01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Glenohumeral osteoarthritis is symptomatic failure of the ball-and-socket joint rather than a radiographic finding alone. Ask about deep joint pain, crepitus, sleep, overhead reach, grooming, toileting, dressing, work and ability to use a walking aid. Define trauma, instability, previous infection, inflammatory disease, steroid or alcohol exposure, cuff symptoms and neurological loss. Shoulder radiographs commonly show degeneration that does not explain every symptom, so document the person's goals and current limitation before discussing escalation.
Examine posture, muscle bulk, scapular compensation and surgical scars. Compare active and passive elevation, external rotation and internal rotation, then assess cuff strength within the available range. Glenohumeral arthritis usually restricts passive movement and produces a firm or crepitant endpoint. Palpate the acromioclavicular joint, examine the cervical spine and distal neurology, and assess the opposite shoulder. Marked weakness or superior migration may indicate cuff-tear arthropathy, which changes reconstructive options.
Plain radiography is the practical reference imaging for established osteoarthritis when confirmation or surgical planning is required. True anteroposterior and axillary or alternative orthogonal views show joint-space loss, osteophytes, sclerosis, cysts, glenoid erosion and humeral-head position. CT quantifies glenoid bone loss and version for replacement planning; MRI or ultrasound assesses cuff integrity when it influences implant selection. Blood tests and aspiration are reserved for inflammatory, infectious or crystal questions rather than ordered routinely.
Core treatment is active and goal based. Explain that exercise does not regrow cartilage but can improve movement, strength and confidence. Prescribe tolerable range work, cuff and scapular strengthening and general aerobic activity, adjusting around irritability rather than immobilising the arm. Occupational therapy can adapt dressing, bathing, work and mobility-aid tasks. Manual therapy may accompany exercise but should not replace it. Weight loss is less joint-specific than in knee disease, yet metabolic health, sleep, smoking and general conditioning affect symptoms and procedural risk.
Medication should enable function. Consider topical NSAID first when practical because systemic exposure is lower; an oral NSAID can follow if expected benefit outweighs gastrointestinal, renal and cardiovascular harm, using the lowest effective dose for the shortest time and gastroprotection. NICE advises against routine paracetamol or weak opioids except infrequent short-term rescue when other options are contraindicated, not tolerated or ineffective, and advises against strong opioids. Review every medicine against an observable functional outcome.
Intra-articular corticosteroid can temporarily reduce pain. Image guidance may improve reliable glenohumeral placement according to local service. Explain that benefit is short term, often weeks rather than durable structural change, and use the window to progress movement or make a decision. Exclude infection, check overlying skin, diabetes and anticoagulation, and discuss rare joint infection, transient glucose rise and post-injection flare. Repeated injections without sustained function may add harm and delay definitive referral.
Replacement is considered when pain, stiffness or loss of function substantially affects quality of life and appropriate non-surgical care is ineffective or unsuitable. Anatomical total shoulder replacement generally requires a functioning cuff; reverse replacement uses the deltoid to compensate for deficient cuff mechanics and is considered in cuff-tear arthropathy and selected complex patterns. Hemiarthroplasty has narrower indications. The specialist decision uses glenoid bone, cuff status, age-related demands, comorbidity and shared goals rather than one radiographic grade.
Optimise without constructing arbitrary barriers. Address smoking, anaemia, diabetes, skin infection, nutrition, bone health and home support while referral proceeds. Older age or high BMI alone should not prevent assessment; individual operative and rehabilitation risks should be discussed transparently. Anticoagulants require a perioperative plan from the responsible teams. During pregnancy, operative decisions are uncommon and individualised; avoid systemic NSAIDs from 20 weeks unless specifically required and avoid them late in gestation.
Key points
- Typical disease produces deep activity-related shoulder pain, night discomfort, crepitus and progressive restriction of both active and passive glenohumeral movement.
- First-line investigation when structural confirmation is needed is plain radiography with true anteroposterior and axillary or equivalent orthogonal views; correlate change with symptoms and function.
