There are many types of arthritis, but osteoarthritis is the most common form affecting the shoulder. It may develop after an injury, years of repetitive use, instability, rotator cuff disease, or gradual degeneration of the cartilage and other tissues that support the joint.
When shoulder movement hurts, people naturally begin using the arm less. This can create a second problem: the capsule and other soft tissues tighten, the muscles weaken, and usable motion declines. In more severe cases, osteoarthritis may coexist with adhesive capsulitis, commonly called frozen shoulder.
Glenohumeral osteoarthritis describes degeneration of the ball-and-socket joint formed by the humeral head and glenoid. X-rays may show joint-space narrowing, bone spurs, sclerosis, cysts, or deformity. These findings are important, but they do not answer the entire clinical question:
Is the arthritic joint actually the principal source of this patient’s pain?
That distinction matters. I do not treat an X-ray. I treat the patient.
Shoulder arthritis on imaging does not always match the pain
One patient may have advanced arthritis on an X-ray yet retain useful motion and manageable pain. Another may have only moderate arthritic change but severe pain because a rotator cuff tendon, biceps tendon, bursa, labrum, capsule, acromioclavicular joint, or unstable ligament is also involved.
A 2022 clinical review described traumatic injury, rotator cuff pathology, instability, glenoid dysplasia, and osteonecrosis among the conditions that may contribute to glenohumeral osteoarthritis. (1)
The practical point is that imaging identifies structural changes; it does not independently prove which structure is generating pain.
The shoulder examination: finding the pain generator
A useful shoulder examination should assess:
- Where the pain is felt and whether it travels down the arm
- Which movements reproduce the pain
- Active motion compared with passive motion
- Strength of the rotator cuff and surrounding muscles
- Tenderness over the biceps tendon, acromioclavicular joint, bursae, and tendon attachments
- Mechanical clicking, catching, or instability
- Prior dislocation, trauma, surgery, or injection history
- Neck pain, numbness, weakness, or other neurologic symptoms
X-rays help define the degree and pattern of arthritis. CT may be useful when bone loss, deformity, fracture, or replacement planning is a concern. MRI can evaluate cartilage, the rotator cuff, labrum, biceps, and other soft tissues. Electrodiagnostic testing may be appropriate when weakness or arm symptoms could arise from a cervical nerve or peripheral nerve injury.
Diagnostic ultrasound adds a dynamic examination. It can show portions of the rotator cuff, biceps tendon, bursae, and fluid while the shoulder is moving. It can also improve the accuracy of a glenohumeral injection. A 2025 systematic review found that ultrasound-guided injections were more accurate than landmark-guided injections, although the available trials did not consistently show superior clinical outcomes simply because ultrasound was used. (2)
Other conditions that can accompany shoulder osteoarthritis
Shoulder arthritis may be the main diagnosis while another structure supplies much of the pain. Common competing or accompanying diagnoses include:
- Rotator cuff tendinopathy or tearing
- Subacromial bursitis
- Biceps tendinopathy
- Labral injury
- Adhesive capsulitis
- Acromioclavicular-joint arthritis
- Glenohumeral instability
- Referred pain from the cervical spine
These problems do not all receive the same treatment. An injection placed inside the glenohumeral joint may not solve pain generated primarily by a torn tendon, unstable ligament, inflamed bursa, or cervical nerve.
A complete traumatic rotator cuff tear with acute weakness, fracture, suspected infection, recurrent dislocation with bone loss, or progressive neurologic deficit requires timely specialist evaluation.
First-line nonsurgical treatment
For many patients, treatment begins with activity modification, rehabilitation, and appropriate pain management. The goal is not indefinite rest. It is to preserve useful movement, improve muscular support, and reduce repeated loading that aggravates the joint.
