Management of Glenohumeral Arthritis
For surgical candidates with glenohumeral osteoarthritis and an intact rotator cuff, total shoulder arthroplasty is preferred over hemiarthroplasty, as it provides superior functional outcomes and pain relief. 1, 2
Treatment Algorithm
Initial Conservative Management
Start with non-pharmacological interventions as the foundation:
- Exercise therapy and physical therapy should be prioritized first, as receiving exercise therapy significantly reduces the odds of requiring arthroscopic surgery (adjusted OR = 0.01) 3. This represents the most impactful conservative intervention.
- Manual therapy can be added as an adjunct 3
- Physical therapy protocols should focus on range of motion, strengthening, and functional restoration 4
Pharmacological Options
When conservative measures alone are insufficient:
- NSAIDs are first-line pharmacological treatment per NICE guidelines 5
- Topical NSAIDs can be considered, though evidence specifically for glenohumeral OA is limited 5
- Acetaminophen as an alternative for patients with NSAID contraindications 5
- Avoid routine opioid use - only 13.4% of patients in real-world practice receive opioids, and they should be reserved for severe, refractory cases 3
Injectable Therapies
For moderate symptoms or non-surgical candidates:
- Intra-articular corticosteroid injections are an option, though graded as weak evidence 1
- Injectable viscosupplementation is available but also carries only weak evidence 1
- Platelet-rich plasma can be considered in select cases 5
Surgical Decision-Making
Critical contraindication: Do not perform total shoulder arthroplasty in patients with irreparable rotator cuff tears - this is a consensus recommendation 1
When surgery is indicated:
- Total shoulder arthroplasty over hemiarthroplasty - this is the single moderate-strength recommendation from AAOS guidelines 1, 2
- Ensure the surgeon performs at least 2 shoulder arthroplasties per year to reduce immediate postoperative complications 1
- Use keeled or pegged all-polyethylene cemented glenoid components (weak recommendation) 1
- Mandatory VTE prophylaxis: Use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for all shoulder arthroplasty patients (consensus recommendation) 1
Special Populations
Younger or active patients not ready for arthroplasty:
Comprehensive arthroscopic management can serve as a bridging procedure with 60% survival at 10-year follow-up 6. This includes:
- Glenohumeral chondroplasty
- Synovectomy and loose body removal
- Capsular release
- Humeral osteoplasty
- Subacromial decompression
- Biceps tenodesis
Important caveat: Patients with end-stage arthritis (<2mm joint space) or significant bony deformity have less favorable outcomes with arthroscopic management 6
Key Clinical Pitfalls
- Underutilization of exercise therapy: 54% of patients receive no non-pharmacological treatment in real-world practice 3, despite exercise therapy being the most effective conservative intervention
- Gender disparities: Males have 1.5x the odds of receiving surgery compared to females 3 - ensure equitable access to appropriate surgical intervention
- Inadequate evidence for many interventions: Nine of 16 AAOS recommendations are inconclusive 1, highlighting significant evidence gaps, particularly for non-surgical treatments
Treatment Considerations by Disease Severity
The evidence shows treatment should be dictated by symptom severity, radiographic findings, age, and medical comorbidities 1. Progress sequentially through conservative measures before considering surgery, with the notable exception that patients with debilitating symptoms severely impairing quality of life may proceed directly to surgical evaluation 5.