Orthopedic Referral and Management for Severe Glenohumeral Osteoarthritis

Indications for Orthopedic Referral

Persistent shoulder pain despite a trial of physical therapy, NSAIDs, and activity modification warrants referral to orthopedics. American Academy of Orthopaedic Surgeons (AAOS) recommendation. 1
Significant functional limitation that interferes with activities of daily living or quality of life is an indication for orthopedic referral. AAOS recommendation. 1
Failure of nonsurgical treatments, including injectable corticosteroids (evidence for steroid benefit is inconclusive), should prompt referral. AAOS consensus. 4
Chronologic age alone should not preclude surgical evaluation; total shoulder arthroplasty can markedly improve pain and function even in very elderly patients. AAOS recommendation. [1][2]

Treatment decisions are driven primarily by the severity of symptoms (pain intensity and functional impairment). AAOS guideline. Strength: not explicitly graded. 2
Patient characteristics and goals (e.g., activity expectations, comorbidities) are essential considerations in selecting therapy. AAOS guideline. Strength: not explicitly graded. [1][3]4

Structured physical‑therapy programs and activity modification are first‑line conservative measures. AAOS recommendation. 1
Intra‑articular viscosupplementation may be offered as a weakly recommended option for symptom relief. AAOS weak recommendation. 2

Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty for glenohumeral osteoarthritis, providing superior pain relief and a lower revision‑rate (≈0 % for primary TSA vs ≈14 % revision of hemiarthroplasty). AAOS moderate‑level recommendation. 2
Both TSA and hemiarthroplasty produce significant improvements in pain, shoulder function, and overall quality of life. AAOS recommendation. 2

An irreparable rotator‑cuff tear is a consensus contraindication to TSA; rotator‑cuff integrity must be confirmed before proceeding. AAOS consensus recommendation. [1][3]

Do not dismiss surgical options solely based on advanced age; functional status and patient goals are more relevant. AAOS recommendation. 1
Do not delay referral when symptoms are significant and radiographic disease is advanced, as the condition is unlikely to improve spontaneously. AAOS recommendation. 1
Ensure rotator‑cuff integrity is assessed before planning TSA to avoid performing the procedure in the presence of an irreparable tear. AAOS consensus. [1][3]