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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Glenohumeral osteoarthritis

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Acute destructive pain needs urgent exclusion

A suddenly hot, swollen or rapidly painful shoulder, systemic illness, recent bacteraemia or injection, trauma, neurovascular change or unexpectedly rapid radiographic destruction may represent sepsis, fracture, dislocation, neuropathic arthropathy or malignancy rather than ordinary osteoarthritis.

Action: Assess observations and the whole limb, use urgent radiographs after trauma, obtain inflammatory tests and arrange same-day joint aspiration and orthopaedic review for suspected infection, and investigate rapid destruction or tumour without delaying behind a chronic osteoarthritis label.

Overview

Diagnose symptomatic glenohumeral osteoarthritis by combining mechanical symptoms, passive restriction and radiographs, exclude urgent destructive disease, deliver person-centred core care, and refer for arthroplasty according to impact rather than imaging alone.

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.

Practice

Two practice questions

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Question 1 of 2
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Musculoskeletal medicine and orthopaedicsOriginal SBA

Imaging and symptom discordance

A 71-year-old has deep shoulder pain, crepitus and restriction of passive external rotation. Radiographs show glenohumeral joint-space loss and an inferior osteophyte. Which statement should guide management?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG226 Osteoarthritis in over 16s RecommendationsCore treatments, medicine hierarchy, injection advice and joint-replacement referral principles.
  • British Elbow and Shoulder Society Patient Care Pathways and GuidelinesUK specialist shoulder pathway and operative planning context.
  • NHS OsteoarthritisSymptoms, activity, medicines and replacement overview.
  • NICE CKS Shoulder painPrimary-care localisation, imaging and red-flag assessment.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

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.

Aetiology

01

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.

02

Post-traumatic disease

Proximal humeral or glenoid fracture, recurrent dislocation and cartilage injury alter congruity and loading, causing earlier secondary joint failure.

03

Cuff-related arthropathy

A chronic massive cuff tear permits superior migration and abnormal contact, producing a biomechanically distinct arthropathy that influences implant choice.

04

Systemic or structural causes

Inflammatory arthritis, avascular necrosis, previous infection, dysplasia and haemophilic or neuropathic disease can destroy cartilage and require cause-specific management.

Pathophysiology

  1. 1
    Cartilage matrix loss

    Chondrocyte and matrix failure reduces smooth load distribution, narrows the joint space and exposes subchondral bone to higher focal stress.

  2. 2
    Subchondral remodelling

    Sclerosis, cyst formation and altered trabecular mechanics contribute to deep movement pain and reduced joint compliance.

  3. 3
    Osteophyte and capsular restriction

    Inferior humeral osteophytes, synovial irritation and capsular thickening produce crepitus and progressive loss of passive external rotation and elevation.

  4. 4
    Muscle-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.

Clinical features and red flags

Deep mechanical pain

Pain arises with use and often at night, feels deep rather than focal over the acromioclavicular joint, and progressively restricts daily reach.

Passive restriction and crepitus

External rotation and elevation are limited when the examiner moves the joint, often with a coarse or painful mechanical endpoint.

Radiographic concordance

Joint-space narrowing, inferior osteophyte, sclerosis and cysts support the diagnosis when they match the symptomatic side and movement pattern.

Cuff-tear arthropathy

Marked loss of active elevation, cuff weakness and superior humeral migration indicate altered mechanics rather than ordinary concentric primary disease.

Inflammatory pattern

Long morning stiffness, several active joints and systemic features suggest inflammatory arthritis and should redirect laboratory and specialist assessment.

Rapid destructive pattern

Fast collapse, systemic illness, severe rest pain or major sensory loss is atypical and requires infection, osteonecrosis, tumour and neuropathic disease exclusion.

Red flags requiring action

  • Fever, warmth, effusion and intense pain with small passive movements requires urgent septic arthritis assessment and aspiration before any steroid injection.
  • Acute pain and loss of function after trauma requires fracture-dislocation imaging even when previous films already demonstrated osteoarthritis.
  • Rapid structural collapse, major sensory loss or painless gross destruction raises neuropathic arthropathy, osteonecrosis, infection or tumour.
  • Persistent rest or night pain, weight loss, mass or cancer history requires oncological investigation rather than escalating routine analgesia.
  • New distal weakness, numbness, coolness or pulse abnormality requires neurological and vascular assessment beyond the degenerative joint.

