Avascular Necrosis Shoulder

Medical research has identified a number of risk factors associated with AVN.

Interestingly, not everyone who has a risk factor gets AVN and not everyone with AVN has an easily identifiable risk factor, meaning the cause is unknown or idiopathic.

People who have a fracture of the proximal humerus (ball part of the shoulder) are at risk for AVN.

With a fracture of the proximal humerus the blood supply can be disrupted and loss of the normal blood flow to the bone may cause it to eventually die and become necrotic.

The more extensive the fracture the more likely is this development of AVN.

Another common cause of AVN is the effect of steroids given for other conditions.

The steroids are believed to damage the health of the cells which make bone in the humeral head and when they die the sequence of AVN occurs.

Other causes of AVN can be radiation or chemotherapy treatment in the case of cancer.

Other rare causes include sickle cell disease, Gaucher’s disease, Caisson’s disease (also known as diver’s disease or the bends:

This is due to sudden change in water pressure in deep sea diving where nitrogen bubbles form in the blood and damage the blood supply to the humeral head). 

AVN Avascular Necrosis aka Osteonecrosis ON

usually presents as pain and may also be associated with noise and crunching sensation (crepitation) in the shoulder with movement.

Movement may be limited due to pain. About 50% of individuals who develop atraumatic (without a fracture) AVN in the shoulder will also have involvement of other joints.

In its early stages AVN may not be apparent on a plain x-ray but it can be seen on an MRI (described above).

As it progresses with collapse of the humeral head and eventual arthritis it is clearly seen on an x-ray (see figures below).


Stage 1 is a shoulder with a normal X-ray but signal changes on MRI showing subchondral edema.

Stage 2 is a shoulder with more whitened bone called sclerosis, near the joint surface (subchondral).

Stage 3 demonstrates a crescent sign or collapse or fracture of the subchondral bone.

Stage 4 demonstrates flattening of the humeral head from advanced collapse.

Stage 5 or end-stage AVN demonstrates advanced collapse of the humerus with degenerative changes of the glenoid (arthritis).

A study that looked at 200 shoulders with AVN found that about 40% of shoulders with early AVN progressed in 3 years to advanced AVN.

Patients that presented with later-stage AVN, 55-80% of patients (depending on how late the stage) progressed to advanced AVN6.

Drilling of the humeral head, called core decompression, is a treatment which may be helpful in the early stages of AVN before the humeral head collapses.

It is believed that pressure in the bone goes up when the blood supply is lost and that pain can be relieved by decompressing the bone by drilling into it.

This is called core decompression. This may also stimulate better blood supply and faster healing in the humeral head.


• A condition caused by interruption of blood supply to humeral head

• Pathophysiology

◦ pathoanatomy 

decreased blood supply to humeral head leading to death of cells in bony matrix.

bone is resorbed and remodeled, causing subchondral bone collapse and may lead to joint incongruity and arthritic changes

◦ etiology similar to hip

Remember ASEPTIC mneumonic 

Alcohol, AIDS

Steroids (most common), Sickle, SLE

Erlenmeyer flask (Gaucher’s)



Idiopathic/ Infection

Caisson’s (the bends)

may be atraumatic


four-part fracture-dislocations approach 100% AVN

displaced four-part fractures ~45% AVN

valgus impacted four-part ~11% AVN

three-part ~14% AVN

• Prognosis

◦ related to stage of disease


• Blood supply

◦ Humeral head

ascending branch of anterior humeral circumflex artery and arcuate artery

provides blood supply to humeral head

vessel runs parallel to lateral aspect of tendon of long head of biceps in the bicipital groove

beware not to injure when plating proximal humerus fractures

arcuate artery is the interosseous continuation of ascending branch of anterior humeral circumflex artery and penetrates the bone of the humeral head

provides 35% of blood supply to humeral head

posterior humeral circumflex artery

most current literature supports this as providing the main blood supply to humeral head 

provides 65% of blood supply 



Cruess Classification (stages)

Stage I

Normal x-ray. Changes on MRI. Core decompression.

Stage II

Sclerosis (wedged, mottled), osteopenia. Core decompression.

Stage III

Crescent sign indicating a subchondral fracture. Resurfacing or hemiarthroplasty.

Stage IV

Flattening and collapse. Resurfacing or hemiarthroplasty.

Stage V

Degenerative changes extend to glenoid. TSA.




• Symptoms

◦ insidious onset of shoulder pain

often without a clear inciting event

◦ pain, loss of motion, crepitus, and weakness

• Physical exam

◦ limited range of motion

◦ crepitus

◦ weakness of the rotator cuff and deltoid muscles


• Radiographs

◦ recommended views

five views of shoulder (shown best in neutral rotation AP)

◦ findings

no findings on radiograph at onset of disease process

osteolytic lesion develops on radiograph demonstrating resorption of subchondral necrosis

most common initial site is superior middle portion of humeral head

crescent sign demonstrates subchondral collapse

may progress to depression of articular surface and consequent arthritic changes.


