great challenge to any consulting physician as at present it is a condition without an ideal solution.
Osteoarthritis can be classified as either primary implying an unknown causative agent or secondary in which the pathological mechanism has been established. Primary osteoarthritis is primarily an age-related disorder associated with repetitive stress on a normal joint. In contrast secondary osteoarthritis has an underlying cause such as trauma, infection, ischaemia or inflammation.
Primary osteoarthritis is less common than secondary in young athletes. Athletes at an increased risk are those involved in repetitive overhead activities, such as cricketers, weightlifters, and in all racquet sport players. Further classifications can be made as below:
Secondary degenerative joint disease
Articular destruction as a consequence of previous trauma or shoulder surgery may be referred to as secondary degenerative arthritis. Patients are often young with a long standing history of previous unsuccessful surgery. This is the commonest type of arthritis in athletes.
Describes arthritis caused by previous surgical treatment for recurrent shoulder instability. This typically occurs in patents whose anterior capsule has been excessively tightened, thereby limiting shoulder movement principally external rotation, such as in a Putti-Platt repair (5). This surfeit tightening causes obligate posterior translation during external rotation resulting in posterior glenoid erosion and capsular damage (3, 4). These patients are often young and athletic with a desire to continue participation at a high level, and can therefore often very challenging to treat.
Osteonecrosis, also known as avascular necrosis, can be subdivided into two categories; traumatic and atraumatic. Traumatic osteonecrosis is caused by disruption of the vascular supply to the humeral head normally following multiple fractures. Atraumatic osteonecrosis may be secondary to separate pathology or may be idiopathic. Common associated conditions include smoking, steroid and alcohol use and haematological disorders e.g. sickle cell anaemia and thalassaemia. Patients are normally younger and may present with few diagnostic indicators besides pain (6).
Inflammatory athritides form the second largest category of glenohumeral arthritis, but are much less common in athletes. The prototypical disease is rheumatoid arthritis. Other inflammatory disease causes include gout, systemic lupus erythematosus (SLE), psoriatic arthritis and ankylosing spondylitis. The effects of such conditions may be unique to the gelenohumeral joint or may occur in other joints of the upper limb for example the elbow or the wrist. Diagnostic indicators include; cervical spine pathology, presence of a cuff tear or bilateral glenohumeral involvement (3). Consequently similar findings should indicate further investigation for inflammatory markers. The interventional prognosis for these individuals is generally poorer compared to other arthritic causes, owing to long standing steroid use and worse general health (4).
Glenohumeral septic arthritis is uncommon and usually only transpires in immunocompromised patients. Eryrthema and warmth in the region surrounding the shoulder are highly suspicious. Diagnosis is confirmed by aspiration, and treatment usually consists of irrigation and debridement, often arthroscopically. If severe, glenohumeral arthrodesis may be required.
Evaluating the Patient
The typical history of a patient suffering from glenohumeral osteoarthritis is of progressive pain and stiffness. Frequent arthritic complaints are pain that intensifies with use and interferes with sleep, especially when sleeping upon one side. Patients may also complain of crepitus on movement and inability to perform day to day tasks involving shoulder rotation such as drying one's hair or scratching one's back.
Pertinent history taking should include questions regarding previous trauma, steroid use, family history, prior surgery, and any received treatment along with its effectiveness or lack thereof (4). Most importantly the clinician must establish the patient's own expectations and concerns about subsequent performance levels. Upon consulting the athlete a thorough discussion of the type of sport played, their level of performance as well as any intentions to return to competition should all be discussed (7).
Finally, it is important to realise that any shoulder pathology may co-exist with other medical conditions. This should not be ignored as these may affect the patient's level of disability and potential for future recovery.
Initial examination of the shoulder should inspect the upper torso for any signs of muscle atrophy and asymmetry. Careful assessment of the cervical spine should be undertaken as pathology in this area can cause referred shoulder pain, which may be misleading. Any positive findings should be worked up and treated prior to proceeding further down the care pathway.
Shoulder mobility should be recorded under both active and passive motion. This usually reveals pain and a restricted range of movement, often accompanied by crepitus. Accurate determination of painful/ restrictive movement is useful in establishing a diagnosis and determining future treatment. Limited external rotation is a common finding in osteoarthritis and may require adjunctive therapy e.g. elongation of the anterior capsule and subscapularis at the time of surgical intervention (8).
The integrity and strength of the rotator cuff muscles should also be assessed, as this may preclude certain treatments i.e. total shoulder arthroplasty. This may however be difficult due to pain upon movement. Unlike in rheumatoid arthritis, most patients with osteoarthritis have preserved or only slightly diminished strength indicating only mild if any rotator cuff dysfunction.
