Evidence-based guidance for patients, athletes and clinicians
- What is Avascular Necrosis?
Avascular Necrosis (AVN – bone death caused by lost blood supply) of the humeral head leads to weakening of the subchondral bone (the layer just beneath the joint cartilage). Untreated, the surface may collapse, triggering premature arthritis and severe loss of shoulder function.
- Who is at risk — and why?
- Corticosteroids: Long-term or high-dose use can raise marrow pressure and reduce flow.
- Trauma: Dislocation or complex fractures may sever the small vessels that feed the humeral head.
- Sickle-cell disease: Misshapen red cells block tiny arteries; up to half of patients develop AVN here.
- Excess alcohol: Alters fat metabolism, increasing intra-osseous pressure.
- Divers / compressed-air workers: Rapid decompression forms nitrogen bubbles (dysbaric AVN).
- Gaucher disease, chemotherapy, radiotherapy, smoking and idiopathic (unknown) causes also occur.
- Warning signs and symptoms
- Deep, aching pain in the shoulder or upper arm, often worse at night.
- Early preservation of movement, followed by stiffness and weakness as collapse begins.
- Clicking or grinding (crepitus) when lifting the arm overhead.
Clinical pearl: Patients are typically younger than those with primary osteoarthritis; index of suspicion must be high.
- How is AVN diagnosed?
Test | Best for | Strengths | Limitations |
Plain X-ray | Stages II–V | Cheap, wide availability | Often normal in Stage I |
MRI | Stage I detection, lesion size, bone marrow oedema | ~99 % sensitivity/specificity | Cost; contraindications |
CT | Confirming subchondral fracture, pre-op planning | Excellent bony detail | Radiation |
Bone scan | Global joint perfusion | Helpful if MRI impossible | Low sensitivity |
The Cruess staging system (I–V) guides management: Stage I is MRI-only change; Stage III shows the “crescent sign” (subchondral crack); Stage V includes glenoid degeneration.
- Management pathways
5.1 Conservative care — suitable for Stage I–II
- NSAIDs for pain; judicious steroid injection for short-term relief.
- Activity modification: avoid heavy lifting and overhead work.
- Physiotherapy: maintain range, strengthen rotator cuff and scapular stabilisers.
- Bisphosphonates: trial data show promise in delaying collapse; discuss risks with your clinician.
5.2 Joint-preserving surgery — early intervention matters
Procedure | Ideal stage | Goal | Key points |
Core decompression | I–II | Lower marrow pressure, stimulate re-vascularisation | May add vascularised graft or biologic adjuncts; best results in small lesions |
Rotational osteotomy | Focal lesions that can be rotated away from load zone | Moves intact bone to weight-bearing surface | May complicate later arthroplasty |
5.3 Joint-replacing options — for collapse or arthritis
Procedure | Indication | Pros | Cons |
Humeral-head resurfacing | Local collapse, preserved glenoid | Preserves bone stock; easier future revision | Not suitable for large cystic defects |
Hemi-arthroplasty | Stage III–IV without glenoid wear | Reliable pain relief | Glenoid may wear over time |
Total shoulder replacement | Stage V, bi-articular disease | Addresses both sides of joint; excellent pain relief | Longevity concerns in younger patients; higher revision risk |
Rehabilitation milestones (typical, may vary)
- Sling support: 1–2 weeks (arthroplasty) or as advised (decompression).
- Passive then active-assisted range: by 4 weeks.
- Strength phase: 6–12 weeks.
- Graduated return to work/sport: 3–6 months.
Clinical Pearls / Key Points
- Persisting night pain in a young steroid-dependent or sickle-cell patient warrants early MRI.
- Core decompression is most effective before the crescent sign appears.
- Collapse of >30 % of humeral-head surface predicts rapid progression to arthroplasty.
- Smoking cessation and alcohol moderation slow disease progression.
Patient FAQs
Question | Plain-English answer |
Is AVN the same as arthritis? | No. AVN is bone death that leads to arthritis if untreated. |
Will I definitely need a replacement shoulder? | Not always. Early-stage disease may stabilise with decompression and lifestyle changes. |
How long does recovery take after decompression? | Most daily activities resume by six weeks; sport and manual work may take three to six months. |
Can I keep using steroids for another condition? | Your doctor may lower the dose or try alternatives to cut risk. Never stop abruptly. |
Call to Action
If you have pain, book an appointment to be reviewed by Prof Imam or another member of our specialist team at The Arm Clinic. Early specialist care helps prevent long-term issues. Visit www.TheArmDoc.co.uk or book your consultation today. Phone: 020 3384 5588 | Email: Info@TheArmDoc.co.uk
Disclaimer
This information is for general educational purposes and should not be used as a substitute for professional medical advice. Consult a healthcare professional for individual guidance on your condition and treatment options.
This page was last clinically updated in May 2025