What is the recommended treatment for a patient with chronic pain and reduced range of motion in the left shoulder, with X-ray findings indicating potential early degenerative changes at the glenohumeral joint?

Management of Early Glenohumeral Degenerative Changes with Chronic Shoulder Pain

Initial conservative management with physical therapy, NSAIDs, and activity modification is the appropriate first-line treatment for this patient with early degenerative changes of the glenohumeral joint. 1, 2

Diagnostic Workup

Advanced imaging is indicated given the chronic nature of symptoms and X-ray findings suggesting early arthropathy:

• MRI shoulder without IV contrast is the next appropriate imaging study to fully characterize soft tissue pathology, assess for rotator cuff pathology, evaluate cartilage integrity, and determine extent of degenerative changes 3
• MRI is preferred over ultrasound in this setting due to restricted range of motion and need to evaluate intraarticular pathology comprehensively 3

Conservative Treatment Protocol

Pain Management

• Start with NSAIDs such as naproxen 500 mg twice daily for anti-inflammatory effect and pain control 4
• Naproxen has demonstrated efficacy in osteoarthritis with reduction in joint pain, increased range of motion, and improved capacity for activities of daily living 4
• If contraindications to NSAIDs exist, acetaminophen can be used for pain relief 3

Physical Therapy

• Gentle stretching and mobilization techniques focusing on external rotation and abduction to address range of motion limitations 3
• Active range of motion should be increased gradually in conjunction with strengthening weak muscles in the shoulder girdle 3
• Avoid aggressive passive range of motion that may exacerbate joint inflammation 3

Activity Modification

• Modify activities that provoke pain while maintaining functional use of the shoulder 2
• The goal is pain control and functional improvement, not complete activity cessation 2

Adjunctive Interventions

Subacromial corticosteroid injections can be considered if pain is thought to be related to subacromial inflammation (rotator cuff or bursa involvement) 3

Surgical Considerations

Surgery is reserved for severe or refractory cases when conservative management fails after an adequate trial (typically 3-6 months) 2, 5:

• Arthroscopic débridement may be attempted in younger, active patients with mild-to-moderate arthropathy 6
• Shoulder arthroplasty (hemiarthroplasty or total shoulder replacement) is indicated for severe arthropathy with pain unresponsive to medical management, with good to excellent results in 86-94% of patients 5
• The choice between hemiarthroplasty and total shoulder replacement depends on the condition of the glenoid 5

Common Pitfalls

• Failing to obtain advanced imaging (MRI) in chronic cases may miss significant rotator cuff pathology or underestimate the extent of degenerative changes 3
• Premature surgical intervention before adequate conservative trial can lead to unnecessary procedures, as many patients respond well to non-operative management 2
• Inadequate pain control may prevent effective participation in physical therapy and delay functional recovery 3

Monitoring and Follow-up

• Reassess response to conservative treatment at 6-12 weeks 2
• If symptoms progress despite conservative management or if there is significant functional limitation, surgical consultation is warranted 2, 5