​​Many people have shoulder pain at some point. Usually, it goes away after a while. But when shoulder pain sticks around, it can indicate a more serious issue, like arthritis.

Although conservative treatments like nonsteroidal anti-inflammatory drugs (NSAIDs) and sometimes physical therapy can help relieve shoulder pain, more severe cases may require surgery. But how do you know when you need surgery? And, if you have surgery, when can you expect to return to your normal activities?

Orthopedic surgeons Paul Favorito, MD, and Namdar Kazemi, MD, and physical therapist Nancy Kleespies, PT, want you to know common causes of shoulder pain and nonsurgical and surgical approaches to treating your pain.

What is shoulder arthritis?

Arthritis means loss or damaged cartilage of a joint. Normal cartilage should be smooth and shiny. A lack of cartilage exposes bones to direct wear and tear, causing pain and swelling.

“The best way to understand arthritis, I think, is this: Just take a nonstick pan and use it for a long time or take some Brillo or steel wool to it. You're wearing off the surface," says Dr. Favorito. “The [pan] underneath is still present, but the nonstick coating is now gone."

Several factors can cause arthritis. The most common cause of arthritis is osteoarthritis or wear and tear arthritis due to aging. It accounts for about 60 percent of arthritis cases. Inflammatory arthritis like rheumatoid or psoriatic arthritis is responsible for about 30 percent of arthritis cases.

Other causes of shoulder pain and arthritis include:

• Avascular necrosis—This disease results from a temporary or permanent loss of blood supply to the bone. It often occurs in people who have taken steroids in large doses. Alcohol abuse and sickle cell disease can also cause avascular necrosis.
  
• Post-traumatic arthritis—Arthritis can occur after a shoulder injury such as a shoulder fracture after a fall.

Dr. Favorito says patients often seek treatment for shoulder pain because they can't get comfortable while sleeping. Others may lose motion or feel a grinding or popping in their shoulder. However, those symptoms don't always mean arthritis. They can also signal a rotator cuff tear​ or impingement (when the tendon rubs against the tip of the shoulder).

How do doctors diagnose shoulder arthritis?

Doctors combine the results from many tools to help diagnose shoulder arthritis:

• The patient's history—Medical history aids surgeons in decision-making.
  
• A physical exam—During an exam, your surgeon will evaluate your range of motion, strength and rotator cuff function and determine possible sources of your shoulder pain.
• X-ray—These imaging tests allow the surgeon to see the location of arthritis and any damage. Different types of arthritis will appear differently on the X-ray.

Dr. Favorito says he also likes to get information about recreational activities and employment and if the patient has weakness or limited motion in their shoulder. He also asks what the patient's goals are for treatment.

“We try to set expectations, so we have realistic ideas about what you'll be able to accomplish after treatment," he says.

Conservative approaches to treating shoulder pain

If you have arthritis that causes shoulder pain, you can get relief with over-the-counter anti-inflammatory medications such as Motrin and Aleve. You can also modify your activities. Others have found relief with glucosamine and other cartilage supplements.

Physical therapy is another conservative approach to treating shoulder pain.

“In physical therapy, we see patients with restricted mobility pain or pain when they lay on their side," Kleespies says. “Radiographs—a type of X-ray—may not show severe osteoarthritis, so first we see if we can make some improvement with physical therapy."

Having a rounded posture can also change how your shoulders work, so physical therapy options may include:

• Improving your posture with stretching
• Improving mobility and reducing stiffness with range of motion activities
• Strengthening the shoulder muscles with exercises

If those approaches don't improve your function and relieve pain, or if you have a lot of arthritis in the joint, your doctor may refer you for a total shoulder replacement.

How to know if you're a candidate for shoulder replacement

If conservative treatments do not relieve your shoulder pain, you may be a candidate for shoulder replacement. But you should keep in mind a few considerations.

“You have to have satisfactory bone stock the surgeon can put the implants on," Dr. Kazemi says. Doctors evaluate bone stock with imaging exams, such as X-rays. “And you need to have functioning muscles and nerves in the shoulder." Patients also need to stick to their after-surgery care plan.

Types of shoulder replacement

Depending on your needs, you may be a candidate for different types of shoulder replacement.

In a conventional or anatomic shoulder replacement, a surgeon replaces the ball and the socket joint and re-creates the shoulder anatomy. A surgeon can perform a hemiarthroplasty (partial shoulder replacement), replacing the ball with a metal ball, but leaving the socket intact. Or, in a total (anatomic) shoulder replacement, a surgeon replaces the ball with a metal ball and the socket with plastic.

Reverse shoulder replacement is a newer type of replacement that reverses the typical ball and socket structure. The surgeon attaches an artificial ball to the socket and attaches an artificial socket to the top of the arm bone.

What to expect after shoulder replacement surgery

You and your doctor will discuss a plan of care in your first appointment after your surgery and update it after your surgery. You'll usually have two physical therapy visits each week for 10 weeks, although it will vary depending on your specific needs.

In the early days after your surgery, you will only remove your sling to shower or to perform physical therapy. If you do your exercises and follow your care plan, you can usually return to typical activities around 12 weeks after your surgery. But, it is important to have realistic expectations about the recovery process.

​“It can take between six months and a year to achieve maximum improvement," Dr. Favorito says. “The first six weeks are the toughest, but by three months, most people feel quite a bit better after shoulder replacement."