A painful, grinding shoulder that limits overhead reach, disrupts sleep, and makes daily tasks a calculation — shoulder arthritis is treatable. Dr. R. David Graham at Jacksonville Orthopaedic Institute manages shoulder arthritis from injection therapy through total shoulder arthroplasty, with the procedure matched precisely to each patient's rotator cuff status, age, and activity demands.
The single most important factor in choosing between anatomic TSA and reverse TSA is the rotator cuff. An anatomic replacement requires a functional cuff to work correctly; a reverse replacement does not. Getting that assessment right before surgery determines whether the replacement will function the way the patient expects.
Understanding Shoulder Arthritis
Shoulder arthritis develops through several pathways. The cause matters for surgical planning — particularly because rotator cuff status varies significantly across different arthritic patterns.
Glenohumeral OA is the gradual wearing away of the cartilage surfaces of the humeral head and glenoid from cumulative use. The posterior glenoid is typically the first to erode, producing the characteristic posterior glenoid wear pattern seen on CT. The rotator cuff is usually intact in primary OA — which is why most primary OA patients are candidates for anatomic TSA, provided age and activity demands support that choice.
Prior shoulder fractures — proximal humerus fractures, glenoid fractures — and shoulder dislocations can damage the articular surfaces directly or create joint incongruity that accelerates wear over years. Post-traumatic arthritis may produce unusual bone anatomy that complicates implant placement, particularly when prior hardware is present or the glenoid is significantly deformed. The rotator cuff may or may not be intact depending on the injury history.
RA affects the glenohumeral joint through synovial proliferation and inflammatory cytokine-mediated cartilage destruction, typically producing centralized glenoid erosion — the opposite of the posterior erosion pattern in OA. Rotator cuff integrity varies; RA can produce rotator cuff tears through chronic synovitis weakening the tendons. Rheumatologist optimization is required before surgery, and the choice between TSA and RTSA depends on cuff status.
Cuff tear arthropathy (CTA) develops when a massive, chronic rotator cuff tear — one that has gone untreated for years — allows the humeral head to migrate superiorly out of the glenoid socket, grinding against the acromion and destroying the glenohumeral cartilage. The pattern of arthritis is distinctive: superior humeral head migration, acetabularization of the acromion, and femoralization of the humeral head. By definition, the rotator cuff is absent or non-functional. RTSA is the required treatment — anatomic TSA cannot function without a cuff.
Avascular necrosis of the humeral head occurs when blood supply is disrupted — from proximal humerus fractures, long-term corticosteroid use, alcohol use disorder, sickle cell disease, or other systemic causes — causing the bone to die and the humeral head to collapse. Early AVN before collapse may be monitored or managed with injections. Once collapse has occurred and the articular surface is destroyed, shoulder arthroplasty is the treatment of choice. The rotator cuff is usually intact in AVN, making anatomic TSA the typical choice.
Gout and CPPD can affect the shoulder joint, producing episodic inflammatory arthritis and cumulative cartilage damage. Psoriatic arthritis and other seronegative spondyloarthropathies also occasionally affect the glenohumeral joint. Management of the underlying systemic condition is coordinated with the treating rheumatologist alongside any surgical planning. Injection therapy is the primary non-operative management tool for all inflammatory causes.
The Key Clinical Question
Three factors — rotator cuff status, age, and activity demands — are weighed together. Cuff status is the most critical: a deficient cuff makes anatomic TSA mechanically unsound regardless of other factors.
Primary OA, AVN, or post-traumatic arthritis with a functional rotator cuff. Patient is relatively younger or has higher physical demands — work, sport, or lifestyle — and wants to maximize activity potential from the reconstruction.
Reproduces normal shoulder anatomy. Requires an intact, functional rotator cuff to power normal mechanics. In younger, higher-demand patients with good cuff tissue, TSA provides the most anatomically correct motion — particularly internal rotation and the fine motor arcs of shoulder use. Longer established track record in this population.
→ Intact cuff + younger/higher demand = anatomic TSA generally preferred, with nuanced individual discussion.
Primary OA, AVN, or post-traumatic arthritis with an intact cuff. Patient is older or has lower activity demands. The goal is durable pain relief and functional motion for daily activities rather than high-load sport or manual work.
For older, lower-demand patients with intact cuffs, both TSA and RTSA can produce excellent outcomes. RTSA has become increasingly favored in this group given its more forgiving mechanics, lower dependence on subscapularis integrity, and excellent track record for pain relief and functional elevation. The conversation between TSA and RTSA in this group is a genuine discussion based on individual anatomy and goals.
→ Intact cuff + older/lower demand = TSA or RTSA — both viable; decision made with the patient.
Rotator cuff tear arthropathy, or any arthritic pattern where the rotator cuff is absent, irreparable, or severely deficient. Includes massive chronic tears with arthritic change, RA with cuff destruction, and revision cases where prior surgery has compromised cuff tissue.