The radiographical features of osteoarthritis of the shoulder are quite typical and help establish a diagnosis and clinical plan. The three preferred radiographical projections of the glenohumeral joint are a true anteroposterior view, a scapular outlet view and an axillary view (see figure 2) (7, 8, 9).
The radiological features of glenohumeral osteoarthritis are characteristic of those found anywhere else in the body, following the classical quartet of: joint space narrowing, osteophyte development, subchondral sclerosis and cyst formation (10, 11).
Further imaging modalities are not always necessary, but computer tomography is often obtained by surgeons to aid preoperative planning and to assess the patient's bone stock and quality. This can be useful as it allows accurate estimation of glenoid version and provides a more precise outline of any osteophytes.
Magnetic Resonance Imaging
This imaging technique has limited use in the evaluation of patients with osteoarthritis. It is only really indicated when there is a suspected rotator cuff tear, which may preclude future management e.g. a major tear may rule out total shoulder replacement (11).
There is wide variability in patient presentation and level of degenerative glenohumeral disease. One patient's set of X-rays may show severe destructive changes but they may be able to function relatively well if their demands are low. On the other hand, another patient's may show only mild cartilage loss but find themselves substantially incapacitated by pain. Given this inconsistency, the success of non-operative therapy cannot be based upon radiological findings but rather by the patient's own views of their functional capabilities. Recognising that the most common arthritides are progressive in nature, much of the basis of conservative management is based on maintenance as well as improvement. Counseling the patient as to the nature and probable course of their disease is essential so that un-realistic expectations are not a barrier to future care and recovery.
The foundations of conservative management in glenohumeral osteoarthritis include: 1) activity modification, 2) medication for pain relief, and 3) a self-conducted physiotherapy program. Activity modification is a commonsense approach, whereby the patient limits performing symptomatic tasks. Activities such as engaging in racquet sports should be discouraged, unless tolerable to the patient. This may seem like a very basic request however with such a big emphasis these days on continued participation in sports many athletes are unwilling to forego playing despite involving pain.
The success of medications in treating osteoarthritis is variable. Nonsteroidal anti-inflammatory medication is often given to relieve symptomatic pain but there is no evidence of it having any affect on the actual course of the disease. It is widely suggested that opiates be avoided due to their potential for dependence. Oral glucosamine and chondroitin supplementation may be beneficial, although data regarding their efficacy is scarce despite widespread over-the-counter use.
Intra-articular corticosteroid injections may provide temporary symptomatic relief in recalcitrant cases. Although repeated injections are discouraged due to their catabolic effect on articular tissue and subsequently should not be used as a mainstay of treatment (4).
Intra-articular hyaluronan injections have been shown to have longer beneficial effects than corticosteroids, with much less side effects. However, these are more costly.
Physiotherapy typically begins with gentle range of movement exercises to preserve and if possible improve range of motion, and to strengthen the rotator cuff muscles to maintain glenohumeral stability (11).
Arthroscopic debridement and microfracture has proved a reasonable approach for treating early glenohumeral osteoarthritis which has failed to respond to non-operative management (12, 13). During arthroscopy careful examination of the joint and level of cartilaginous destruction should be made and unstable fragments and osteophytes removed. To slow further arthritic progression as much residual cartilage as possible should be retained (4). This treatment has the additional benefit that often the athlete will have associated underlying conditions that could also be addressed at the time of arthroscopy. Associated procedures might include repair of labral/rotator cuff pathology, subacromial decompression and for any associated acromioclavicular joint problems (14).
Arthroscopic debridement is principally a temporary treatment measure for shoulder arthritis, and its results depend greatly on the severity of the disease. It is however a valid option for younger athletic patients, in whom more definitive procedures such as arthroplasty may be contraindicated due to risk of component deterioration and subsequent failure.
Shoulder Replacement (Arthroplasty)
Patients are typically considered for arthroplasty when their pain is refractory to non-operative measures and/or previous non-arthroplasty options have failed. Arthroplasty offers somewhat reliable pain relief and should be the main determinant for surgical intervention in comparison to recovery of strength and function.
Discouraging factors for replacement include mild to moderate arthritic changes, young patient age, high functional demands, lack of glenoid bone stock and rotator cuff deficiency. The potential for failure in these patients is generally attributable to mechanical loosening of the glenoid component or due to wear related destruction of the polyethylene element (15). However, with newer resurfacing prostheses and biological glenoid resurfacing the risks of failure may be lower.
