Avascular Necrosis of the Shoulder

Avascular necrosis of the shoulder is a condition in which the blood supply to the head of the humerus fails and an area of bone dies. It is sometimes called osteonecrosis. Without treatment, the weakened bone can cave in and the joint can wear out. This page explains the causes, stages, tests and treatment, including options in turkey.

What is avascular necrosis of the shoulder?

"Avascular" means without blood vessels and "necrosis" means tissue death. Living bone constantly renews itself, and it needs a steady flow of blood to do that. When flow to a patch of the humeral head stops, the cells in that patch die and the area can no longer repair normal daily stress.

The cartilage on top is not yet harmed at first. As the underlying bone softens, the surface may buckle like the shell of a boiled egg that someone has pressed. Doctors call this humeral head collapse. After that, the socket wears and arthritis follows.

Who gets it?

It is more often seen in people between 30 and 60 than classic wear-and-tear arthritis, and it is less common than the same problem in the hip. Many patients have a clear risk factor, such as months of high-dose steroids for asthma, lupus or an organ transplant, or sickle cell disease. Some have no known cause.

How serious is it?

The condition is not life-threatening, yet it can be disabling. Small, early areas sometimes stay stable for years. Larger areas near the weight-bearing centre of the ball tend to progress. Speed of progression is hard to predict, which is why regular review and imaging matter after a diagnosis.

How is this page organised?

We start with anatomy and blood supply, then staging, tests and look-alike problems. After that we cover joint-saving treatments, replacement surgery and travel planning. Our shoulder hub links to related pages, and the free case review is available when you want an opinion on your scans.

To understand why bone in the shoulder can die, it helps to know how fragile the blood supply of the humeral head is. Unlike muscles, which have rich blood flow, the ball of the joint depends on a small number of vessels that can fail after injury, drugs or disease.

How does the humeral head get its blood?

Two main arteries feed the upper humerus: the anterior and posterior circumflex humeral arteries. They send branches into the bone, mostly through the front groove and around the neck of the humerus. Because the head is covered by cartilage on most of its surface, blood must arrive through narrow channels near its base.

The ball itself is a rounded cap, about 4 to 5 cm across in adults, that sits against the shallow socket of the shoulder blade (the glenoid). A thick layer of cartilage covers both surfaces. Muscles of the rotator cuff surround the joint and keep the ball centred while the arm moves.

What goes wrong in the bone?

Scan reports often call this pattern humeral head osteonecrosis, and you may see that phrase on your own paperwork. It means the same thing as the title of this page: a patch of the ball has lost its blood supply, and the bone inside it is no longer alive or able to renew itself.

When blood flow stops, the bone marrow and the bone cells within the affected zone die over days to weeks. The body then tries to repair the area by growing new vessels and removing dead bone. This repair process temporarily makes the area weaker, since the body clears old bone faster than it lays down new bone.

If the dead area is small, the repair may succeed and the head keeps its shape. If it is large, the supporting layer beneath the cartilage can crack, which lets the surface sink. A crescent-shaped gap on imaging, called a subchondral fracture line, is an early sign of this.

Why does the socket suffer next?

Once the head loses its smooth round shape, it grinds against the glenoid with each movement. The glenoid cartilage wears, and secondary arthritis develops. This is why late-stage avascular necrosis of the shoulder may look like shoulder osteoarthritis on an X-ray, although its cause and typical age are different.

Doctors describe this condition in stages, because the stage reflects how much damage has occurred and therefore which treatments still make sense. Different staging systems exist, but all rely on X-ray and MRI findings.

How are the stages described?

Knowing the avascular necrosis of the shoulder stages explains why advice can change between two scans a year apart. Disease can move from one stage to the next over 6 to 24 months, or stay put for a long time, so each stage describes a moment in time rather than a fixed sentence.

The Cruess system, a modification of an older hip classification, is the one most surgeons use for the shoulder. The table below summarises it in plain words.

Why does the size of the dead area matter?

Small lesions, affecting less than about 15% of the head surface, often remain stable. Medium and large lesions have a higher risk of collapse, mainly if they sit in the area that bears most load when you raise the arm. MRI measures the size and position of the lesion.

What do primary and secondary forms mean?

Doctors say "primary" when they find no cause. "Secondary" describes cases linked to a known factor, for example steroids or trauma. Secondary cases often involve other joints, and doctors may screen the hips and knees, since osteonecrosis can occur in several places at once.