Investigations

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

Differential diagnosis

01

Adhesive capsulitis

Both restrict passive movement, but capsulitis usually has preserved joint surfaces on radiographs and a characteristic evolution from severe pain to stiffness.

02

Rotator-cuff disease

Cuff-related pain commonly preserves passive range and produces weakness or a painful arc; large chronic tears may coexist with arthropathy.

03

Cervical or plexus disease

Neck provocation, pain below the elbow, sensory change, reflex loss or disproportionate weakness indicates a neurological source or additional lesion.

04

Inflammatory arthritis

Prolonged morning stiffness, several swollen joints, systemic manifestations or erosive change suggests rheumatoid or another inflammatory process.

05

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.

Management

01First-lineConfirm concordant joint diseaseFirst stepFirst lineDeep mechanical pain and passive restriction suggest glenohumeral osteoarthritis without an acute red flag.+
  1. 1Document sleep, dressing, grooming, work, mobility-aid use and goals and examine cuff, neck, acromioclavicular joint and neurology.
  2. 2Obtain orthogonal radiographs when diagnosis or treatment planning requires structural confirmation.
  3. 3Explain that symptoms and imaging correlate imperfectly and agree active treatment targets rather than a radiographic endpoint.
  4. 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.+
  1. 1Prescribe progressive glenohumeral range, cuff and scapular strengthening with supervised input when technique or confidence requires it.
  2. 2Consider a topical NSAID, then a time-limited oral NSAID with gastroprotection only after individual risk review.
  3. 3Use one intra-articular corticosteroid injection selectively when temporary relief will enable rehabilitation or clarify decisions.
  4. 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.+
  1. 1Refer for shoulder-arthroplasty assessment without demanding a numerical severity score or arbitrary age or BMI threshold.
  2. 2Provide radiographs and document cuff function, previous surgery, infection history, goals, comorbidity and support at home.
  3. 3Discuss anatomical versus reverse replacement as a specialist decision shaped by cuff function and bone pattern.
  4. 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.+
  1. 1Assess physiology and limb threat and obtain immediate trauma imaging when relevant.
  2. 2Arrange same-day aspiration and orthopaedic review for suspected joint infection before injecting corticosteroid.
  3. 3Use CT, MRI or oncology pathways for rapid destruction, osteonecrosis or tumour according to the suspected process.
  4. 4Do not let a previous degenerative radiograph explain a new acute syndrome without reassessment.
Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
Can provide local analgesia with less systemic exposure and may enable exercise and sleep.

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.

Offers a trial of stronger short-term pain control when topical treatment is ineffective or impractical.

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.

Provides short-lived symptom reduction that can support rehabilitation or a shared decision while awaiting definitive care.

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.

Complications

01

Functional dependency

Loss of elevation and rotation impairs dressing, washing, transfers, mobility aids, work and sleep, particularly when the opposite shoulder is also affected.

02

Muscle wasting and stiffness

Pain avoidance reduces cuff, deltoid and scapular capacity and may add fixed capsular shortening to structural joint loss.

03

Analgesic toxicity

Long-term NSAIDs or opioids can cause gastrointestinal bleeding, kidney injury, cardiovascular events, falls, sedation and dependence without correcting joint mechanics.

04

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.

Monitoring and follow-up

  • 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.

Special situations

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.

Common pitfalls

  1. 01

    Treating radiographic degeneration as the cause of all arm pain without examining the neck, cuff and acromioclavicular joint.

  2. 02

    Calling a globally stiff shoulder adhesive capsulitis without obtaining radiographs when arthritis is plausible.

  3. 03

    Using long-term NSAIDs or opioids without monitoring toxicity and a measurable functional benefit.

  4. 04

    Injecting an acutely warm effusion before septic arthritis has been excluded.

  5. 05

    Delaying replacement referral until an arbitrary imaging grade, age, BMI or scoring threshold is reached.

  6. 06

    Failing to assess cuff integrity and glenoid bone pattern when planning the type of arthroplasty.