- Do not attribute a hot acute shoulder, rapid collapse or constitutional pain to known osteoarthritis without excluding infection, fracture, osteonecrosis, neuropathic disease and malignancy.
- First-line management follows NICE osteoarthritis principles: information, tailored therapeutic exercise and support for weight and general health where relevant, with aids or adaptations for specific functional loss.
- A topical NSAID may be considered, followed by a short oral NSAID at the lowest effective dose with gastroprotection and individual gastrointestinal, renal, cardiovascular, pregnancy and anticoagulation review.
- Do not routinely use paracetamol or weak opioids except infrequently for short-term rescue when other options are unsuitable, and do not offer strong opioids for routine osteoarthritis care.
- A glenohumeral corticosteroid injection may give short-term relief and support exercise; exclude infection, counsel about glucose and bleeding, and do not present it as disease modification.
- Refer for shoulder-replacement assessment when pain, stiffness and functional loss substantially impair quality of life despite suitable non-operative care; do not use imaging severity, age or BMI as the sole gate.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Primary osteoarthritis
Age, genetic susceptibility and accumulated mechanical and biological change can produce degeneration without one preceding lesion, though the shoulder is affected less often than hip or knee.
Post-traumatic disease
Proximal humeral or glenoid fracture, recurrent dislocation and cartilage injury alter congruity and loading, causing earlier secondary joint failure.
Cuff-related arthropathy
A chronic massive cuff tear permits superior migration and abnormal contact, producing a biomechanically distinct arthropathy that influences implant choice.
Systemic or structural causes
Inflammatory arthritis, avascular necrosis, previous infection, dysplasia and haemophilic or neuropathic disease can destroy cartilage and require cause-specific management.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Cartilage matrix loss
Chondrocyte and matrix failure reduces smooth load distribution, narrows the joint space and exposes subchondral bone to higher focal stress.
- 2Subchondral remodelling
Sclerosis, cyst formation and altered trabecular mechanics contribute to deep movement pain and reduced joint compliance.
- 3Osteophyte and capsular restriction
Inferior humeral osteophytes, synovial irritation and capsular thickening produce crepitus and progressive loss of passive external rotation and elevation.
- 4Muscle-mechanics interaction
Pain inhibits cuff and deltoid function, while cuff integrity determines humeral-head control and whether an anatomical or reverse replacement can restore mechanics.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Pain arises with use and often at night, feels deep rather than focal over the acromioclavicular joint, and progressively restricts daily reach.
External rotation and elevation are limited when the examiner moves the joint, often with a coarse or painful mechanical endpoint.
Joint-space narrowing, inferior osteophyte, sclerosis and cysts support the diagnosis when they match the symptomatic side and movement pattern.
Marked loss of active elevation, cuff weakness and superior humeral migration indicate altered mechanics rather than ordinary concentric primary disease.
Long morning stiffness, several active joints and systemic features suggest inflammatory arthritis and should redirect laboratory and specialist assessment.
Fast collapse, systemic illness, severe rest pain or major sensory loss is atypical and requires infection, osteonecrosis, tumour and neuropathic disease exclusion.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
First-line clinical and functional assessmentFirst stepFirst line - Why
- Establish whether pain and passive restriction arise from the glenohumeral joint and quantify quality-of-life impact.
- Interpretation and limitations
- Crepitus and global passive loss support joint disease, but cervical, cuff and acromioclavicular sources may coexist and require examination.
- 02
First-line structural imaging with radiographsFirst line - Why
- Confirm osteoarthritis, identify humeral and glenoid pattern and exclude fracture or gross destructive disease.
- Interpretation and limitations
- Use true anteroposterior plus axillary or equivalent orthogonal views; radiographic severity must not replace symptom and function assessment.
- 03
CT for preoperative bone planning - Why
- Define glenoid version, erosion, bone stock and three-dimensional anatomy before selected replacements.
- Interpretation and limitations
- CT answers an implant-planning question and is not needed for every person managed non-operatively.