Is it related to a fracture?

Post-traumatic cases follow a break of the upper arm, particularly displaced four-part fractures. Our page on proximal humerus fracture explains why some breaks threaten the blood supply, and why surgeons sometimes choose replacement at the time of injury.

This condition is diagnosed from a medical history, a physical examination and imaging, with MRI giving the earliest and clearest answer. Because early disease may be silent, doctors often search for it when a risk factor is present or when shoulder pain does not match a plain X-ray.

What does the history reveal?

Expect questions about steroid courses in recent years, alcohol intake, sickle cell disease, past injuries, radiation, diving and other joint pain. Your doctor wants to know when the shoulder pain began, whether it is present at rest, and whether the other shoulder or a hip is also sore.

What will the physical examination show?

Typical findings include tenderness around the joint, limited and painful movement, and sometimes a grating sensation as the arm rotates. Muscle bulk may shrink if the problem has lasted a long time. The doctor will also check the neck and the rotator cuff to exclude other sources of pain.

Which imaging gives the answer?

Plain X-rays in two views are the starting point. In early disease they may look normal, which is why the diagnosis is sometimes missed for months. In later disease they show sclerosis, a crescent line or flattening of the ball.

An MRI can show dead bone and the surrounding repair zone long before any change on an X-ray. A CT scan describes the bone surface and the socket in detail and guides surgical planning. Bone scans are rarely needed now.

Should doctors check other joints?

Often, yes. When doctors find avascular necrosis in one shoulder, an MRI of the other shoulder and the hips may be advised, particularly if the cause is steroids or sickle cell disease. Finding silent disease early gives more treatment choices and prevents surprises later.

What should you bring to a remote review?

Gather the images from every scan in digital form, as well as reports, a list of past and current medicines with doses and dates (especially steroids), and a short timeline of symptoms. Read about medical record review to see how a specialist uses these records before suggesting a plan.

Non-surgical care for avascular necrosis of the shoulder aims to reduce pain, protect the weakened bone and address the cause. It cannot bring back dead bone, but it can help small early lesions stay stable and make life comfortable while you make other decisions.

What is the first step?

The first step is to deal with the trigger. If steroids are involved, the prescribing doctor reviews whether the dose can be lowered or changed, but you must never stop them suddenly yourself, since this can be dangerous. Reducing alcohol, treating high blood fats and stopping smoking support bone health.

How is activity adjusted?

Doctors advise avoiding heavy lifting, pushing, or loaded overhead work while the bone is vulnerable. This is often described as protected use, since the shoulder carries no body weight but still bears the load of the arm and anything it holds. A sling may help briefly in a painful flare, not for weeks.

Which exercises are safe?

Doctors encourage gentle range-of-motion exercise, because immobility leads to stiffness. A physiotherapist can teach pendulum movements and assisted lifting in a pain-free range. Strengthening starts cautiously, usually after the pain settles. Expect programmes of 6 to 12 weeks, with review scans if symptoms change.

What medicines can help?

Doctors use simple pain relief such as paracetamol first, with non-steroidal anti-inflammatory drugs (NSAIDs) added if safe for you. Some doctors also prescribe bisphosphonates, which slow bone breakdown, for early disease. Evidence for this use in the shoulder is limited, so treat it as one option to discuss, not a standard cure.

Are there other non-surgical options?

Extracorporeal shockwave therapy, pulsed electromagnetic fields and hyperbaric oxygen have all had trials in osteonecrosis. Studies disagree and are mostly small, and they come largely from the hip. Do not expect these approaches to replace surgery for advanced disease, and be cautious about expensive courses that promise a cure.

How is progress followed?

A typical schedule is a clinic visit and X-ray at 6 weeks, then every 3 months for the first year. Doctors repeat the MRI if symptoms change, or after 6 to 12 months to check whether the dead area has grown. Keep copies of every scan so you can compare each new image with the last.

Repeat X-rays or MRI every 3 to 6 months show whether the lesion is stable. If pain continues, if the ball starts to flatten, or if function drops, the plan changes. This monitoring is a key part of care and prevents missing the moment when surgery would be most helpful.

Surgery for this condition ranges from procedures that try to save the joint to replacement of the damaged surfaces. The right choice depends on the stage, the size of the lesion, your age and whether the socket has worn.

What is core decompression?

Core decompression is a small operation in which the surgeon drills one or more channels into the humeral head to lower pressure and encourage new blood vessels. It may be combined with bone graft or bone marrow cells. It is used mostly in stages I and II, and results are best when done before collapse.

