Shoulder Avascular Necrosis: Symptoms, Causes, Stages & Physiotherapy Management
Shoulder avascular necrosis (AVN), also known as osteonecrosis, is a condition that literally means “bone death.” While it most commonly affects the hip joint, it can also occur in the shoulder joint—though this is comparatively rare.
In shoulder avascular necrosis, the blood supply to a part of the humeral head (the “ball” of the shoulder joint) gets disrupted. When this happens, the affected bone tissue begins to die, weaken, and may eventually collapse. This leads to pain, stiffness, restricted movement, and eventually arthritis if left untreated.
Shoulder AVN can develop due to either traumatic or atraumatic causes, and early diagnosis plays a major role in improving outcomes.
What is Traumatic and Atraumatic AVN?
Shoulder osteonecrosis can broadly be divided into two types:
A) Traumatic Osteonecrosis
Traumatic osteonecrosis is caused by an external injury or fracture that affects the blood supply to the humoral head.
Common causes include:
Fracture of the humeral head
Fracture with shoulder dislocation
Fracture without dislocation
Surgical complications after shoulder procedures
This type is more commonly seen in elderly patients after falls or injuries, though it can occur at any age.
B) Atraumatic Osteonecrosis
Atraumatic osteonecrosis occurs without a direct injury and is usually associated with medical or lifestyle-related factors.
Common causes include:
Long-term or high-dose corticosteroid use
Excessive alcohol consumption
Blood disorders such as sickle cell anaemia
Autoimmune conditions
Idiopathic causes (when no clear cause is identified)
This form is more commonly seen in younger individuals and often progresses slowly.
Symptoms of Shoulder Avascular Necrosis
The symptoms of shoulder AVN may differ slightly depending on whether the condition is traumatic or atraumatic.
In Atraumatic Cases
Symptoms usually develop gradually over time and may initially be ignored because of their slow progression.
In Traumatic Cases
Symptoms may appear after an injury and may involve:
Fracture non-union
Malalignment
Soft tissue injury
Persistent pain after trauma
Common Symptoms in Both Types
Shoulder pain
Joint stiffness
Restricted range of motion
Weakness in the shoulder
Difficulty lifting the arm
Pain during overhead activities
Loss of joint mobility
Traumatic osteonecrosis is generally easier to detect because the symptoms are linked to a clear injury, whereas atraumatic osteonecrosis can remain unnoticed until the condition progresses.
Stages of Shoulder Osteonecrosis
Shoulder AVN progresses in stages, and treatment often depends on the stage of diagnosis.
Stage I
Normal X-ray findings. Changes are visible only on MRI (pre-radiographic stage)
Stage II
Sclerosis or mottling appears on X-ray. No collapse of the humeral head
Stage III
Subchondral fracture appears (“crescent sign”). Early collapse begins
Stage IV
Flattening and collapse of the humeral head
Stage V
Secondary arthritis develops and affects the glenoid (the socket of the shoulder joint)
What Does It Mean to Have This Condition?
If you have osteonecrosis of the shoulder joint, it means your shoulder is being affected because of reduced or absent blood supply to the joint.
Without proper blood circulation, the bone becomes weaker over time. As the condition progresses, patients begin to experience:
Increasing pain
Reduced joint mobility
Loss of strength
Difficulty performing daily activities
Progressive joint damage
This is a serious condition and requires timely medical attention. However, the good news is that in many early-stage cases, it can be managed conservatively—especially with physiotherapy.
Can Physiotherapy and Conservative Management Help Avoid Surgery?
Yes—especially in early stages (Stage I and Stage II), and even in some advanced cases, physiotherapy can help delay or avoid surgery.
Physiotherapy plays a major role in:
Reducing stress on the damaged bone
Maintaining shoulder movement
Preventing stiffness
Preserving joint function
Managing pain
Improving long-term shoulder health
It is effective in both traumatic and atraumatic AVN, although traumatic cases may require additional attention for fracture healing or post-surgical rehabilitation.
Evidence-Based Conservative Management for Shoulder AVN
1. Activity Modification (Most Important)
This is the most critical part of conservative treatment.
Strictly Avoid:
Overhead lifting
Heavyweight training
Push-ups
Dips
Supporting body weight on the arm
High-impact physical activities
Reducing these activities helps decrease mechanical stress on the necrotic area and may prevent or slow down joint collapse.
2. Pain-Controlled Gentle Movement (Early Phase)
Early movement is important—but only within pain-free limits.
Recommended Exercises:
Pendulum exercises (arm hanging circles)
Passive range-of-motion exercises
Assisted movement without strain
Goal:
To prevent frozen shoulder and maintain basic joint mobility.
3. Gradual Mobility Work
Once pain is under control, mobility can be gradually improved.
Helpful Exercises:
Table slides
Wall walks (supported)
Assisted shoulder elevation
Gentle rotation exercises
Important Rule:
Progress only if pain remains mild (3/10 or less).
4. Strengthening (Introduced Carefully)
Strengthening should be gradual and controlled.
Focus Areas:
Scapular stabilizers
Light rotator cuff strengthening
Postural correction muscles
Avoid:
Aggressive strengthening
Jerky movements
Heavy resistance training
The goal is stability—not overload.
5. Pain Management
Pain management is an essential part of rehabilitation and may include:
Ice therapy
Heat therapy (when appropriate)
Manual therapy
Postural correction
Joint protection strategies
Guided physiotherapy sessions
A structured rehabilitation program helps reduce symptoms and improve quality of life.
Final Thoughts
Shoulder avascular necrosis is a serious but manageable condition—especially when diagnosed early.
Understanding the symptoms, identifying the cause, and beginning physiotherapy at the right time can make a significant difference. Conservative treatment may help preserve the joint, reduce pain, and improve function without immediate surgery.
If you are experiencing persistent shoulder pain, stiffness, or difficulty moving your arm—especially after injury or prolonged steroid use—early evaluation is strongly recommended.
The earlier AVN is identified, the better the chances of protecting your shoulder joint and avoiding long-term damage.
Comments