What is the recommended treatment for a patient with early osteoarthritis of the glenohumeral joint, presenting with chronic pain and popping, and radiographic findings of early osteophytic ridging along the inferior margin of the glenoid?

Treatment of Early Glenohumeral Osteoarthritis

For early glenohumeral osteoarthritis presenting with chronic pain and popping, with radiographic evidence of early osteophytic ridging, first-line treatment should focus on conservative measures including physical therapy, NSAIDs, and activity modification before considering more invasive options. 1, 2

Initial Conservative Management

Physical Therapy

• Focus on strengthening rotator cuff and periscapular muscles 2
• Aim to improve joint stability and function
• Typically prescribed for 6-12 weeks initially

Pharmacological Management

• NSAIDs for pain control and anti-inflammatory effects
  • No evidence suggests negative effects on tendon healing 2
  • Can be used orally or topically
• Injectable options:
  • Viscosupplementation (hyaluronic acid injections) is a weak recommendation (Grade C) but may provide symptomatic relief 1, 2
  • Three weekly Hylan G-F 20 injections have shown improvement in pain scores and function for up to 6 months 1
  • Insufficient evidence to recommend for or against corticosteroid injections 2

Activity Modification

• Reduce activities that exacerbate symptoms
• Avoid repetitive overhead movements
• Maintain range of motion with gentle stretching exercises

Treatment Algorithm

1. First 3-6 months: Conservative management

   • Physical therapy + NSAIDs + activity modification
   • Consider viscosupplementation if initial measures fail

2. If symptoms persist after 3-6 months of conservative treatment:

   • Re-evaluate with additional imaging (MRI) to assess for associated soft tissue pathology 2
   • Consider surgical options based on:
     • Patient age
     • Severity of symptoms
     • Extent of joint damage
     • Functional demands

3. Surgical considerations:

   • For younger patients (<50 years): Concern exists about performing shoulder arthroplasty due to potential risks of prosthetic loosening and decreased survivorship 1, 2
   • Arthroscopic options may be considered, though evidence is inconclusive 1
   • For more advanced disease in appropriate candidates: Total shoulder arthroplasty has shown better outcomes than hemiarthroplasty (moderate recommendation, Grade B) 1

Important Considerations and Caveats

• Early intervention is crucial - treatment within 3 months of symptom onset may lead to better outcomes 1
• Surgical volume matters - patients should avoid shoulder arthroplasty performed by surgeons who do fewer than two shoulder arthroplasties per year (weak recommendation, Grade C) 1
• Preoperative evaluation of rotator cuff muscle quality is essential if surgical intervention is considered, as fatty degeneration and atrophy correlate with worse outcomes 2
• Young patients (<60 years) with glenohumeral osteoarthritis represent a particularly challenging population due to higher functional demands and higher failure rates after surgical management 3

The management of glenohumeral osteoarthritis remains somewhat controversial with limited high-quality evidence, particularly for early disease. Treatment decisions should be guided by symptom severity, functional limitations, and radiographic findings, with conservative measures exhausted before considering surgical intervention.