◦ preferred imaging modality

~100% sensitivity in detection

◦ will demonstrate edema at the site of subchondral sclerosis 


• Nonoperative

◦ pain medications, activity modification, physical therapy


first line of treatment


physical therapy

restrict overhead activity and manual labor

• Operative

◦ core decompression + arthroscopy (confirm integrity of cartilage)  


early disease (precollapse Cruess Stage I and II)

◦ humeral head resurfacing


Stage III disease with focal chondral defects, and sufficient remaining epiphyseal bone stock for fixation.

◦ hemiarthroplasty  


moderate disease (Cruess Stage III and IV)

◦ total shoulder arthroplasty 


advance stage (Cruess V)


  1. Mont MA, Payman RK, Laporte DM, Petri M, Jones LC, Hungerford DS: Atraumatic osteonecrosis of the humeral head. J Rheumatol 2000; 27:1766-1773
  2. Hasan S, Romeo A: Nontraumatic osteonecrosis of the humeral head J Shoulder Elbow Surg 2008; 281-298
  3. CruessRL: Corticosteroid-induced osteonecrosis of the humeralhead. Orthop Clin North Am 1985; 16:789-796.
  4. LaPorteDM, MontMA, MohanV, JonesLC, HungerfordDS: Multifocal osteonecrosis. J Rheumatol 1998; 25:1968-1974.
  5. CruessRL: Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip. Clin Orthop Relat Res 1978; 130:86-93
  6. HattrupSJ, CofieldRH Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history. J Shoulder Elbow Surg 1999; 8:559-564.
  7. Feeley BT, Fealy S, Dines DM, Warren RF, Craig EV. Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head. J Shoulder Elbow Surg 2008;17(5): 689-694.
  8. Harreld KL, Marker DR, Wiesler ER, Shafiq B, Mont M. Osteonecrosis of the Humeral Head. J Am Academy of Orthop Surgeons 2009;17(6): 345-355.

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Signs It May Be Time For Hip Replacement

When you have tried everything an all non-surgical treatments stop relieving your chronic hip pain, or your pain reaches debilitating levels, hip replacement surgery may be the best option to relieve your discomfort, restore your mobility and improve your quality of life.

Hip pain due to Osteonecrosis is an increasing problem for many.

After time over-the-counter pain medications can lose their efficacy and chronic hip pain can quickly escalate often requiring prescription medications, physical therapy, and the use of canes or walkers to aid mobility.

If your pain is severe and debilitating, isn’t it time to do something about it.

Talk to your Doctor or Orthopedic because you don’t need to suffer and have a poor quality of life.

What Signs & Symptoms Indicate a Need for Hip Replacement Surgery?

Hip pain can have a number of causes, not all of which can be relieved by a hip joint replacement.

Among the listed causes of AVN are steroid use, trauma, hypertension, rheumatoid arthritis, and alcoholism, blood clot disorder, smoking, vasculitis Bisphosphonate use, Chemo or radiation or it could be idiopathic, meaning no cause can be determined. Certainly Napoli has had his share of wear and tear, being a catcher.

For instance, constant or long-lasting stiffness in your hip joint can be a sign of rheumatoid arthritis while pain that centers in the buttocks region and radiates down the leg may be related to sciatica.

However, many cases of hip pain and discomfort are directly related to your hip joint.

Symptoms and signs that it may be time for hip replacement surgery include:

• Mobility issues, especially if your level of mobility progressively worsens

• Persistent or recurring pain, swelling or discomfort in your hip

• Hip pain that worsens during rainy weather

• Inability to sleep due to hip pain and discomfort

• A “grating” feeling in your hip joint

• Increasing difficulty in climbing stairs or getting in and out of cars, bathtubs, and chairs

• OTC medications no longer effectively manage your hip pain

If you have any or all of these symptoms, talk to an orthopedic surgeon about the possible need for hip replacement surgery.

How Is a Diagnosis Made?

To determine if you are a good candidate for hip replacement surgery, you will need a thorough examination by an experienced orthopedic surgeon. This examination will include:

• A complete medical history evaluation, including any previous injuries or illnesses that could be contributing to your pain

• A physical assessment to determine your range of motion, pain level and the strength of your affected hip

Your orthopedic surgeon may also order additional medical testing, including MRIs and X-rays. If your surgeon decides that the next step is hip replacement surgery, be sure to discuss any questions or concerns you have about the surgery or recovery from hip replacement surgery.

