What is the recommended treatment for a patient with a narrowed humeral acromial distance and moderate glenohumeral joint degenerative changes?

Treatment Recommendation for Narrowed Humeral-Acromial Distance with Moderate Glenohumeral Osteoarthritis

Begin with conservative management including physical therapy, NSAIDs (oral or topical), and weight loss if appropriate, reserving surgical intervention (total shoulder arthroplasty preferred over hemiarthroplasty) for patients with debilitating pain unresponsive to conservative measures. 1, 2

Initial Conservative Treatment Algorithm

First-line therapy should include:

• Physical therapy as the cornerstone of initial management, though evidence specific to glenohumeral OA is limited and extrapolated from hip/knee literature 1
• NSAIDs (oral or topical) as first-line pharmacological agents per NICE guidelines, despite limited shoulder-specific evidence 3
• Patient education about activity modification and joint protection strategies 1
• Weight loss if the patient is overweight, as this improves outcomes across all OA types 1

Second-line conservative options when first-line fails:

• Viscosupplementation (hyaluronic acid injections) is a treatment option with weak supporting evidence (Grade C recommendation), showing improvement in pain scores at 1,3, and 6 months 1, 2
• Corticosteroid injections have insufficient evidence to recommend for or against use (Grade I recommendation), though widely used in clinical practice 1, 2
• Acetaminophen may be considered, though evidence is conflicting across guidelines 1

When to Consider Surgical Referral

Absolute indications for orthopedic referral:

• Pain unresponsive to 3-6 months of conservative management that significantly impairs quality of life 4, 3
• Severe functional limitation despite maximal medical therapy 5
• Progressive joint destruction on serial radiographs 6

Surgical Treatment Algorithm

Total shoulder arthroplasty (TSA) is superior to hemiarthroplasty with moderate-strength evidence (Grade B recommendation), providing better pain relief and global health scores, with 14% of hemiarthroplasty patients requiring revision to TSA due to progressive glenoid pain 1, 2, 5

Critical pre-surgical considerations:

• Rotator cuff integrity must be assessed - TSA is contraindicated with irreparable rotator cuff tears; reverse total shoulder arthroplasty is required instead 2, 5
• Patient age matters - avoid arthroplasty in patients <50 years when possible due to increased prosthetic loosening and decreased survivorship 1, 5
• Pre-operative imaging must evaluate glenoid morphology, bone loss, retroversion, and bone quality 2, 7
• Surgeon volume is critical - choose surgeons performing ≥2 shoulder arthroplasties per year to reduce complications (Grade C recommendation) 2, 5

Prosthetic selection:

• All-polyethylene cemented glenoid components have lower revision rates (1.7%) compared to metal-backed designs (6.8%) 1, 5

Perioperative Management

Mandatory thromboembolism prophylaxis using mechanical and/or chemical VTE prophylaxis for all shoulder arthroplasty patients (consensus recommendation) 2, 5

Expected Outcomes and Complications

Realistic expectations:

• Good to excellent results in 86-94% of shoulder arthroplasty patients 4
• Complications occur in up to 39.8% of cases with revision rates up to 11% 2, 5
• Most common TSA complications: glenoid loosening (14.3%) and glenoid erosion (20.6%) 2, 5

Critical Pitfalls to Avoid

• Do not extrapolate all hip/knee OA evidence to the shoulder without recognizing the limited shoulder-specific data 1, 2
• Do not perform TSA without confirming rotator cuff integrity - this is the most critical pre-operative assessment 2, 5
• Do not rush to surgery in younger patients - exhaust all conservative options first given prosthetic longevity concerns 1, 5
• Do not use glucosamine/chondroitin - insufficient evidence for glenohumeral OA specifically 1