A 2023 current-concepts review described three principal goals of physical therapy: decreasing pain, increasing shoulder range of motion, and protecting the glenohumeral joint. Rotator cuff strengthening may help protect the joint, while the structures limiting motion should be identified rather than forcing every stiff shoulder through the same program. (3)
Physical therapy may include:
- Gentle mobility work within a tolerable range
- Progressive rotator cuff and scapular strengthening
- Postural and movement retraining
- Modification of overhead and repetitive activities
- A gradual return to work, exercise, golf, tennis, or other sports
Therapy should be adjusted if exercise repeatedly causes a major pain flare, increasing night pain, or progressive loss of function. Rest pain and severe mechanical restriction may behave differently from pain that occurs only at the edge of motion.
What if conservative care has already failed?
Many people seeking another opinion have already tried therapy, medication, and injections and have been told to consider replacement. That history matters, but it does not establish that another injection will help. I want to know which treatments were tried, what each targeted, how long any relief lasted, and whether the examination still points to the arthritic joint.
A 2025 prospective cohort followed 62 patients who chose nonsurgical treatments for glenohumeral osteoarthritis. Roughly 30% achieved a clinically meaningful improvement, while 14 patients (23%) underwent shoulder replacement during follow-up. Because treatment was selected rather than randomly assigned, the study cannot establish which individual treatment worked best. Avoiding surgery during a short follow-up period also does not necessarily mean that pain resolved. (4)
The practical goal is useful improvement: sleeping more comfortably, dressing, reaching, or returning to a valued activity. Some patients improve substantially, some partially, and some do not. A reasonable plan includes a time to reassess rather than repeating an unsuccessful treatment indefinitely.
Medication and corticosteroid injections
Medication options may include acetaminophen, topical or oral anti-inflammatory medication, and other symptom-directed drugs when medically appropriate. A 2022 review emphasized that pharmacologic treatment is usually one part of management and does not correct the mechanical or structural causes of glenohumeral osteoarthritis. (5)
A corticosteroid injection may temporarily reduce inflammation and pain. It does not rebuild cartilage, repair a torn rotator cuff, or correct instability. Repeated injections should not be presented as a regenerative strategy. Their use should also be coordinated carefully when shoulder replacement is being considered because timing, infection risk, tissue health, and the individual patient’s medical situation may affect decision-making.
A 2024 retrospective study of 230 shoulder-replacement patients found that judicious corticosteroid use during the preceding year was not associated with worse patient-reported outcomes at a minimum of two years after surgery. This addresses later pain and function; it does not establish that every injection schedule is safe or remove concerns about infection risk close to surgery. The operating surgeon should guide timing. (6)
Hyaluronic acid injections
Hyaluronic acid is intended to supplement the lubricating and shock-absorbing properties of joint fluid. A 2023 systematic review and meta-analysis reported improvement from baseline in patients receiving hyaluronic acid and found signals of benefit compared with corticosteroid injections. However, the included trials differed in design, patient selection, products, injection schedules, and comparators. (7)
The evidence is conflicting. The American Academy of Orthopaedic Surgeons’ 2020 guideline concluded that strong evidence showed no benefit from hyaluronic acid for glenohumeral osteoarthritis. That guideline predates the 2023 review, but the later review does not erase the uncertainty or establish cartilage restoration. Hyaluronic acid should therefore not be presented as an established effective treatment for shoulder arthritis. (8)
PRP injections for glenohumeral osteoarthritis
Platelet-rich plasma is prepared from the patient’s blood. The resulting preparation contains concentrated platelets and signaling proteins, but PRP products are not identical. Platelet concentration, leukocyte content, activation, processing, and injection technique vary among studies and clinics.
In a randomized, double-blind trial involving 70 patients with chronic glenohumeral osteoarthritis, one ultrasound-guided leukocyte-poor PRP injection was compared with one hyaluronic-acid injection. Both groups improved in pain and function, but there were no significant between-group differences in the principal outcomes through 12 months. (9)
Both groups improved, and PRP was not proven superior to hyaluronic acid. Because there was no saline or sham-injection group, this study also cannot establish how much of the improvement was caused by either preparation rather than other influences, including the course of symptoms and the injection encounter itself.
