Background: Humeral head osteonecrosis (AVN) occurs when disruption of the vascular supply to the proximal humeral head leads to bone necrosis. Radiographical staging is based on the extent of subchondral destruction and integrity of the articular surface and glenoid cavity. Once AVN progresses to subchondral collapse, treatment requires shoulder arthroplasty. Early-stage disease may be managed with conservative approaches aimed at improving perfusion, stabilizing bone, and slowing disease progression; however, there is little literature evaluating outcomes of conservative management in early-stage AVN.
Case presentation: A 74-year-old female with hypertension, hyperlipidemia, osteopenia, and a 56-pack-year smoking history presented with 6 months of progressive right shoulder pain and functional limitation with overhead activity. She denied trauma or corticosteroid use. Exam revealed mild weakness in shoulder abduction, painful range of motion, and a positive Empty Can Test. Initial differential included rotator cuff tendinopathy and glenohumeral osteoarthritis. CT and MRI demonstrated early-stage (Ficat-Arlet II, pre-collapse) osteonecrosis of the superior-medial humeral head with mild acromioclavicular arthropathy and rotator cuff tendinopathy. No alternative etiologies were identified. The patient was treated with atorvastatin 20 mg daily, alendronate 70 mg weekly, a home exercise program, and reduced tobacco use. At 3-month follow-up, she showed increased range of motion and reported improved pain and function.
Conclusion: Conservative management may provide favorable early outcomes in patients with early-stage AVN. Statins may improve perfusion and osteogenesis, while bisphosphonates may delay subchondral collapse by inhibiting osteoclastic activity. Home exercise program supports joint functionality. Short follow-up and lack of repeat imaging limit definite conclusions.
Case presentation: A 74-year-old female with hypertension, hyperlipidemia, osteopenia, and a 56-pack-year smoking history presented with 6 months of progressive right shoulder pain and functional limitation with overhead activity. She denied trauma or corticosteroid use. Exam revealed mild weakness in shoulder abduction, painful range of motion, and a positive Empty Can Test. Initial differential included rotator cuff tendinopathy and glenohumeral osteoarthritis. CT and MRI demonstrated early-stage (Ficat-Arlet II, pre-collapse) osteonecrosis of the superior-medial humeral head with mild acromioclavicular arthropathy and rotator cuff tendinopathy. No alternative etiologies were identified. The patient was treated with atorvastatin 20 mg daily, alendronate 70 mg weekly, a home exercise program, and reduced tobacco use. At 3-month follow-up, she showed increased range of motion and reported improved pain and function.
Conclusion: Conservative management may provide favorable early outcomes in patients with early-stage AVN. Statins may improve perfusion and osteogenesis, while bisphosphonates may delay subchondral collapse by inhibiting osteoclastic activity. Home exercise program supports joint functionality. Short follow-up and lack of repeat imaging limit definite conclusions.