Articular cartilage, or joint cartilage, lines the ends of our bones. It is a smooth and sturdy surface enabling motion and painless weight bearing. Typically the end of the bone lined by cartilage sees very little stress due to the unique load sharing characteristics of cartilage. Chondromalacia, or bad cartilage, refers to the wearing of the articular, or joint, cartilage. Similar to roadways, wear can range from cracks in the pavement (relatively minor, but potentially serious with time) to potholes (serious). The complete erosion of the cartilage leads to exposed bone. This is arthritis. As our cartilage thins, the supporting bone sees an increased amount of stress. Our bone often will have a haphazard response to this stress creating an inflammatory response causing pain and swelling. Figure One depicts a normal shoulder with smooth white, articular or joint cartilage lining the humeral head and
glenoid. Figure Two depicts a shoulder with an increasing amount of cartilage wear. Often the development of chondromalacia is silent. However, issues related to chondromalacia often cause disability and prompt medical evaluation. Symptoms may range from discomfort with changes of weather, stiffness and even loss of motion, pain with activity, and night pain.
Figure One: A normal appearing shoulder with pristine cartilage of the humerus and socket
Figure Two: A shoulder with substantial cartilage wear.
There are many different treatment options for chondromalacia.
Nonoperative treatments for chondromalacia include:
1) anti-inflammatory medications (ibuprofen (e.g. advil); naproxen (e.g. aleve); celecoxib (e.g. Celebrex)
2) physical therapy
3) glucosamine and chondroitin sulfate
4) steroid injections
5) activity modification (avoidance of aggressive weight lifting)
Arthroscopy can play a role in certain situations. Instruments may be used to polish the surface of the roughened cartilage to eliminate loose flaps causing pain and swelling. This also prevents the propagation of the flaps. It should be noted that this does not regenerate the cartilage. Figure 3 shows the same humeral head in figure 2 after the cartilage flap has been debrided and cleaned.
Figure 3. The large cartilage flap has been polished and smoothed.
Substantial arthritis with loss of motion, pain at rest, and pain with sleeping despite all treatment is best treated with a shoulder replacement. Younger patients may undergo a less aggressive and invasive procedure where the head is resurfaced with a metal cup (humeral head resurfacing). Older patients are better served with a metal stem and plastic socket (total shoulder replacement).
Below is an xray of a gentleman with severe arthritis. He had pain with sleeping at night, pain with moving his shoulder, and restricted motion.
The gentleman elected to proceed with a shoulder replacement. He is able to sleep through the night with improved motion and virtually no pain. Here is his last xray with the shoulder replacement in place.