Shoulder Osteoarthritis: Overview and Evidence Summary

Condition Overview

Shoulder osteoarthritis (OA), or glenohumeral osteoarthritis, is a degenerative joint condition characterized by the gradual breakdown of articular cartilage, changes in subchondral bone, synovial inflammation, and progressive functional limitation. Although the shoulder is not a weight-bearing joint, it endures complex multidirectional forces and relies heavily on the interplay between the glenohumeral joint, scapulothoracic articulation, and rotator cuff. When degeneration occurs, the consequences are felt not only in the joint itself but throughout the entire kinetic chain that supports shoulder motion.

In its earliest stages, OA often presents subtly—perhaps a dull ache at the end of a long day or stiffness after holding the arm in one position. Over time, symptoms become more persistent: deep joint pain, a grinding or catching sensation with movement, fatigue of the surrounding musculature, and gradual loss of range of motion. External rotation often becomes limited early, affecting everyday tasks such as grooming, reaching overhead, or fastening clothing.

Shoulder OA can be classified as either primary, where the cause is idiopathic and linked to age-related changes, or secondary, where degeneration arises after trauma, surgery, rotator cuff tears, chronic instability, or systemic disease. Increasingly, research highlights the importance of rotator cuff integrity in preserving joint health. When the cuff becomes insufficient—due to chronic tears or longstanding tendinopathy—the humeral head may migrate superiorly, altering normal biomechanics and accelerating cartilage wear. This condition, known as cuff tear arthropathy, behaves differently than classic OA and requires a modified therapeutic approach.

Unlike the hip or knee, many individuals with shoulder OA continue functioning for years, compensating through altered movement patterns and muscular adaptation. Yet for others, the gradual erosion of mobility and confidence can profoundly affect quality of life. The emotional component cannot be overlooked; loss of shoulder function often affects sleep, work, sport, and self-care, contributing to frustration and, in some cases, fear of movement.

The good news is that shoulder OA is highly responsive to conservative management. Well-designed rehabilitation programs—focused on restoring joint mechanics, improving motor control, reducing strain on vulnerable tissues, and optimizing the entire upper-body kinetic chain—can significantly improve comfort and restore meaningful function, even in individuals with advanced radiographic changes.

Summary of Current Evidence for Shoulder Osteoarthritis

Evidence-Based Management Discussion

Understanding Degenerative Processes in the Glenohumeral Joint

While cartilage breakdown is the hallmark of OA, degeneration rarely occurs in isolation. The shoulder is a complex, interdependent system. As cartilage thins, the joint space narrows; subchondral bone responds by becoming denser; synovial irritation produces intermittent inflammation; and the capsule gradually stiffens, further restricting movement. Muscles respond with protective guarding or disuse atrophy, and joint mechanics become increasingly compromised.

Unlike lower-limb OA, where compressive forces predominate, shoulder OA is shaped by rotational shearing, repetitive overhead demands, muscular imbalance, and sometimes decades-old injuries that went unnoticed at the time. The rotator cuff plays a major protective role by keeping the humeral head aligned within the glenoid; when cuff function declines, even slightly, loading patterns shift dramatically, accelerating wear.

It is also important to note that symptoms do not always correlate with imaging. Some individuals with severe radiographic OA experience only mild stiffness, while others with moderate findings report significant disability. Understanding this variability is key to individualized care.

Clinical Presentation and Functional Limitations

Patients often describe a deep, poorly localized ache that worsens with activity and improves with rest. Crepitus—described variously as grinding, crunching, or “sandpaper in the joint”—is frequently reported. Range-of-motion loss tends to follow a predictable pattern: external rotation first, then abduction, then internal rotation. Strength may appear reduced, but often the limitation is due to pain inhibition or altered biomechanics rather than true muscle weakness.

Sleep disturbance is common, as is difficulty with tasks requiring rotation: reaching overhead into cupboards, fastening a bra, or putting on a coat. Some individuals report a sense of fatigue in the arm during sustained activity, reflecting the increased workload placed on the surrounding musculature as the joint becomes less efficient.

Exercise Therapy

Exercise is the cornerstone of conservative management. While exercise cannot reverse structural degeneration, it can dramatically improve the way the joint behaves, reducing pain and improving movement efficiency.