What updated injection research shows
A 2026 systematic review of randomized trials evaluated bone marrow aspirate and bone marrow aspirate concentrate across several orthopedic conditions. Some trials reported improvements in pain and function, but superiority over comparison treatments was inconsistent. Results from knees, tendon surgery, or other diagnoses cannot be assumed to apply to an arthritic shoulder. The shoulder-specific evidence remains small. (10)
An evidence-based multispecialty consensus report similarly concluded that the evidence supporting PRP and bone marrow aspirate concentrate for shoulder osteoarthritis remains limited compared with the much larger knee osteoarthritis literature. (11)
The AAOS guideline also stated, by consensus in the absence of reliable evidence, that injectable biologics such as PRP and stem-cell treatments could not be recommended for glenohumeral osteoarthritis. Subsequent trials add information, but they have not established routine effectiveness for every patient. (8)
Improved pain and function are meaningful outcomes. They are not the same as proven cartilage regrowth.
PRP compared with bone marrow aspirate concentrate
PRP and bone marrow aspirate concentrate, or BMAC, are different autologous products.
PRP is derived from blood and contains platelets and associated signaling proteins. BMAC is prepared from a patient’s bone marrow aspirate and contains platelets, cytokines, marrow cells, and a small population of stromal or progenitor cells. It is not a purified stem-cell product, and same-day BMAC is not culture-expanded MSC therapy.
At present, there is no high-quality shoulder trial demonstrating that BMAC is consistently superior to PRP for glenohumeral osteoarthritis. If either procedure is considered, the decision should be based on:
- The structure believed to be causing the pain
- The degree of cartilage loss and bone deformity
- Rotator cuff integrity
- The presence of instability, bursitis, or tendon disease
- Previous treatment response
- The patient’s functional goals and treatment burden
The word “stem cell” should not be used to promise a stronger treatment, cartilage regrowth, or avoidance of surgery.
Bone marrow aspirate is not the same as bone marrow concentrate
Unconcentrated bone marrow aspirate, sometimes described as whole bone marrow, is collected marrow used without the concentration step. BMAC is processed to concentrate selected components. Neither name tells you the exact cell count, composition, or clinical effect. A study of one preparation should not be used as proof for another.
A small randomized pilot trial compared unconcentrated bone marrow aspirate with corticosteroid for shoulder osteoarthritis. It included 25 shoulders in 22 patients and stopped early. At 12 months, the between-group difference in change on the primary Western Ontario Osteoarthritis of the Shoulder score did not reach statistical significance. Some secondary measures favored marrow, but the small sample and early termination limit confidence. This was not a trial demonstrating that BMAC is superior to PRP or that marrow regrows cartilage. (12)
What our shoulder study contributes
In our 2019 report, we analyzed outcomes in 47 patients representing 50 shoulders treated for osteoarthritis, rotator cuff tears, or both. Patients received one or two injections using bone marrow concentrate or whole bone marrow. Reported overall improvement averaged about 42% in the one-injection group and 50% in the two-injection group. These numbers describe patients’ reported degree of improvement; they are not success rates. (13)
This was an observational analysis without a randomized control group. The preparations were used during different time periods, the diagnostic groups were mixed, and disease severity was not accounted for. It cannot establish that one preparation was better, that two injections caused better results, or that the improvement exceeded placebo or other care. It also did not demonstrate cartilage regrowth.
The findings support further study and a careful discussion of expectations. Readers can review the separate summary of our bone marrow shoulder research for additional detail.
When shoulder replacement becomes reasonable
Shoulder replacement may provide substantial pain relief for patients with advanced joint destruction, severe motion loss, and persistent disability after reasonable nonsurgical care. Surgery becomes more compelling when the structural disease, symptoms, examination, and functional limitations all point to the glenohumeral joint.
An injection cannot correct severe glenoid deformity, reconstruct missing bone, or reliably restore a nonfunctional rotator cuff. Conversely, arthritis on an X-ray alone does not mean that replacement is immediately necessary.
The major replacement options include:
- Anatomic total shoulder replacement: generally relies on a functional rotator cuff and attempts to reproduce normal shoulder anatomy.
- Reverse total shoulder replacement: changes the mechanics of the joint so the deltoid can contribute more to elevation; it is often considered when the rotator cuff is deficient, although indications have expanded.
