Clinical Roadmap: Glenohumeral Joint Osteoarthritis

Clinical Roadmap · Shoulder

Glenohumeral Joint Osteoarthritis

Thinking Clinically · A guide for PT students and new grads

An older patient has a shoulder that has gradually gotten stiffer and more painful over months or years, with no single injury. It’s tempting to reach for “frozen shoulder” or “rotator cuff,” but glenohumeral osteoarthritis (GHOA) deserves a real seat at the table. This roadmap covers how to recognize it, confirm it, differentiate it from close competitors, and build a treatment approach around what the evidence actually supports.

1

Recognize It

• Middle-aged or older adult, with prevalence rising with age
• Deep, diffuse pain around the glenohumeral joint with gradual, progressive onset rather than a single injury
• Pain with reaching, lifting, pushing, or pulling, and increasing trouble reaching overhead, behind the back, and across the body
• Progressive loss of both active and passive ROM, with passive ER often the most restricted, and crepitus
• Strength limited more by pain and mechanical inefficiency than by true neurologic weakness. There may be a history of trauma, instability, surgery, or fracture
• Shorthand: older adult + progressive mechanical shoulder pain + global AROM/PROM loss + limited passive ER = think GHOA

2

Confirm It

• History: a slow build over months or years, starting with higher-demand activities and creeping into everyday tasks. Ask about prior trauma, instability, surgery, or high-load use, since secondary OA can follow any of these.
• AROM and PROM both restricted globally points toward a joint process rather than isolated tendon pathology.
• Passive ER particularly limited, a firm or hard end-feel as degeneration progresses, and crepitus during movement.
• AROM down with PROM preserved suggests a contractile, neurologic, or pain-inhibition problem. AROM and PROM down together suggests a joint or capsular restriction.
• A pathway cited in the APTA guideline describes GHOA as shoulder pain lasting more than 3 months, without instability or localized AC joint pain, with global ROM loss that is greatest in passive ER, and radiographs used to confirm the diagnosis.
• No validated special test cluster exists. Confidence comes from age, progressive mechanical history, global ROM loss with disproportionate ER restriction, and radiographs when appropriate. MRI isn’t automatically the next step. It is useful when more diagnostic clarification is needed.
• Weakness doesn’t automatically mean a rotator cuff tear, and excessive scapular motion may be compensation for a stiff glenohumeral joint rather than the problem itself.

3

Differentiate It

Condition	More likely if
Adhesive capsulitis	Closest look-alike. Favored with diabetes or prolonged immobilization and a painful-then-stiff evolution
RCRSP or cuff tear	Pain tracks with active loading, PROM preserved, weakness out of proportion to pain, or traumatic onset
AC joint osteoarthritis	Superior pain, a clearly tender AC joint, cross-body loading reproduces symptoms, GH PROM preserved
Cervical radiculopathy	Neck pain, neurologic distribution below the shoulder, numbness or tingling, or myotomal or reflex changes
Red flag or non-MSK causes	Severe or disproportionate pain, constitutional symptoms, fever, weight loss, or new neurologic or vascular findings

Don’t Miss This

• Neurologic deficits, severe unexplained pain, fever, or constitutional symptoms need further evaluation, not routine rehab.
• Continued decline in pain, ROM, or function despite an appropriate trial of conservative care, or goals beyond what it can achieve, are reasons to involve the referring provider or an orthopedic specialist.

4

Treat It

• Be honest about the evidence:
  The 2023 APTA guideline found insufficient evidence to identify one superior nonoperative PT intervention, and a 2026 systematic review reportedly found no eligible RCTs on physiotherapist-led nonsurgical care. The approach is impairment- and response-driven, not a validated protocol.
• Frame education carefully:
  The joint surfaces have changed, which makes the joint painful and stiff, but that doesn’t mean stopping use. Radiographic severity and symptoms don’t always match.
• Modify activity by irritability.
  High: reduce repetitive overhead work and prolonged end-range loading. Lower: progress resistance, overhead exposure, and functional demands.
• Use manual therapy as a symptom and mobility tool, not the whole treatment.
  Ask what is restricted, whether mobilization immediately improves it, and whether that carries over to active movement. One small RCT (30 participants completed it) found gains with exercise alone and with exercise plus manual therapy, with greater improvement in several outcomes in the manual therapy group. It is too small to support a universal protocol. Modify or stop if symptoms flare, nothing changes, or the patient becomes dependent on passive treatment.
• Build five areas one variable at a time:
  Mobility, rotator cuff strength, deltoid strength, scapular strength, and functional loading (reach, lift, carry, push/pull, overhead).
• Track more than one measure:
  ROM, strength, pain, function, and a patient-reported outcome score together, not a single number.

Key Takeaway

Think joint when both AROM and PROM are restricted together. Think glenohumeral OA when that pattern appears in an older adult with progressive mechanical pain and disproportionate passive ER loss. No single test or X-ray finding makes the diagnosis. Recognize the pattern, rule out close alternatives, and treat the patient’s pain, mobility, strength, and function, not just the X-ray.

Want the full field note?

This Clinical Roadmap is a condensed teaser. The complete field note will be in the upcoming Thinking Clinically Shoulder Field Guide, which will include:

• The complete examination sequence, with every test, finding, and interpretation
• A worked clinical reasoning question with the answer explained
• Common mistakes, progression criteria, and prognostic factors
• Treatment frameworks and exercise progressions in full detail

Need exercise ideas?

Watch exercise demonstrations and clinical reasoning videos on the Thinking Clinically YouTube channel: youtube.com/@Thinking.Clinically

References

1. Michener LA, Heitzman J, Abbruzzese LD, et al. Physical Therapist Management of Glenohumeral Joint Osteoarthritis: A Clinical Practice Guideline From the American Physical Therapy Association. Phys Ther. 2023;103(6):pzad041. doi:10.1093/ptj/pzad041
2. Khazzam M, Gee AO, Pearl M, et al. Management of Glenohumeral Joint Osteoarthritis. J Am Acad Orthop Surg. 2020;28(19):781–789. doi:10.5435/JAAOS-D-20-00404
3. American Academy of Orthopaedic Surgeons. Management of Glenohumeral Joint Osteoarthritis Clinical Practice Guideline. 2020.
4. Muhammad DG, Foster NE, Pelaez M, et al. The effectiveness of physiotherapy-led non-surgical and perioperative interventions for glenohumeral osteoarthritis: a systematic review. Shoulder Elbow. 2026. doi:10.1177/17585732261450961
5. Atan SG, Akbaba YA, Altun S. Are manual therapy applications an effective treatment approach in patients with glenohumeral arthritis? A randomized controlled trial. J Hand Ther. 2026.
6. Karimi AH, El-Abtah ME, Sinkler MA, et al. The role of conservative treatment of glenohumeral joint osteoarthritis: a systematic review. Semin Arthroplasty. 2024;34(1):34–43. doi:10.1053/j.sart.2023.07.012

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