When Do I Need a Shoulder Replacement?

Shoulder replacement surgery can be an extremely effective treatment for shoulder arthritis, but it is not usually the first step in treatment. The decision to have a shoulder replacement is based on how much your shoulder is affecting your quality of life, together with your examination and imaging findings.

What is shoulder arthritis?

The shoulder is a ball-and-socket joint. The ball at the top of the arm bone (humeral head) moves against the socket (glenoid). Both surfaces are normally covered with smooth cartilage, allowing the shoulder to move with very little friction.

With arthritis, this cartilage gradually wears away. As the joint becomes increasingly “bone-on-bone”, patients may develop pain, stiffness, grinding or catching sensations, and difficulty using the arm.

The most common reason for shoulder replacement is osteoarthritis, although replacement may also be considered for other conditions, including:

• Rotator cuff tear arthropathy
• Rheumatoid or inflammatory arthritis
• Some complex shoulder fractures
• Avascular necrosis of the humeral head
• Previous shoulder injuries resulting in arthritis
• Failed previous shoulder surgery

What are the signs that I may need a shoulder replacement?

There is no single symptom that means you definitely need surgery. Instead, I usually consider several factors.

1. Your shoulder hurts most days

Pain is generally the most important reason to consider shoulder replacement.

Early arthritis may cause pain mainly with strenuous activity. As arthritis progresses, pain can occur with increasingly simple activities such as reaching overhead, getting dressed, lifting objects or playing sport.

More advanced arthritis can cause pain at rest or at night, sometimes making it difficult to sleep.

2. Your shoulder is becoming increasingly stiff

Shoulder arthritis often causes progressive loss of movement.

You may notice difficulty:

• Reaching above your head
• Reaching behind your back
• Putting on a jacket or shirt
• Washing or brushing your hair
• Reaching into cupboards
• Performing work or sporting activities

For some patients, loss of movement becomes just as troublesome as the pain.

3. It is affecting your quality of life

An X-ray alone does not determine whether you need a shoulder replacement.

Some people have quite severe arthritis on an X-ray but relatively manageable symptoms. Others find that their shoulder significantly interferes with their work, sleep, exercise and everyday activities.

The important question is therefore not simply “How bad does my X-ray look?” but “How much is my shoulder affecting my life?”

4. Non-operative treatments are no longer working

Shoulder arthritis does not always require surgery.

Depending on your circumstances, treatment before considering replacement may include:

• Activity modification
• Simple pain medication or anti-inflammatory medication when appropriate
• Physiotherapy to maintain movement and strength
• Corticosteroid injections
• Modification of work, gym or sporting activities

These treatments cannot restore worn-out cartilage, but they can sometimes control symptoms for a considerable period.

If your symptoms remain acceptable, there is generally no need to rush into shoulder replacement surgery simply because arthritis is present on an X-ray.

How bad does the arthritis need to be?

Before recommending replacement, I would normally expect imaging to demonstrate significant structural damage to the shoulder joint that corresponds with your symptoms.

Standard shoulder X-rays provide a great deal of this information. A CT scan may also be obtained when planning surgery, particularly to assess the shape and amount of bone remaining in the socket.

However, we treat the patient rather than the X-ray. Severe arthritis on imaging does not automatically mean you require surgery.

Am I too young for a shoulder replacement?

There is no absolute age at which somebody becomes eligible for a shoulder replacement.

Age is important because artificial joints can eventually wear or loosen. A younger patient has more years in which this can occur and is generally more likely to require further surgery during their lifetime.

For this reason, in younger patients I carefully consider whether symptoms justify proceeding with replacement and whether there are reasonable alternatives.

Conversely, there is no strict upper age limit. General health, independence, symptoms and expected benefit from surgery are often more important than chronological age alone.

What type of shoulder replacement would I need?

There are several different types of shoulder replacement.

Anatomic total shoulder replacement

An anatomic shoulder replacement replaces the arthritic ball and socket while maintaining the shoulder’s normal anatomy.

It is particularly suitable for patients with shoulder arthritis who have a functioning rotator cuff and appropriate bone anatomy.

Reverse shoulder replacement

A reverse shoulder replacement changes the mechanics of the joint by placing a ball on the socket side and a socket on the arm side.

It was originally developed for patients with severe rotator cuff damage but is now used for a wider range of shoulder conditions. It is by far the most common type of shoulder replacement in Australia. 

It may be preferable when there is:

• A large or irreparable rotator cuff tear
• Significant deformity or bone loss
• Certain complex fractures
• Some failed previous shoulder operations
• Other situations in which an anatomic replacement may be less reliable

Partial shoulder replacement

In selected patients, replacing only the humeral head may be considered. This is much less commonly performed for routine osteoarthritis because, when both sides of the joint are significantly affected, replacing both surfaces generally provides more predictable pain relief.

How successful is shoulder replacement?

Modern shoulder replacement is generally a very successful operation when performed for the appropriate indication.

The main aims are to:

Reduce pain, improve movement and allow you to use your arm more comfortably for everyday activities.

Most patients experience substantial improvement in pain and function. However, a replacement shoulder is not identical to a normal shoulder, and the degree of movement and strength achieved varies between patients.

Recovery also takes time. Improvement continues for many months after surgery, and rehabilitation is an important part of achieving the best possible result.

What are the risks?

As with any major operation, shoulder replacement has potential risks. These include infection, stiffness, bleeding, nerve or blood vessel injury, fracture, instability or dislocation, problems with the rotator cuff, loosening or wear of the implants, and the possibility of further surgery in the future.

The specific risks vary depending on your age, general health, shoulder anatomy and the type of replacement being performed.

These risks need to be balanced against the severity of your current symptoms and the potential improvement in your quality of life.

So, when is the right time?

There is rarely a precise point at which you suddenly “need” a shoulder replacement.

For most patients, the right time is when:

You have significant shoulder arthritis, your pain and stiffness are interfering with the things that matter to you, non-operative treatment is no longer providing acceptable relief, and the expected benefits of surgery outweigh its risks.

Importantly, the decision is usually yours. Shoulder replacement for arthritis is generally an elective operation, which means you can discuss the options with your surgeon and decide when — or whether — surgery is appropriate for you.

If shoulder pain is becoming an increasing problem, an assessment with a shoulder surgeon can help determine the cause of your symptoms and whether non-operative treatment, another type of surgery, or shoulder replacement is the most appropriate option.

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