Can surgeons graft the bone?

Some surgeons place a bone graft under the cartilage or a strut of bone to support the weakened area. Others use a vascularised graft. These operations are specialised, are not widely available and have limited published data in the shoulder. Ask how often your surgeon performs them.

When is arthroscopy used?

Keyhole surgery (shoulder arthroscopy) can remove loose cartilage or release a tight capsule in selected cases, which may ease pain for a time. It does not fix the bone itself and does not prevent collapse, so surgeons treat it as a stopgap in specific patients.

What is partial shoulder replacement?

In a partial shoulder replacement (hemiarthroplasty), the collapsed ball is replaced by a metal head and the socket is retained. It is appropriate when the socket cartilage is still healthy, which is more common in younger patients. Pain relief is generally good, but it can fade if the socket wears. See the turkey page for partial replacement.

What is total shoulder replacement?

In total shoulder replacement, the surgeon replaces both the ball and the socket. It is the usual choice once the glenoid has worn and the rotator cuff is healthy. Most patients report significant pain relief, and the implant may last many years. Details of care are on the turkey page for total replacement.

How do the options compare?

You can compare costs through the total shoulder replacement cost guide and the partial shoulder replacement cost guide.

Not every case of this condition can be prevented, but many risk factors are modifiable, and early detection gives the best chance of protecting the joint. Prevention is mostly about being aware of your own risk and acting early.

How can you lower the risk?

• Use steroids only when needed and at the lowest effective dose and duration, and never stop them abruptly without medical advice.
• Limit alcohol to within recommended limits, and seek help if drinking is heavy.
• Manage sickle cell disease and clotting problems with your specialist team.
• Treat high cholesterol and blood fats, and avoid smoking.
• Follow safe diving practice, including decompression stops and certified training.

Should high-risk people be screened?

There is no routine screening for the general public. People on prolonged high-dose steroids who develop new shoulder or hip pain should mention it early and ask whether an MRI is appropriate. A normal X-ray does not exclude early disease, which is the main reason to speak up.

How can you protect the joint once diagnosed?

Plan daily tasks so that heavy items sit between waist and chest height, ask for help with luggage and groceries, and use the stronger arm for pulling and pushing. Wearing a supportive bag strap across the body rather than on the sore shoulder also reduces strain during long days.

Avoid heavy loading, keep the shoulder moving gently, take medicines as advised and attend follow-up scans. These steps cannot promise that collapse will be avoided, but they give small lesions the best chance and reduce unnecessary strain.

What cannot be prevented?

Sometimes no cause is found, and a displaced fracture that cuts the blood supply cannot be undone by lifestyle. If your trauma was severe, discuss monitoring with your surgeon. The aim is to catch the problem early, not to blame yourself, since many causes are beyond personal control.

The outlook for avascular necrosis of the shoulder depends on the stage at diagnosis, the size of the lesion and the underlying cause. Early small lesions may remain stable, while advanced disease usually needs replacement, which gives good pain relief for most people.

What is the natural course?

The course varies widely. Some people have a slow, mild course for years, while others have rapid collapse within months. Large lesions in the central load-bearing part of the head are more likely to collapse. Regular imaging is the best way to know where you are on this spectrum.

What is recovery after replacement like?

What can you do afterwards?

Most people return to desk work in 4 to 8 weeks and to lighter physical work after 3 to 6 months. Swimming, cycling, golf and light gym work are usually possible. Heavy lifting, contact sport and repeated overhead loading are generally discouraged, because younger patients put more strain on implants.

How long do results last?

Many shoulder implants work well for 10 to 15 years or more, though results for younger and active patients are less predictable than for older ones, and revision may be needed in some. Regular check-ups with X-rays allow wear to be caught early. See also rotator cuff tear arthropathy for what failed cuffs mean for implant choice.

What is the long-term picture?

Satisfaction is high after replacement when expectations are realistic. Patients commonly tell us that sleeping through the night was the first big change, usually within 2 to 3 weeks, and that reaching and lifting returned more slowly over the following months. Keep attending review visits at 1 year and every 2 to 5 years afterwards.

Most people report much less pain, better sleep and a shoulder that allows ordinary life. Movement is usually good for daily tasks but may not return to full range. Realistic goals, steady rehabilitation and management of the underlying cause give the best chance of a satisfying result.