When the rotator cuff cannot be relied upon, anatomic TSA will fail — the cuff is required to center the humeral head and power normal mechanics. RTSA's reversed geometry shifts the center of rotation medially and inferiorly, allowing the deltoid muscle to power shoulder elevation without any cuff contribution. For CTA patients, RTSA is the only arthroplasty option that reliably restores functional overhead motion.
→ Deficient cuff / CTA = RTSA is required. Anatomic TSA is not appropriate in this setting.
Recognizing Shoulder Arthritis
Shoulder arthritis shares several symptoms with rotator cuff disease — the distinction matters because the treatments differ. Pain with motion and the quality of the grinding sensation are the most diagnostically useful features.
The characteristic sensation of glenohumeral arthritis is a deep, grinding or catching pain felt within the shoulder with active motion — reaching overhead, reaching behind the back, or rotating the arm. Patients often describe feeling or hearing grinding or crunching. This differs from the lateral shoulder pain of rotator cuff disease, which is typically felt more at the deltoid rather than deep within the joint.
Stiffness is a prominent feature — particularly loss of external rotation and internal rotation behind the back. The combination of pain and stiffness makes reaching overhead, dressing, grooming, and many work tasks increasingly difficult. In advanced arthritis, shoulder motion may be severely restricted in all planes.
Night pain is one of the most functionally disruptive symptoms of shoulder arthritis. Patients often cannot sleep on the affected side, and position-related pain wakes them repeatedly. Night pain that is severe enough to regularly interrupt sleep is one of the cleaner indications that injection management is no longer adequate and that a surgical conversation is appropriate.
Pain inhibition reduces effective shoulder strength — the shoulder guards against painful arc loading. In CTA specifically, rotator cuff failure produces true functional weakness in elevation and external rotation that is distinct from pain-related inhibition. The pattern of weakness helps distinguish CTA from primary OA at clinical evaluation.
Advanced arthritis and chronic rotator cuff tear arthropathy can produce visible asymmetry — flattening of the deltoid contour from muscle atrophy, prominence of the acromioclavicular joint, or superior humeral head migration visible at rest in severe CTA. These visible changes help confirm disease severity at evaluation.
Overhead activity, lifting, and reaching precipitate pain flares that can last hours to days after the provoking activity. Patients begin avoiding activities that consistently cause flares — reducing their activity level progressively as the arthritis worsens. When the activities being avoided include basic daily tasks, the functional impact crosses the threshold for a surgical evaluation conversation.
Non-Surgical Management
Cortisone and PRP are both offered for shoulder arthritis. Many patients manage well with periodic injections for years before the surgical conversation becomes necessary.
A targeted cortisone injection into the glenohumeral joint reduces the inflammatory component of arthritic pain — particularly effective during active flares in primary OA, RA, and inflammatory arthritis. The injection is placed precisely into the glenohumeral joint space, usually from a posterior approach. Relief typically lasts weeks to months depending on disease severity.
In Dr. Graham's experience, intra-articular cortisone provides meaningful relief in the majority of shoulder arthritis patients, at least initially. Patients who find injection relief shortening significantly — needing repeat injections more frequently with shorter intervals of benefit — are approaching the point where a surgical conversation is appropriate.
Platelet-Rich Plasma delivers concentrated growth factors into the glenohumeral joint, targeting both the inflammatory cascade and the degenerative biology of arthritic cartilage. It is most relevant for early-to-moderate arthritis where meaningful cartilage surface remains and biological stimulation is likely to produce a response. For patients with CTA or end-stage bone-on-bone arthritis, PRP has little to offer in the glenohumeral joint itself.
PRP is offered alongside cortisone as an alternative or complement — for patients who want to reduce steroid exposure, who have not responded adequately to cortisone, or who want a biologically targeted approach while managing the arthritis non-operatively. PRP is cash-pay and not covered by insurance.
Regenerative Option
The glenohumeral joint — particularly in early primary OA and post-traumatic arthritis — often retains meaningful cartilage through much of the joint surface even as the posterior glenoid begins to wear. In this stage, PRP's biological action on the remaining cartilage and joint environment is most meaningful. PRP can reduce the inflammatory component of arthritic pain, modulate the synovial environment, and support cartilage health during the years of non-operative management before arthroplasty becomes necessary.
For patients with CTA or advanced end-stage arthritis with bone-on-bone changes across the entire glenohumeral joint, PRP has limited utility — there is insufficient remaining tissue to respond to biological stimulation, and arthroplasty is the appropriate conversation. The candidacy discussion at your appointment includes an honest assessment of where each patient sits on this spectrum.
PRP is offered alongside cortisone as part of Dr. Graham's shoulder arthritis management toolkit. Some patients use cortisone for acute flares and PRP periodically as a maintenance injection — a reasonable strategy for managing the condition non-operatively over years. PRP is cash-pay and not covered by insurance.
Surgical Treatment
Two procedures, one principle: the implant design must match the patient's rotator cuff status. An anatomic replacement in a patient without a functional cuff will fail. A reverse replacement in a patient with an intact cuff works but gives up some motion arcs that the anatomic design preserves better.
