Glenohumeral osteoarthritis — Rapid

Synopsis

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.

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.

Key red flags

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.

Investigation priorities

First-line clinical and functional assessmentFirst stepFirst line

Establish whether pain and passive restriction arise from the glenohumeral joint and quantify quality-of-life impact.

First-line structural imaging with radiographsFirst line

Confirm osteoarthritis, identify humeral and glenoid pattern and exclude fracture or gross destructive disease.

Management branches

First-lineConfirm concordant joint disease

Deep mechanical pain and passive restriction suggest glenohumeral osteoarthritis without an acute red flag.

Document sleep, dressing, grooming, work, mobility-aid use and goals and examine cuff, neck, acromioclavicular joint and neurology.
Obtain orthogonal radiographs when diagnosis or treatment planning requires structural confirmation.
Explain that symptoms and imaging correlate imperfectly and agree active treatment targets rather than a radiographic endpoint.
Start tailored range and strengthening work, functional adaptation and the safest suitable short analgesic strategy.

Key medicines

Topical diclofenac gelApply 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 inhibitorWhen 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.

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