What is the best management approach for a patient with Glenohumeral (shoulder joint) arthritis?

Management of Glenohumeral Arthritis

First-Line Treatment: Conservative Management

All patients with glenohumeral arthritis should begin with exercise-based physical therapy, patient education, and weight loss (if appropriate) as the foundation of treatment. 1, 2

Exercise Therapy

• Exercise is the cornerstone intervention with goals of decreasing pain, increasing range of motion, and protecting the glenohumeral joint through rotator cuff strengthening 2, 3
• 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 2
• Physical therapy is most effective for motion-related pain rather than rest pain 3
• Scapular stabilization exercises should be included, as abnormal scapular motion develops as adaptation to restricted glenohumeral motion 3

Pharmacologic Management (Second-Line)

NSAIDs (oral or topical) should be used as first-line pharmacologic therapy after exercise therapy. 1

Injectable Corticosteroids

• Evidence is insufficient to recommend for or against corticosteroid injections (Grade I recommendation), though they are widely used in clinical practice 1, 2, 4
• Use cautiously in athletes due to potential cartilage damage 2
• May provide temporary relief but should not be relied upon as sole treatment 2

Viscosupplementation (Hyaluronic Acid)

• Represents a treatment option with Grade C recommendation 2, 4
• Typically administered as three weekly injections 2
• Provides improvements in pain and function scores at 1,3, and 6 months 2
• Evidence is mixed, particularly in athletes 3

Oral Supplements

• Vitamin C and vitamin D supplementation may help slow cartilage degeneration 3
• Glucosamine and chondroitin have insufficient evidence for glenohumeral OA specifically (unable to recommend for or against) 1

Avoid These Medications

• Do NOT use bisphosphonates, colchicine, hydroxychloroquine, methotrexate, or diacerein for glenohumeral OA 1

Surgical Management (Third-Line)

When to Consider Surgery

• Surgery is indicated when conservative management fails and symptoms remain debilitating 5
• Arthroscopic treatment may be considered as a bridging procedure in young or active patients (<50 years) with early-stage OA who are not candidates for arthroplasty 2, 6
• Arthroscopic management has 60% survival rate at 10-year follow-up but works best in patients with >2mm joint space remaining 6

Total Shoulder Arthroplasty (TSA) - Preferred Surgical Option

Total shoulder arthroplasty is superior to hemiarthroplasty for glenohumeral osteoarthritis (Grade B recommendation, Level II evidence). 2, 4, 5

• TSA provides statistically superior pain relief and global health assessment scores compared to hemiarthroplasty 2, 4, 5
• 14% of hemiarthroplasty patients require revision to TSA due to progressive glenoid arthrosis and pain 2, 4, 5
• All-polyethylene glenoid components have lower revision rates (1.7%) compared to metal-backed designs (6.8%) 5

Critical Contraindications and Special Considerations

DO NOT perform traditional TSA in patients with irreparable rotator cuff tears (consensus recommendation). 2, 4, 5

• Reverse total shoulder arthroplasty should be used instead when irreparable rotator cuff tears are present 2, 4, 5
• Avoid arthroplasty in patients under 50 years when possible due to increased risk of prosthetic loosening and decreased survivorship 2, 4, 5
• Pre-operative imaging must evaluate glenoid morphology, bone loss, retroversion, bone quality, and rotator cuff integrity 2, 4, 5

Surgeon Selection

• Refer to surgeons performing at least 2 shoulder arthroplasties per year to reduce immediate postoperative complications and length of stay (Grade C recommendation) 2, 4, 5

Expected Complications

• Complications occur in up to 39.8% of cases with revision rates up to 11% 2, 4, 5
• Most common TSA complications: glenoid loosening (14.3%) 2, 5
• Most common hemiarthroplasty complications: glenoid erosion (20.6%) 2, 5

Perioperative Management

All shoulder arthroplasty patients must receive mechanical and/or chemical venous thromboembolism prophylaxis (consensus recommendation). 2, 4, 5

Post-Operative Physical Therapy

• Physical therapy following shoulder arthroplasty is commonly practiced, but no high-quality studies demonstrate whether it improves outcomes (Grade I recommendation) 1, 4
• Despite lack of evidence, formal physical therapy remains a consistent recommendation in clinical practice 1

Common Pitfalls to Avoid

• Do not extrapolate all treatment recommendations from hip and knee OA literature, as shoulder-specific evidence is limited 2, 4
• Do not rely solely on corticosteroid injections without concurrent exercise therapy 2
• Do not perform traditional TSA in patients with irreparable rotator cuff tears 2, 4, 5
• Do not skip pre-operative imaging assessment of rotator cuff integrity and glenoid morphology 2, 4, 5
• Do not refer to low-volume surgeons (<2 cases per year) 2, 4, 5