The selection is individualized according to rotator cuff integrity, glenoid anatomy, bone quality, age, activity requirements, and surgeon assessment.
Does failed arthroscopic surgery prevent a successful replacement?
Many patients worry that a previous unsuccessful arthroscopic procedure has reduced their chance of benefiting from shoulder replacement. A matched cohort study evaluated patients younger than 70 who underwent total shoulder replacement either directly or after failed comprehensive arthroscopic management. Both groups improved, and failure rates were not significantly different in that study. (14)
This does not mean that every previous operation is inconsequential. The effect may depend on the procedure, infection history, scar tissue, rotator cuff condition, bone loss, and other patient factors. It does show that prior arthroscopy does not automatically rule out a successful replacement.
What satisfaction research shows after reverse shoulder replacement
A 2024 systematic review included 5,234 patients and 5,288 shoulders treated with reverse total shoulder replacement. Reported satisfaction ranged from approximately 78% to 88%, depending on the satisfaction measure used. Patients treated for glenohumeral osteoarthritis reported better satisfaction than those treated for cuff-tear arthropathy or massive rotator cuff tears. (15)
These are generally favorable results, but they also show that replacement does not guarantee a normal or pain-free shoulder for every patient.
Anatomic versus reverse replacement: will the shoulder feel normal?
A 2025 comparative study examined patients who achieved a very high patient-reported shoulder score after anatomic or reverse total shoulder replacement. Among the broader groups studied, 40% of anatomic replacement patients and 26% of reverse replacement patients reached the study’s threshold for perceiving the shoulder as close to normal. Among high-performing patients, the anatomic group demonstrated better motion and greater ability to perform demanding work, sport, and lifting tasks. Similar patterns were seen in the subgroup with osteoarthritis and an intact rotator cuff. (16)
This was not a randomized comparison, and the patients selected for the two operations may differ in important ways. It does not prove that implant choice alone caused the difference. This does not mean an anatomic replacement is always preferable. A reverse replacement may be the appropriate operation when the rotator cuff or anatomy cannot support an anatomic implant. The study helps clarify expectations: pain relief and satisfaction may be high after either procedure, while the highest functional ceiling may differ.
Persistent pain after shoulder replacement
Pain after replacement requires a different diagnostic approach. Possible causes include:
- Infection
- Implant loosening or wear
- Fracture
- Instability
- Rotator cuff or deltoid dysfunction
- Nerve injury
- Acromial or scapular stress injury
- Pain from surrounding tendons, bursae, or the cervical spine
Injections should not be placed casually into a replaced joint because infection around an implant can be devastating. Persistent or increasing pain, fever, drainage, new deformity, or sudden loss of function requires prompt evaluation.
References
1 Stanborough RO, Bestic JM, Peterson JJ. Shoulder Osteoarthritis. Radiologic clinics of North America. 2022;60(4):593-603. doi:10.1016/j.rcl.2022.03.003.
2 Enriquez R, Jones E, Özçakar L, Jain NB. Accuracy and Efficacy of Ultrasound-Guided Glenohumeral Joint Injections: A Systematic Review. American journal of physical medicine & rehabilitation. 2025;104(12):1071-1085. doi:10.1097/phm.0000000000002786.
3 Yamamoto N, Szymski D, Voss A, Ishikawa H, Muraki T, Cunha RA, Ejnisman B, Noack J, McCarty E, Mulcahey MK, Itoi E. Non-operative management of shoulder osteoarthritis: Current concepts. Journal of ISAKOS : joint disorders & orthopaedic sports medicine. 2023;8(5):289-295. doi:10.1016/j.jisako.2023.06.002.
4 Su F, Sampson H, Anigwe C, Ma CB, Lansdown DA, Feeley BT. Effectiveness of nonoperative treatment in patients with glenohumeral osteoarthritis: a prospective cohort study. JSES international. 2025;9(2):404-410. doi:10.1016/j.jseint.2024.08.189.
