What is the best treatment approach for a patient with shoulder pain, mild degenerative changes of the glenohumeral joint, and a history of possible pulmonary or infectious disease, with imaging showing no acute fracture or dislocation, but a calcified granuloma and slight cortical irregularity of the scapula?

Treatment Approach for Shoulder Pain with Mild Glenohumeral Osteoarthritis

Begin with conservative management consisting of physical therapy and NSAIDs as first-line treatment for this patient's mild degenerative glenohumeral joint changes. 1

Immediate Clinical Actions

Address the Scapular Cortical Irregularity

• Obtain CT imaging of the scapula if clinical suspicion for acute fracture exists, as the radiologist notes this finding is only visible on one view and cannot exclude acute fracture. 2
• If CT confirms no acute fracture and the irregularity represents old trauma or normal variant, proceed with conservative management for the degenerative changes. 2

Incidental Calcified Granuloma

• The 6 mm perihilar calcification stable from prior imaging requires no acute intervention, as it likely represents a benign calcified granuloma. 2
• No further pulmonary workup is needed for stable calcified granulomas.

Conservative Treatment Protocol

Physical Therapy (First-Line)

Physical therapy should target three specific goals for glenohumeral OA: 3

• Pain reduction: Most effective for motion-related pain rather than rest pain. 3
• ROM improvement: Identify and target specific soft tissue restrictions limiting shoulder motion. 3
• Joint protection: Implement rotator cuff strengthening exercises to stabilize the glenohumeral joint. 3
• Address abnormal scapular motion patterns that develop as compensation for restricted glenohumeral movement. 3

Pharmacological Management

NSAIDs are recommended as first-line pharmacological therapy per NICE guidelines, though evidence is extrapolated from hip and knee OA literature rather than shoulder-specific studies. 1, 4

• Oral NSAIDs provide pain relief and reduce joint inflammation, enabling more effective physical therapy participation. 3, 4
• Topical NSAIDs can be considered as alternatives. 4
• Acetaminophen may be used for pain control. 4
• Vitamin C and D supplementation may slow cartilage degeneration. 3

Injectable Options (If Conservative Measures Fail)

Corticosteroid injections have insufficient evidence to recommend for or against use (Grade I recommendation), but may provide longer-term symptom relief in refractory cases. 1

Viscosupplementation (hyaluronic acid) is a treatment option with weak supporting evidence (Grade C recommendation). 1

• Biologics (platelet-rich plasma, bone marrow aspirate concentrate, mesenchymal stem cells) may decrease pain but do not stop OA progression or improve underlying disease. 3
• Limited evidence exists for biologics, requiring cautious use. 3, 4

When to Consider Surgical Intervention

Surgery is reserved for severe or refractory cases when conservative management fails after adequate trial (typically several months). 5

Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty for advanced glenohumeral OA, providing superior pain relief and clinical outcomes with moderate-strength evidence (Grade B recommendation). 1

Surgical Contraindications and Considerations

• Avoid TSA in patients with irreparable rotator cuff tears; consider reverse total shoulder arthroplasty instead. 1
• Delay arthroplasty in patients <50 years when possible due to increased prosthetic loosening risk and decreased survivorship. 1
• Pre-operative imaging must evaluate glenoid morphology, bone loss, retroversion, and bone quality. 1

Common Pitfalls to Avoid

• Do not attempt reduction without proper imaging if dislocation is suspected, as this could worsen fracture-dislocations. 2
• Most treatment recommendations are extrapolated from hip/knee literature rather than shoulder-specific studies, requiring clinical judgment. 1
• Physical therapy lacks high-quality evidence for glenohumeral OA specifically, but remains standard practice. 1
• Shoulder arthroplasty complications occur in up to 39.8% of cases with revision rates up to 11%. 1

Clinical Algorithm Summary

1. Obtain CT of scapula if acute fracture cannot be excluded clinically
2. Initiate physical therapy targeting pain, ROM, and rotator cuff strengthening
3. Start oral NSAIDs for pain and inflammation control
4. Consider corticosteroid or hyaluronic acid injections if conservative measures fail after 3-6 months
5. Refer for surgical evaluation only if symptoms remain debilitating despite exhaustive conservative treatment