Shoulder Osteonecrosis and Avascular Necrosis 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.

The humeral head is the second most common site of osteonecrosis in the body after the hip, and catching it before the surface collapses changes what can be offered. Steven Struhl, MD is board certified in orthopedic surgery and separately in sports medicine, has practiced since 1991, and serves as an attending surgeon at NYU Hospital for Joint Diseases, where he treats the full spectrum of shoulder conditions from early stage disease through joint replacement.

What Is Osteonecrosis of the Shoulder?

Osteonecrosis, also called avascular necrosis or AVN, is the death of bone tissue caused by loss of blood supply. In the shoulder it affects the humeral head, 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.

The timeline matters clinically, because treatment before collapse aims at preserving the joint, and treatment after collapse generally means replacing part or all of it.

Causes and Risk Factors for Humeral Head Osteonecrosis

• Corticosteroid Use: long term or high dose steroid treatment, the most common non traumatic cause.
• Prior Fracture: a proximal humerus fracture that disrupted the blood supply to the head.
• 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 called caisson disease.

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

Shoulder Osteonecrosis Symptoms and Stages

Symptoms follow the structural damage rather than preceding it, which is why the condition is often found late.

• 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 as the surface flattens.
• Late Stage: arthritic change extending to the socket, producing symptoms like advanced shoulder arthritis.

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

Dr. Struhl treats early imaging as the difference between preserving a joint and replacing one, noting that “by using high quality imaging modalities such as MRI early in the treatment process, we get to the heart of the problem quickly and precisely.” – Steven Struhl, MD, Board Certified Orthopedic and Sports Medicine Surgeon

Shoulder Osteonecrosis Treatment Options

• Observation And Modification: monitoring with imaging while reducing load through the joint.
• Medication Management: pain control alongside treatment of any underlying contributing condition.
• Physical Therapy: maintaining range of motion and the strength of the surrounding musculature.
• Core Decompression: drilling into the affected area to relieve pressure and stimulate new blood supply.
• Shoulder Resurfacing: replacing only the damaged surface of the humeral head in selected patients.
• Shoulder Replacement: partial or total replacement once the head has collapsed significantly.

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.

Frequently Asked Questions About Shoulder Osteonecrosis

What causes osteonecrosis of the shoulder?

Anything that interrupts blood flow to the humeral head. The most common causes are long term corticosteroid use, prior fracture of the proximal humerus, sickle cell disease, heavy alcohol use, and prior radiation. A meaningful share of cases have no identifiable cause.

Can shoulder osteonecrosis be reversed?

Bone that has died does not come back, but progression can sometimes be slowed or halted, and in early stage disease core decompression can relieve pressure and encourage new blood vessel formation. Once the surface has collapsed, treatment shifts from preservation to reconstruction.

Will an X ray diagnose it?

Not in the early stages, when plain films look entirely normal. MRI is the study that detects osteonecrosis before structural collapse, which is why it is ordered when a patient has deep unexplained shoulder pain along with a risk factor such as steroid use or sickle cell disease.

Is this the same as shoulder arthritis?

No, though it can end there. Arthritis is primary wearing of the cartilage surface, while osteonecrosis begins in the bone beneath the cartilage and damages the surface secondarily as the dead bone collapses. In late stages the two look similar and are treated similarly.

Does it affect both shoulders?

It can, and it frequently affects more than one joint in the same patient, most often the hips. Someone with known osteonecrosis in another joint who develops shoulder pain should be imaged rather than watched.

What is core decompression?

A joint preserving procedure in which a channel is drilled into the affected region of the humeral head to relieve internal pressure and encourage new blood vessels to form. It is most effective before the joint surface has collapsed, which is why the stage at diagnosis matters so much.

Why Patients Choose Dr. Struhl for Osteonecrosis Care

• Full Treatment Range: joint preserving options through replacement, chosen by stage.
• Dual Board Certification: orthopedic surgery plus subspecialty certification in sports medicine.
• Hospital Standing: attending surgeon at NYU Hospital for Joint Diseases.
• Early Imaging: MRI used when plain films would miss the diagnosis entirely.

Schedule a Shoulder Evaluation in New York City

Deep shoulder pain that is worse at rest and at night, particularly in a patient 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. Call the New York City office at (212) 207-1990 or the Westchester office at (914) 328-4111 to schedule an appointment.