5 Al-Mohrej OA, Prada C, Leroux T, Shanthanna H, Khan M. Pharmacological Treatment in the Management of Glenohumeral Osteoarthritis. Drugs & aging. 2022;39(2):119-128. doi:10.1007/s40266-021-00916-9.
6 Cooper BJ, Kesinger A, Welch GE, Carroll JM, Lutz A, Shanley E, Thigpen CA, Tolan SJ, Kissenberth MJ, Pill SG. Judicious use of corticosteroid injections prior to shoulder arthroplasty does not compromise outcomes at a minimum of 2 years following surgery. Journal of shoulder and elbow surgery. 2024;33(6S):S49-S54. doi:10.1016/j.jse.2024.03.006.
7 Familiari F, Ammendolia A, Rupp MC, Russo R, Pujia A, Montalcini T, Marotta N, Mercurio M, Galasso O, Millett PJ, Gasparini G, de Sire A. Efficacy of intra-articular injections of hyaluronic acid in patients with glenohumeral joint osteoarthritis: A systematic review and meta-analysis. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 2023;41(11):2345-2358. doi:10.1002/jor.25648.
8 American Academy of Orthopaedic Surgeons. Management of Glenohumeral Joint Osteoarthritis Evidence-Based Clinical Practice Guideline. March 23, 2020.
9 Kirschner JS, Cheng J, Creighton A, Santiago K, Hurwitz N, Dundas M, Beatty N, Kingsbury D, Konin G, Abutalib Z, Chang R. Efficacy of Ultrasound-Guided Glenohumeral Joint Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Hyaluronic Acid in the Treatment of Glenohumeral Osteoarthritis: A Randomized, Double-Blind Controlled Trial. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2022;32(6):558-566. doi:10.1097/jsm.0000000000001029.
10 Dias Batista J, Dias Silva L, Dias Batista J, Santos Pereira G, da Silva ML. Efficacy and safety of bone marrow aspirate and bone marrow aspirate concentrate in orthopedic conditions: a systematic review of randomized controlled trials. Frontiers in surgery. 2026;13():1932090. doi:10.3389/fsurg.2026.1932090.
11 D’Souza RS, Her YF, Hussain N, Karri J, Schatman ME, Calodney AK, Lam C, Buchheit T, Boettcher BJ, Chang Chien GC, Pritzlaff SG, Centeno C, Shapiro SA, Klasova J, Grider JS, Hubbard R, Ege E, Johnson S, Epstein MH, Kubrova E, Ramadan ME, Moreira AM, Vardhan S, Eshraghi Y, Javed S, Abdullah NM, Christo PJ, Diwan S, Hassett LC, Sayed D, Deer TR. Evidence-Based Clinical Practice Guidelines on Regenerative Medicine Treatment for Chronic Pain: A Consensus Report from a Multispecialty Working Group. Journal of pain research. 2024;17():2951-3001. doi:10.2147/jpr.s480559.
12 Dwyer T, Hoit G, Lee A, Watkins E, Henry P, Leroux T, Veillette C, Theodoropoulos J, Ogilvie-Harris D, Chahal J. Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial. Arthroscopy, sports medicine, and rehabilitation. 2021;3(5):e1431-e1440. doi:10.1016/j.asmr.2021.07.005.
13 Darrow M, Shaw B, Schmidt N, Boeger G, Budgett S. Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections. Cogent Medicine. 2019;6(1):1628883. doi:10.1080/2331205X.2019.1628883.
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15 Smith KL, Karimi A, Harlow ER, Gillespie RJ, Chen RE. Defining patient satisfaction after reverse total shoulder arthroplasty: a systematic review. Journal of shoulder and elbow surgery. 2024;33(10):2298-2305. doi:10.1016/j.jse.2024.03.036.
16 Beleckas CM, Schodlbauer DF, Mousad AD, Levy JC. Evaluation of new normal after shoulder arthroplasty: comparison of anatomic vs. reverse total shoulder arthroplasty. Journal of shoulder and elbow surgery. 2025;34(6S):S43-S49. doi:10.1016/j.jse.2025.02.010.
This article provides general education and does not replace an individual medical evaluation.