Restoring Mobility and Reducing Capsular Restriction

Gentle, controlled stretching helps maintain or improve joint play. Many patients respond well to slow, sustained stretches targeting the anterior and posterior capsules. Mobilization-with-movement techniques may also be useful, as they combine stretching with functional activities.

Strengthening the Rotator Cuff and Scapular Stabilizers

Strengthening should be tailored to irritability levels. For some, low-load, high-repetition work is more appropriate, while others benefit from progressive resistance training.

Key goals include:

• Improving centration of the humeral head

• Reducing excessive superior translation during elevation

• Restoring endurance of the external rotators and subscapularis

• Enhancing the ability of the scapula to upwardly rotate, posteriorly tilt, and stabilize dynamically

These improvements reduce joint stress, conserve energy, and improve comfort.

Thoracic Spine Mobility and Postural Training

The shoulder cannot function optimally atop a stiff or kyphotic thoracic spine. Increasing thoracic extension and rotational mobility can have profound effects on glenohumeral mechanics, reducing impingement-like sensations and improving the efficiency of overhead motion.

Kinetic Chain Integration

The shoulder rarely works alone. Core stability, trunk rotation, pelvic alignment, and lower-limb mechanics all influence how force travels to the arm—particularly in active adults or athletes. Addressing deficits in the kinetic chain offloads the shoulder and supports more efficient movement patterns.

Manual Therapy

Manual therapy plays a meaningful supportive role. While it does not alter the underlying degenerative process, it helps patients move more freely, reduces muscular guarding, and creates an environment in which therapeutic exercise can be more effective.

Common interventions include:

• Glenohumeral joint mobilizations

• Soft tissue techniques targeting the posterior cuff, upper trapezius, pecs, and deltoid

• Thoracic spine mobilization

• Assisted stretching to gently challenge capsular tightness

Across the literature, manual therapy’s best outcomes occur when combined with exercise rather than used as a stand-alone intervention.

Pain Management and Injections

NSAIDs and analgesics may help patients stay active and engaged in their rehabilitation plan. Corticosteroid injections can provide meaningful short-term relief, especially when night pain or inflammatory flares limit progress. These injections are not curative but can open a therapeutic window during which the patient is more comfortable participating in rehabilitation.

Biologic treatments such as PRP and viscosupplementation remain under investigation in the shoulder. Some individuals report benefits, but evidence remains inconsistent, and these interventions are not considered first-line care.

Surgical Pathways and Expected Outcomes

Surgery becomes a consideration when conservative management no longer provides relief or when functional limitations interfere with daily life. Options include:

• Total shoulder arthroplasty (TSA): best for patients with intact rotator cuffs

• Reverse total shoulder arthroplasty (RTSA): ideal for cuff tear arthropathy or massive, irreparable cuff tears

• Hemiarthroplasty: used more selectively today, often in younger patients with isolated humeral head degeneration

Modern shoulder arthroplasty procedures have excellent outcomes, with many patients achieving substantial pain relief and functional improvement.

Clinical Considerations for Therapists

Therapists play a key role in guiding patients through a long-term management plan. This involves:

• Building realistic expectations

• Tailoring exercise to current irritability levels

• Addressing compensatory adaptations

• Encouraging consistent home practice

• Supporting psychological resilience as patients navigate a chronic condition

The goal is not just to improve mobility but to restore confidence in movement, allowing patients to engage more fully in their daily lives.

References

Matsen, F., et al. “Shoulder Osteoarthritis: Pathophysiology and Clinical Management.” Journal of Bone and Joint Surgery, 2013.

Lo, I., et al. “Glenohumeral Osteoarthritis: Diagnosis and Treatment Considerations.” Journal of Shoulder and Elbow Surgery, 2019.

Hanchard, N., et al. “Best Practice for Conservative Management of Shoulder Osteoarthritis.” Physiotherapy Journal, 2015.

Kontaxis, A., et al. “Biomechanics of Shoulder Degeneration: Implications for Therapy.” Clinical Orthopaedics and Related Research, 2010.

Singh, J., et al. “Effectiveness of Corticosteroid Injections in Glenohumeral Osteoarthritis.” BMC Musculoskeletal Disorders, 2020.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.