What is the best initial management for a patient with chronic left shoulder pain, reduced range of motion, and X-ray evidence of potential early degenerative changes at the glenohumeral joint?

Initial Management of Early Glenohumeral Osteoarthritis

Begin with a structured 6-12 week trial of conservative management combining physical therapy with NSAIDs, as this represents the evidence-based first-line approach for early degenerative glenohumeral changes before considering advanced imaging or interventional procedures. 1, 2

Conservative Management Framework

Physical Therapy (Primary Treatment)

Physical therapy should target three specific goals for glenohumeral osteoarthritis 2:

• Pain reduction: Physical therapy is most effective for motion-related pain rather than rest pain, so assess pain timing to set realistic expectations 2
• Range of motion restoration: Identify which specific soft tissues (capsule, rotator cuff, or periscapular muscles) are restricting movement and target these structures with manual therapy and stretching 2
• Joint protection: Prescribe rotator cuff strengthening exercises to stabilize the glenohumeral joint and reduce abnormal loading patterns 1, 2
• Scapular mechanics: Address abnormal scapular motion patterns that develop as compensation for restricted glenohumeral movement 2

Pharmacological Management

NSAIDs are recommended as first-line pharmacological therapy to reduce pain and diminish joint inflammation 2:

• NSAIDs interrupt the chronic inflammatory state, enabling more effective pain-free physical therapy 2
• Oral vitamin C and vitamin D supplementation may help slow cartilage degeneration 2
• Tailor medication selection based on individual comorbidities and contraindications 2

Interventional Options (If Conservative Measures Insufficient)

Corticosteroid injections may be considered for subacromial pathology, though evidence is insufficient to formally recommend their use specifically for glenohumeral arthritis 1:

• Intra-articular corticosteroid injections provide longer-term pain relief but must be used cautiously 2
• Hyaluronic acid (viscosupplementation) injections show mixed evidence for efficacy 2
• Biologics (platelet-rich plasma, bone marrow aspirate concentrate, mesenchymal stem cells) may decrease shoulder pain but do not stop progression or improve the underlying osteoarthritis, and further evidence is needed 2

When to Advance Beyond Conservative Management

Indications for MRI

Order MRI without contrast if the patient fails 6-12 weeks of appropriate conservative management 1:

• MRI helps distinguish between isolated glenohumeral arthritis versus concurrent rotator cuff pathology that may require different treatment 1
• MRI is essential for surgical planning if arthroplasty is being considered 1

Surgical Referral Criteria

Refer for orthopedic surgical evaluation when 1, 3:

• Severe or refractory pain despite adequate conservative management (typically 6+ months) 3
• Significant functional limitations affecting activities of daily living 3
• Progressive loss of motion despite therapy 3
• MRI demonstrates advanced degenerative changes with consideration for shoulder arthroplasty 1

Critical Clinical Considerations

Age-Based Treatment Approach

• Patients >60 years: Shoulder replacement (total shoulder arthroplasty preferred over hemiarthroplasty) is the definitive treatment for severe glenohumeral arthritis 1, 3
• Younger active patients (<40-50 years): Treatment is directed toward joint preservation whenever possible, including aggressive conservative management and consideration of corrective osteotomy before arthroplasty 4

Common Pitfalls to Avoid

• Do not overlook concurrent rotator cuff pathology: Older patients with glenohumeral arthritis commonly have associated rotator cuff tears that require separate evaluation and may alter treatment strategy 5, 6
• Assess for secondary causes: In younger patients, consider whether the arthritis is secondary to prior trauma, instability, rotator cuff pathology, or osteonecrosis, as this influences prognosis 7
• Monitor for rest pain: If pain occurs primarily at rest rather than with motion, physical therapy may be less effective and earlier consideration of injections or surgery may be warranted 2