When consulting the patient with regard to prosthetic reconstruction realistic expectations must be set. The type of arthroplasty chosen must take into account a variety of factors not just the diagnosis. Patient factors (e.g. age and desire to return to high activity levels) as well as pathological features (insufficient bone stock, cuff tearing etc) must all be considered. Studies by Lo et al (16) and Sperling et al (17) comparing the follow up of hemiarthroplasty to total shoulder arthroplasty have shown no significant difference in quality of life outcome between the two procedures.
Hemiarthroplasty involves prosthetic reconstruction of the proximal humerus without resurfacing the glenoid, resulting in metal on bone articulation. It may be used as an alternative to total shoulder arthroplasty for the treatment of osteoarthritis and is the treatment of choice for cases of cuff tear arthropathy (18). In the instance of rotator cuff insufficiency and proximal humeral head translation hemiarthroplasty should be performed.
Fortunately, complications of shoulder arthroplasty are rare. The most common complaint is joint instability. One reason for instability will be technical error resulting from improper implant sizing or glenoid version. This can typically be amended by subsequent revision surgery. Another complication associated with total shoulder arthroplasty is glenoid component loosening. A strong correlation between loosening and the presence of a full-thickness cuff tear has been identified, thus glenoid implantation is contraindicated in such circumstances. Other rarer problems include rotator cuff deficiency usually due to subscapularis rupture, periprosthetic fracture, thromboembolic event and of course infection (3, 19).
Cementless Humeral Head Resurfacing
Humeral head resurfacing is a relatively simple technique that provides a valid alternative to hemiarthroplasty, particularly in younger patients. The procedure utilizes a pegged metal cap, usually made of cobalt chromium to resurface the head of the humerus. Initially humeral head resurfacing was carried out alongside glenoid component placement however studies by Levy and Copeland (20, 21) have shown that outcomes of resurfacing alone are just as good. With resurfacing, normal anatomy is maintained therefore potential errors in humeral head height, glenoid version and alignment associated with stem placement are avoided (19). The main contraindication to using resurfacing implants is inadequate proximal humeral bone quality. This form of surgery is less invasive than traditional shoulder replacement and therefore recovery is typically much faster. Insertion of a surfacing implant can help prolong or avoid altogether the need for future joint replacement. It is therefore an attractive option for young athletes in whom undergoing arthroplasty at an early age carry a greater risk of future revision.
Biological resurfacing of the glenoid
Biological resurfacing provides an alternative to the traditional polyethylene component placement of a total glenohumeral arthroplasty. A variety of biological agents can be used to resurface the glenoid: the two most common being autogenous fascia lata and Achilles tendon allograft. A recent 15 year follow up study of thirty six patients by Krishnan et al (22) has showed encouraging results with this method. They concluded that hemiarthroplasty combined with biological resurfacing provides similar pain relief to that of total shoulder replacement and recommended Achilles tendon allograft as their preferred surfacing material. This technique allows glenoid deformity to be addressed without prosthetic component placement, which is attractive for young patients for whom the likelihood of revision is higher.
This technique can also be done arthroscopically, although this is not common practice yet (24).
Glenohumeral arthrodesis is a fairly crude technique involving fusion of the humeral head to glenoid and acromion, thereby relying solely on scapulothoracic rotation to move the upper limb. Nowadays, it is rarely employed as modern forms of arthroplasty are so good and reasons for not being amenable to replacement surgery are very limited. Indications for joint fusion include severe septic arthritis and previous failed joint reconstruction with severe bone loss. Complications of this surgery include infection, nerve injury, and subsequent inability to perform activities of daily living due to decreased range of motion (23).
Attempts at conservative management should always be made initially as any surgery carries risk from both the procedure itself and of revision in the future. Trial and exhaustion of various conservative treatment options should therefore be undertaken before surgical consideration. In terms of which surgical treatment is most appropriate, each patient's case should be assessed on its own merits (functional demands, type of arthritis, amount of bone stock etc). Patients with only minor arthritic changes may benefit from arthroscopic treatment initially whereas those with extensive damage may necessitate total arthroplasty.
In individuals suffering from advanced osteoarthritis there is much to be said for less invasive techniques such as cementless resurfacing of the glenoid. It is a less destructive procedure than hemi- or total shoulder arthroplasty preserving more natural bone and requiring no stem implantation. These factors have several advantages; 1) by avoiding stem placement problems such as periprosthetic fracture and removal of cement fixation in the case of revision are avoided, and 2) in the procedure only limited bone is excised therefore if appropriate future total shoulder arthroplasty can still be performed.
Despite good initial results a long term randomized study comparing cementless humeral head arthroplasty to stemmed hemiarthroplasty and total shoulder arthroplasty is required if a conclusion to the optimal treatment of young arthritic athletes is to be reached.
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