Osteonecrosis (AVN) of the Shoulder Treatment

Bone is living tissue with its own blood supply, and when that supply is interrupted the bone dies. In the shoulder this happens at the humeral head, the ball at the top of the arm bone, and the process is quiet for a long time before it is not. Patients often have no symptoms through the early stages, then develop deep aching pain as the weakened bone begins to lose its round shape.

Osteonecrosis is quiet until it is not, and catching it before the joint surface collapses changes what can be offered. Steven Struhl, MD is board certified in orthopedic surgery and separately in sports medicine, has practiced in New York since 1991, and serves as an attending surgeon at NYU Hospital for Joint Diseases, where he treats this condition from early stage disease through joint replacement.

What Osteonecrosis Is

Also called avascular necrosis or AVN, it is the death of bone tissue caused by loss of blood supply. The humeral head is the second most common site in the body after the hip, and the damage progresses in a recognizable sequence.

The bone dies first, which produces no symptoms. It then weakens, which begins to. Eventually the weakened bone beneath the cartilage fractures and the round surface of the ball flattens, and once that shape is lost the joint no longer moves smoothly against the socket.

Causes and Risk Factors

• Corticosteroid Use: long term or high dose steroid treatment, the most common non traumatic cause.
• Prior Fracture: a proximal humerus fracture disrupting the blood supply.
• Sickle Cell Disease: blocked circulation within the small vessels supplying the bone.
• Excessive Alcohol Use: a well established contributor to non traumatic osteonecrosis.
• Radiation Treatment: prior radiation to the region affecting bone vascularity.
• Decompression Sickness: nitrogen bubble formation in divers, historically caisson disease.

A meaningful number of cases have no identifiable cause. Patients frequently develop it in more than one joint, so someone with known hip osteonecrosis reporting new shoulder pain deserves imaging rather than reassurance.

Symptoms and Staging

• Early Stage: no symptoms at all, with changes visible only on MRI.
• Progressing Stage: deep aching pain in the shoulder, often worse at night and at rest.
• Collapse Stage: pain with motion, grinding, and progressive loss of range.
• Late Stage: arthritic change extending to the socket, resembling shoulder arthritis.

Because plain X rays appear normal in the earliest stage, MRI is the study that establishes the diagnosis when suspicion exists. That single decision is the most consequential one in this condition.

Treatment

• Observation And Modification: monitoring with imaging while reducing load through the joint.
• Medication Management: pain control alongside treatment of any contributing condition.
• Physical Therapy: maintaining range of motion and surrounding muscular strength.
• Core Decompression: drilling into the affected area to relieve pressure and stimulate blood supply.
• Shoulder Replacement: partial or total, once the head has collapsed.

Core decompression is a joint preserving option and it works best before the surface has collapsed. That is the practical argument for imaging a patient with unexplained deep shoulder pain and a steroid history rather than treating them empirically for months.

Schedule a Shoulder Evaluation in New York City

Deep shoulder pain that is worse at rest and at night, particularly in someone with a history of steroid treatment, sickle cell disease, or a prior shoulder fracture, is worth imaging rather than treating empirically, because the options narrow considerably once the joint surface collapses. Dr. Struhl evaluates osteonecrosis at his Manhattan and White Plains offices. Contact the practice to schedule an appointment.