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

Diagnosis and Management of Early Glenohumeral Osteoarthritis

The diagnosis is early glenohumeral osteoarthritis, and initial management should consist of conservative treatment including physical therapy, NSAIDs (extrapolated from hip/knee OA evidence), and potentially intra-articular corticosteroid injections, with surgical intervention (total shoulder arthroplasty preferred over hemiarthroplasty) reserved for patients with severe, refractory pain unresponsive to conservative measures. 1, 2

Diagnosis

The radiographic finding of moderately reduced glenohumeral joint spacing without notable osteophyte development in a patient with chronic pain and reduced range of motion is consistent with early glenohumeral osteoarthritis 1. This represents degenerative changes affecting the articular surfaces of the humeral head and glenoid 3.

Initial Conservative Management

Begin with non-operative treatment for at least 3-6 months before considering surgical options: 1, 2

• Physical therapy is the first-line treatment, though high-quality evidence specifically for glenohumeral OA is limited 1
• NSAIDs and analgesics for pain control, with evidence extrapolated from hip and knee osteoarthritis literature 1
• Intra-articular corticosteroid injections are an option, though current evidence neither strongly supports nor refutes their use for glenohumeral OA (Grade I recommendation) 2, 1
• Viscosupplementation (hyaluronic acid injections) is a treatment option with weak supporting evidence (Grade C recommendation) 2, 1
• Activity modification to avoid aggravating movements while maintaining shoulder function 4

Advanced Imaging Considerations

While the diagnosis can be made on plain radiographs, MRI without contrast may be considered if there is clinical suspicion of concomitant rotator cuff pathology, labral tears, or other soft-tissue injuries that could influence treatment planning 2, 5. MRI is superior to radiography for assessing cartilage integrity, bone marrow changes, and associated soft-tissue structures 2.

Surgical Intervention Criteria

Surgery is indicated when: 2, 1, 6

• Pain is severe and unresponsive to conservative management for 3-6 months
• Significant functional limitation persists despite non-operative treatment
• Patient has realistic expectations and is medically fit for surgery

Surgical Options

Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty (Grade B recommendation) based on superior outcomes: 2, 1

• TSA provides better pain relief and global health assessment scores compared to hemiarthroplasty 2
• Hemiarthroplasty has a 14% revision rate to TSA due to progressive glenoid arthrosis, while TSA rarely requires revision to hemiarthroplasty 2
• Function and quality-of-life measures are comparable between procedures, but the lower revision rate favors TSA 2

Critical contraindication: TSA should NOT be performed in patients with irreparable rotator cuff tears; reverse total shoulder arthroplasty should be considered instead 1

Common Pitfalls to Avoid

• Do not rush to surgery in early-stage disease—most patients respond to conservative management 1, 3
• Do not perform TSA in patients with rotator cuff deficiency—this leads to poor outcomes and high failure rates 1
• Do not overlook concomitant pathology such as adhesive capsulitis, which can coexist and requires different treatment approaches 7
• Be aware that most treatment recommendations are extrapolated from hip/knee OA literature rather than shoulder-specific studies 1
• Consider patient age carefully—concerns exist about performing arthroplasty in patients under 50 years due to increased risk of prosthetic loosening and decreased survivorship 2

Perioperative Considerations (If Surgery Pursued)

• Mechanical and/or chemical VTE prophylaxis should be used for all shoulder arthroplasty patients 1
• Pre-operative imaging should evaluate glenoid morphology, bone loss, retroversion, and bone quality 1
• Complication rates for shoulder arthroplasty reach 39.8%, with revision rates up to 11% 1
• Postoperative physical therapy is commonly practiced, though high-quality evidence demonstrating improved outcomes is lacking 1