Avascular Necrosis of the Shoulder

Today, we’re talking about Avascular Necrosis in the shoulder. Avascular Necrosis is essentially a lack of blood flow, eventually resulting in necrosis, or dying of the bone. This happens in multiple joints. And today we’re talking specifically about the shoulder. So talking about AVN in the shoulder, patients typically come up with two main questions.

Number one, can this heal on its own? And if not, how long or how fast will this progress?

Now we classify AVN in multiple different stages:

1. Number one: we have stage one, where it’s very normal X-ray  — usually, typically, someone just has pain with activity.
2. Two: is the bone itself continues to deteriorate, then we start getting some changes on your X-ray.
3. Number three: as that lack of blood flow to the bone progresses, we’re getting what we call a crescent-shaped lesion in the bone. And we start changing some of the architecture of the joint.
4. Stage four and stage five is when we start losing full architecture, where we have collapse or flattening of the joint’s surface. That flattening of the joint’s surface essentially leads to severe degeneration or secondary arthritis of the joint.

 Symptoms of Shoulder AVN

Avascular necrosis of the shoulder causes pain and a crackling sound when moving your arms and shoulder. The humeral head may collapse, causing discomfort and dysfunction. Changes in the cartilage on the humeral head can cause shoulder joint pain as well.

How Fast Is this Progress?

For each individual, it can be extremely different. It could progress over a number of months — could progress over a number of years. Typically, at the time of diagnosis, if someone is symptomatic, the chances of progressing over a three-year period are probably in the 85/90 percent range. If someone is asymptomatic, meaning this was found just by chance, or for a different reason, someone has a chance progression of probably 65 percent.

And that progression looks like this. Where, initially, you have some mild changes on the X-ray. Typically, the symptoms are very mild. As we progress, here is that crescent shape lesion. And, on the bottom right, total destruction of the joint.

Is AVN of the Shoulder Serious?

In one word: yes. It’s extremely serious from the perspective of joint preservation. Now, the earlier we are able to identify this, the quicker we’re able to identify some of the causes of the AVN, remove those causes, and, hopefully, stop the progression. And if we treat this early enough, the goal is joint preservation, so we can avoid the need for a total joint replacement.

What Is the Best Treatment for Avascular Necrosis of the Shoulder?

If we look at the last 15 to 20 years from a research standpoint, there have been two main treatments that become the standard of care.

Remove the Cause of AVN

One is the removal of whatever is causing Avascular Necrosis, such as if it is high-dose cortical steroids; stop the steroid use. Or, if someone’s consuming high amounts of alcohol. Ideally, abstaining from alcohol use itself will, ideally, help stop the progression.

PRP

Early Diagnosis is Key

From a treatment standpoint, trying to get the Avascular Necrosis to reverse or cure. That’s why identifying early on and getting in that early stage one to stage three is extremely important.

An orthopedic surgeon typically does what’s called a core decompression, where they take a large drill bit, go into the bone itself and ideally try to stimulate the bone, to regenerate it. Aside from that, a less invasive option would be a bone marrow concentrate, utilizing the repair cells in your bone marrow — concentrating them, and, with a small needle, injecting them directly into the lesion to stimulate your body to regenerate the blood flow, as well as try to heal the bone itself.

Here’s a nice progression from someone that was diagnosed from stage three (see above). All this area is Avascular Necrotic lesions. We can see the crescent-shaped lesion here (where it says “Pre-treatment,” to the left). But the good news is they still had preservation of the joint structure. After treatment, we can see five months (middle). We have a resolution of the majority of the bone swelling. We still have a small lesion, but it hasn’t progressed, and, if we fast forward several years, the patient themselves is 95 percent improved from pain and function after two years. And there’s been no progression of the Avascular Necrosis lesion, as well as the joint preservation aspects are maintained (the right-most image).

So, if you or any loved one have been dealing with any issues with Avascular Necrosis in the shoulder, feel free to give us a call. If you have any questions, you can always reach out to us on social media, such as Instagram, Facebook, and we’re always more than welcome to do Telemedicine evaluations. You can send in your imaging and set up a review of your imaging to see if you are a candidate for these advanced regenerative techniques. Have a good day.

Related: Avascular Necrosis Staging 

Our Doctors Who Assist with Shoulder AVN

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training in both. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI). Dr. Schultz trained at George Washington School of…

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Other Resources for AVN