What is the initial treatment plan for a patient with mild degenerative joint disease (DJD) of the glenohumeral joint?

Treatment Plan for Mild Glenohumeral Joint Degenerative Joint Disease

Begin with exercise-based physical therapy as the foundation of treatment, combined with NSAIDs for pain control, reserving corticosteroid injections and viscosupplementation for patients who fail initial conservative management. 1

First-Line Conservative Management

Exercise Therapy (Mandatory)

• Exercise is strongly recommended for all patients with shoulder osteoarthritis as the cornerstone of treatment 2, 1
• Primary goals include 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 recommendations should be based on patient preference and access, including walking, cycling, resistance training, or neuromuscular training 1
• Physical therapy should focus on maintaining joint mobility and preventing capsular contracture 3

Pharmacologic Management

• Oral NSAIDs (such as ibuprofen 400-800 mg three to four times daily) should be initiated alongside physical therapy for pain control 4, 3
• Acetaminophen can be used as an alternative analgesic, though evidence for osteoarthritis is mixed across guidelines 2, 3
• Administer NSAIDs with meals or milk to minimize gastrointestinal complaints 4
• Use the lowest effective dose for the shortest duration consistent with treatment goals 4

Second-Line Options for Inadequate Response

Injectable Therapies

• Viscosupplementation (hyaluronic acid injections) is recommended as the preferred injectable option (Grade C recommendation) 1, 5

  • Administered as three weekly injections 1, 5
  • Provides improvements in pain and function scores at 1,3, and 6 months after treatment 1, 5

• Intra-articular corticosteroid injections have insufficient evidence to recommend for or against their use (Grade I recommendation), though they are widely used in clinical practice for more advanced cases refractory to other conservative measures 1, 5

Patient Education Components

• Patient education should be incorporated as part of first-line care alongside exercise therapy 2
• Discuss activity modifications to avoid exacerbating symptoms 3
• Set realistic expectations about the progressive nature of degenerative joint disease 6, 3

Monitoring and Follow-Up

• Reassess response to conservative management at 2-4 weeks 3
• If symptoms persist or worsen despite 3-6 months of appropriate conservative management, consider referral to orthopedic surgery for evaluation of surgical options 1, 3

Critical Pitfalls to Avoid

• Do not rely solely on corticosteroid injections as evidence for their efficacy in glenohumeral osteoarthritis is insufficient 1
• Do not delay physical therapy while waiting for pharmacologic interventions to take effect—these should be initiated simultaneously 2, 1
• Do not exceed 3200 mg total daily dose of ibuprofen, and use the smallest dose that yields acceptable control 4
• Do not extrapolate all treatment recommendations from hip and knee osteoarthritis literature, as shoulder-specific evidence is limited 1

When to Consider Surgical Referral

• Severe or refractory cases when nonoperative management has failed after 3-6 months 6, 3
• Presence of debilitating pain that significantly impairs quality of life despite maximal conservative therapy 1, 3
• Radiographic evidence of advanced joint space narrowing (less than 2 mm) with large osteophytes suggests higher likelihood of requiring eventual arthroplasty 7