Anatomic TSA reproduces the normal ball-and-socket geometry of the glenohumeral joint — a humeral head prosthesis replacing the arthritic humeral surface, and a glenoid component replacing the arthritic socket. The mechanics of the reconstructed shoulder depend entirely on the rotator cuff to center the humeral head in the glenoid and power normal shoulder motion.
For patients with an intact, functional cuff — typically primary OA, AVN, and post-traumatic arthritis — anatomic TSA produces excellent long-term pain relief and functional motion, including the internal rotation arcs that are somewhat limited after RTSA. Younger, higher-demand patients in particular benefit from the more anatomic mechanics.
→ Requires intact rotator cuff. Generally preferred for younger/higher-demand patients. Not appropriate when cuff is deficient.
RTSA inverts the ball-and-socket geometry — placing a hemispherical ball (glenosphere) on the glenoid side and a concave socket on the humeral side. This reversal shifts the center of rotation medially and inferiorly, dramatically increasing the moment arm of the deltoid muscle. The deltoid can now power shoulder elevation without any rotator cuff contribution.
Required for CTA and any situation where the cuff is absent or irreparable. Increasingly used for older patients with intact cuffs given its reliable pain relief, durable mechanics, and less dependence on subscapularis healing. Trade-off: some internal rotation limitation compared to anatomic TSA, but typically not functionally significant for most patients.
→ The only appropriate arthroplasty for CTA and cuff-deficient shoulders. Also used for selected older/lower-demand patients with intact cuffs.
Performed at Baptist Beaches Hospital or Horizon Surgery Center. Regional block (interscalene or supraclavicular brachial plexus) with sedation or general anesthesia. The patient is positioned in the beach-chair position, which provides optimal access to the shoulder and allows intraoperative range-of-motion assessment. Operative time is typically 90 to 120 minutes.
A longitudinal incision in the deltopectoral groove — between the deltoid and pectoralis major — provides the standard approach to the glenohumeral joint. This is a truly internervous approach that does not require splitting any muscle bellies and minimizes surgical trauma to the surrounding musculature. The subscapularis is addressed next — either taken down and repaired (anatomic TSA) or managed according to technique requirements (RTSA).
The arthritic humeral head is removed and the humeral canal is prepared for the stem component. The glenoid is prepared for the glenoid component (anatomic TSA) or the baseplate and glenosphere (RTSA). In post-traumatic or revision cases, prior hardware may need to be removed and bone defects addressed with grafting before implant placement. Glenoid version correction is performed when significant retroversion (posterior wear) is present.
Trial components are placed and the shoulder is reduced to assess stability, range of motion, and soft tissue tension. Component sizing, offset, and version are confirmed before final implants are cemented or press-fit in place. For RTSA, glenosphere position and inferior tilt are critical technical factors that determine impingement-free motion.
For anatomic TSA, the subscapularis is repaired back to its footprint on the lesser tuberosity — a critical step whose integrity determines the success of postoperative internal rotation and anterior stability. The repair must be protected during early recovery. Wound closure and a shoulder immobilizer are applied. The patient goes home the same day or after an overnight stay.
Before shoulder arthroplasty in any patient with rheumatoid or inflammatory arthritis, Dr. Graham requires coordination with the patient's rheumatologist. Biologic medications — including TNF inhibitors and IL-6 inhibitors — are typically held perioperatively to reduce wound healing complications and infection risk. The rheumatologist manages the specific hold and restart timing based on each medication's pharmacokinetics.
RA patients often have medialized glenoid erosion that complicates component placement, compromised bone quality that affects fixation strategy, and rotator cuff status that varies — all of which are assessed preoperatively to plan the most appropriate reconstruction. Dr. Graham coordinates with the treating rheumatologist from preoperative optimization through postoperative disease management.
Recovery
Shoulder arthroplasty recovery is measured in months, not weeks. The specific timeline varies slightly between anatomic TSA and RTSA — primarily because of the subscapularis repair protection required after anatomic TSA.
Shoulder sling worn at all times except during exercises and hygiene. Passive range-of-motion exercises begin within the first week under therapist guidance. After anatomic TSA: strict internal rotation and active use restrictions to protect the subscapularis repair. After RTSA: fewer restrictions on active use, but elevation precautions apply.
Sling discontinued. Active range of motion and progressive strengthening under formal therapy. After anatomic TSA, the subscapularis repair is now healed sufficiently for active internal rotation to begin. Overhead reaching goals are typically achievable by 8 to 12 weeks.
Progressive strengthening through formal therapy. Most patients are fully functional for daily activities by 3 months. Return to golf, swimming, and recreational sport typically occurs in the 4 to 6 month range with therapist clearance.
In Dr. Graham's experience, approximately one year is required to reach the full functional result of shoulder arthroplasty. Pain relief comes much earlier — often within weeks — but strength, endurance, and fine motion arcs continue improving through the full year. Patience with the process produces significantly better outcomes.
"I had been unable to sleep on my shoulder for two years. Dr. Graham was honest about what the surgery could and couldn't do, and set realistic expectations about recovery. Within three months I was sleeping through the night for the first time in years."
Amanda · Shoulder Surgery · Verified Google Review ★ 5/5
Common Questions