What is the treatment for moderate glenohumeral joint chondrosis with labral degeneration?

Treatment for Moderate Glenohumeral Joint Chondrosis with Labral Degeneration

Begin with exercise-based physical therapy focused on rotator cuff strengthening and range of motion, as this is the foundation of conservative management for glenohumeral osteoarthritis, though you should prepare the patient that evidence quality is limited and surgical intervention may ultimately be necessary if conservative measures fail. 1

Initial Conservative Management

Physical Therapy (First-Line Treatment)

• Exercise therapy is strongly recommended for all patients with shoulder osteoarthritis, with primary goals of decreasing pain, increasing range of motion, and protecting the glenohumeral joint through rotator cuff strengthening. 1
• No specific exercise prescription (duration, intensity, frequency) has proven superior, so tailor recommendations to patient preference and access, including walking, cycling, resistance training, or neuromuscular training. 1
• The American Academy of Orthopaedic Surgeons acknowledges that physical therapy lacks high-quality evidence supporting its efficacy specifically for glenohumeral OA, but it remains the recommended initial approach. 1, 2

Injectable Options (Second-Line)

• Viscosupplementation (hyaluronic acid injections) is a reasonable treatment option (Grade C recommendation), typically administered as three weekly injections, with improvements in pain and function scores documented at 1,3, and 6 months. 3, 1, 2
• Injectable corticosteroids have insufficient evidence to recommend for or against their use (Grade I recommendation), though they are widely used in clinical practice. 3, 1, 2
• Critical pitfall: Do not rely solely on corticosteroid injections, as evidence for their efficacy in glenohumeral OA is insufficient. 1

Pharmacotherapy

• Oral pharmacotherapy is extrapolated from hip and knee osteoarthritis literature, with limited specific evidence for glenohumeral OA. 2

Arthroscopic Treatment Considerations

When to Consider Arthroscopy

• Arthroscopic treatments have insufficient evidence to recommend for or against their use (Grade I recommendation) for glenohumeral osteoarthritis. 3, 1
• Arthroscopic management may be considered for younger patients with early-stage OA who are not candidates for arthroplasty, though outcomes are uncertain. 1
• For moderate chondrosis with labral degeneration specifically, arthroscopic strategies include debridement, abrasion, microfracture, capsulolabral advancement, and labral interposition to restore the glenoid articular surface and minimize exposed defects. 4

Evidence Limitations

• A systematic review found only observational, retrospective case series without control groups for arthroscopic procedures (debridement, microfracture, osteochondral transplants), resulting in "very low" quality evidence where "any estimate of effect is very uncertain." 5
• Critical pitfall: Avoid intra-articular pain pump catheters with bupivacaine, as this has been associated with glenohumeral joint chondrolysis in multiple case series. 6

Surgical Intervention Algorithm

When Conservative Treatment Fails

• Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty for patients with glenohumeral OA (Grade B recommendation, Level II evidence). 1, 2
• TSA provides statistically superior pain relief and global health assessment scores compared to hemiarthroplasty, with 14% of hemiarthroplasty patients requiring revision to TSA due to progressive glenoid arthrosis and pain. 1, 2

Critical Contraindications

• TSA should NOT be performed in patients with irreparable rotator cuff tears (consensus recommendation); reverse total shoulder arthroplasty should be considered instead. 1, 2, 7
• Avoid arthroplasty in patients under 50 years when possible due to increased risk of prosthetic loosening and decreased survivorship. 1, 2, 7

Surgeon Selection

• Refer to surgeons performing at least 2 shoulder arthroplasties per year to reduce immediate postoperative complications and length of stay. 1, 2

Perioperative Management (If Surgery Pursued)

• Use mechanical and/or chemical venous thromboembolism prophylaxis for all shoulder arthroplasty patients (consensus recommendation). 1, 2, 7
• Pre-operative imaging is essential to evaluate glenoid morphology, bone loss, retroversion, and bone quality before arthroplasty. 1, 2, 7
• Be aware that shoulder arthroplasty complications occur in up to 39.8% of cases, with revision rates up to 11%, including glenoid erosion (20.6%) for hemiarthroplasty and glenoid loosening (14.3%) for TSA. 1, 2

Key Clinical Pitfalls to Avoid

• Do not extrapolate all treatment recommendations from hip and knee OA literature, as shoulder-specific evidence is limited and most recommendations are based on lower-quality evidence. 1, 2
• Do not perform traditional TSA in patients with irreparable rotator cuff tears, as this will lead to poor outcomes and likely revision surgery. 1, 7
• Treatment should be dictated by patient age, severity of symptoms, radiographic findings, and medical comorbidities rather than a one-size-fits-all approach. 2