- 04
Ultrasound or MRI for cuff integrity - Why
- Assess tendon continuity and muscle quality when weakness or arthroplasty selection makes cuff status actionable.
- Interpretation and limitations
- A degenerative tear may coexist without causing all pain; combine imaging with active-passive discrepancy and specialist planning.
- 05
Inflammatory tests and aspiration when indicated - Why
- Investigate infection, crystal disease or inflammatory arthritis in an acute, warm or systemically abnormal presentation.
- Interpretation and limitations
- Synovial culture and crystal analysis are decisive for the relevant differential; normal serum markers do not safely clear early sepsis.
- 06
Preoperative optimisation assessment - Why
- Identify anaemia, diabetes, infection, cardiorespiratory risk, anticoagulation and support needs before surgery.
- Interpretation and limitations
- Optimisation should reduce individual risk while avoiding arbitrary exclusion based on age, disability or BMI alone.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Adhesive capsulitis
Both restrict passive movement, but capsulitis usually has preserved joint surfaces on radiographs and a characteristic evolution from severe pain to stiffness.
Rotator-cuff disease
Cuff-related pain commonly preserves passive range and produces weakness or a painful arc; large chronic tears may coexist with arthropathy.
Cervical or plexus disease
Neck provocation, pain below the elbow, sensory change, reflex loss or disproportionate weakness indicates a neurological source or additional lesion.
Inflammatory arthritis
Prolonged morning stiffness, several swollen joints, systemic manifestations or erosive change suggests rheumatoid or another inflammatory process.
Infection or tumour
Rapid progression, fever, unremitting night pain, mass or destructive radiographs requires urgent sampling and cross-sectional imaging rather than routine osteoarthritis treatment.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01First-lineConfirm concordant joint diseaseFirst stepFirst lineDeep mechanical pain and passive restriction suggest glenohumeral osteoarthritis without an acute red flag.+
- 1Document sleep, dressing, grooming, work, mobility-aid use and goals and examine cuff, neck, acromioclavicular joint and neurology.
- 2Obtain orthogonal radiographs when diagnosis or treatment planning requires structural confirmation.
- 3Explain that symptoms and imaging correlate imperfectly and agree active treatment targets rather than a radiographic endpoint.
- 4Start tailored range and strengthening work, functional adaptation and the safest suitable short analgesic strategy.
02Stepwise non-operativeBuild function before proceduresSymptoms affect activity but urgent disease and immediate replacement need are absent.+
- 1Prescribe progressive glenohumeral range, cuff and scapular strengthening with supervised input when technique or confidence requires it.
- 2Consider a topical NSAID, then a time-limited oral NSAID with gastroprotection only after individual risk review.
- 3Use one intra-articular corticosteroid injection selectively when temporary relief will enable rehabilitation or clarify decisions.
- 4Review objective function and medicine toxicity; stop passive treatments that do not produce a meaningful gain.
03ReferralEscalate from lived impactEscalationPain, stiffness or loss of use substantially reduces quality of life and suitable conservative care is ineffective or unsuitable.+
- 1Refer for shoulder-arthroplasty assessment without demanding a numerical severity score or arbitrary age or BMI threshold.
- 2Provide radiographs and document cuff function, previous surgery, infection history, goals, comorbidity and support at home.
- 3Discuss anatomical versus reverse replacement as a specialist decision shaped by cuff function and bone pattern.
- 4Optimise modifiable risk and maintain movement and conditioning while the patient waits for assessment or surgery.
04Urgent alternativeLeave the osteoarthritis pathwayAlternativeFever, rapid collapse, trauma, severe rest pain, mass or neurovascular abnormality appears.+
- 1Assess physiology and limb threat and obtain immediate trauma imaging when relevant.
- 2Arrange same-day aspiration and orthopaedic review for suspected joint infection before injecting corticosteroid.
- 3Use CT, MRI or oncology pathways for rapid destruction, osteonecrosis or tumour according to the suspected process.
- 4Do not let a previous degenerative radiograph explain a new acute syndrome without reassessment.
Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
Topical diclofenac gel
Apply 2–4 g of diclofenac 1.16% gel to the painful shoulder at each use, up to three or four applications per day for a limited trial and never above the licensed product maximum.Avoid broken skin and NSAID hypersensitivity, consider cumulative exposure with oral NSAIDs, and follow pregnancy restrictions; even topical therapy can produce systemic adverse effects.
Oral NSAID plus proton-pump inhibitor
When suitable, use naproxen 250–500 mg orally twice daily with food at the lowest effective dose for the shortest period and add omeprazole 20 mg orally once daily while treatment continues when indicated.Review ulcer or bleeding history, kidney and liver function, heart failure, blood pressure, cardiovascular risk, frailty, anticoagulants and antiplatelets; avoid combining NSAIDs and apply pregnancy restrictions from 20 weeks.
Glenohumeral corticosteroid injection
Under an aseptic trained local protocol, give one intra-articular dose such as triamcinolone acetonide 20–40 mg, preferably with reliable anatomical or image-guided placement, and review before considering any repeat.Exclude infection, assess overlying skin and bleeding risk, warn about flare and rare septic arthritis, and arrange glucose monitoring after injection in people with diabetes.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Functional dependency
Loss of elevation and rotation impairs dressing, washing, transfers, mobility aids, work and sleep, particularly when the opposite shoulder is also affected.
Muscle wasting and stiffness
Pain avoidance reduces cuff, deltoid and scapular capacity and may add fixed capsular shortening to structural joint loss.
Analgesic toxicity
Long-term NSAIDs or opioids can cause gastrointestinal bleeding, kidney injury, cardiovascular events, falls, sedation and dependence without correcting joint mechanics.
Arthroplasty complications
Replacement carries risks of infection, instability, fracture, nerve injury, loosening, wear, stiffness and revision; reverse implants also have distinct scapular and acromial complications.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Review sleep, dressing, grooming, reach, work and use of mobility aids alongside active and passive range.
- Track strength and exercise progression, distinguishing pain inhibition from worsening cuff failure or neurological loss.
- Monitor NSAID gastrointestinal, renal, cardiovascular and blood-pressure safety and stop when no functional benefit is demonstrated.
- After injection, provide sepsis return advice, review glucose where relevant and record duration of meaningful response.
- Repeat imaging only for changed symptoms, rapid progression or a new surgical-planning question, not as routine surveillance.
- During a surgical wait, review anaemia, diabetes, smoking, skin health, anticoagulation planning, falls risk and rehabilitation support.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
The radiograph is not the disability
Joint-space loss confirms structure, but replacement referral depends on pain, function, goals and response to care rather than an image grade alone.
Cuff status changes the operation
A functioning cuff supports anatomical replacement mechanics; major deficiency may require a reverse design that relies more on deltoid power.
Passive loss localises the joint
When both patient and examiner cannot rotate or elevate the humerus, glenohumeral or capsular disease is more likely than isolated tendinopathy.
Crepitus needs context
Mechanical grinding supports arthritis but can coexist with painless radiographic change; reproduce the patient's symptom and excluded referred sources.
Injection is a bridge
Temporary relief can advance exercise or decision-making, but repeated short responses should prompt reassessment and timely surgical discussion.
Optimisation is not exclusion
Diabetes, smoking, obesity and frailty modify risk and preparation; they should not become unexamined reasons to deny specialist assessment.
11Common pitfallsFrequent interpretation and management errors.
- 01
Treating radiographic degeneration as the cause of all arm pain without examining the neck, cuff and acromioclavicular joint.
- 02
Calling a globally stiff shoulder adhesive capsulitis without obtaining radiographs when arthritis is plausible.
- 03
Using long-term NSAIDs or opioids without monitoring toxicity and a measurable functional benefit.
- 04
Injecting an acutely warm effusion before septic arthritis has been excluded.
- 05
Delaying replacement referral until an arbitrary imaging grade, age, BMI or scoring threshold is reached.
- 06
Failing to assess cuff integrity and glenoid bone pattern when planning the type of arthroplasty.