What Do You Need to Know About Hip Replacement Surgical Procedures?

Potential candidates for hip replacement surgery need to know that the surgery is a time-tested procedure that has been used successfully for more than four decades to relieve chronic hip pain and improve both flexibility and mobility. More than 300,000 Americans opt for hip replacement surgery each year to rid themselves of hip pain and improve their quality of life.

Total hip replacement surgery, or total hip arthroplasty, uses a ball and socket prosthetic joint to replace your damaged one. Special metals, such as cobalt-chromium and titanium, and polyethylene plastics, are used to make your prosthetic joints. These materials are safe for use inside the body and are extremely durable and long lasting.

The procedure for your total hip replacement surgery will most likely include the following steps:

1 Separating your femur from your hip socket

2 Removing the damaged ball from the femur

3 Removing your damaged bone and cartilage

4 Inserting a metal shell into your pelvic bone socket and using bone grafting material to secure it

5 Completing the artificial socket by adding the plastic liner

6 Preparing your femur to receive the metal implant

7 Placing the metal implant into the hollowed end of your femur

8 Attaching a metal ball component to the stem

Hip replacement surgery is a very effective procedure, and most patients experience a dramatic reduction in pain and improvements in their mobility and stamina. With the proper recovery procedures and physical therapy, you should be able to enjoy walking, swimming, biking and other low-impact activities without impediment.

If you can no longer bare the pain or have problems walking talk to your ortho about your options.

Good luck

We’re praying for you

Is Your Hip Pain The Sign of a Rare Condition?

Your hips are largest and most powerful of muscle groups—the glutes, quads, and hamstrings—all connect at the hips, and they allow you to walk, run, climb. The hip joint is crucial to all movement, in sports and day-to-day life, which is why persistent hip pain can be such a pain in the ass literally and often debilitating.



Wear and tear on your hip joint can worsen with age. According to the Centers for Disease Control and Prevention, 7 percent of adults in the U.S. suffer from hip pain, the third most common joint pain behind shoulder pain, at 9 percent, and knee pain, at 18 percent. There’s also a growing prevalence of young athletes with hip injuries, especially young women, due to repetitive overuse and acute trauma.

Trauma can sometimes lead to osteonecrosis  in any joint but we are focusing on the hip , and some of the medications given to help inflammation and strengthen bones can also be a cause of osteonecrosis aka avascular necrosis.

Your Hip Pain May be the Sign of a Rare Condition

If you have hip pain don’t always brush it off as arthritis, if it persists, get it checked out to be safe

Persistent or worsening hip pain warrants a visit to your health care provider and possibly a sports medicine specialist or ortho. Some problems, particularly hip stress fractures, are commonly misdiagnosed due to the confusing presentation of symptoms.


A thorough evaluation is necessary and often includes X-rays and other studies, such as an MRI or bone scan. As with all injuries, the absence of pain does not mean that all is well. Strength and flexibility deficits must be addressed to allow a healthy return to helping your quality of life.



Although a person may not initially experience symptoms, hip pain is usually the first indicator. The earlier the diagnosis is achieved, the better the patient’s potential outcome. AVN has four stages that can progress over a period of several months to more than a year. In Stage I, the hip is healthy; in Stage II, the patient experiences mild to moderate pain in direct proportion to the deterioration of the head of the femur (or ball of the hip joint). By Stage III, usually the patient will find it difficult to stand and bear weight on the hip, and joint movement will be painful. During this stage, the ball of the hip has deteriorated to what is called a subchondral fracture and early collapse. Stage IV is a full collapse of the femoral head and degenerative joint disease (DJD).


Treatment for AVN is recommended based on the stage of the disease coupled with the age of the patient. In Stage I, medication and crutches may be prescribed to provide relief and enable the bone to heal on its own. This treatment may require the patient to be non-weight-bearing for up to six months. It also has a failure rate greater than 80-percent.

On the horizon treatments are stem cell.


Surgical treatment is recommended with a Stage II diagnosis, or very early in a Stage III diagnosis. A procedure, known as a core decompression, typically involves drilling one large hole in the core of the effected bone, with or without a bone graft, to reduced pressure and improve blood circulation in the hip. Another surgical option is the vascularized fibular graft, which takes a healthy piece of bone from the fibula, along with the artery or vein, and transplants and reattaches it into the hip, to help healthy bone grow. Recovery can take several months.


Because most patients are diagnosed in late Stage III or IV of the disease, when the bone quality of the femoral head is poor (subchondral fracture) or has collapsed, total hip replacement is the most successful treatment for AVN. This procedure replaces the damaged bone with artificial parts. Recovery takes about eight to twelve weeks. If left untreated, AVN progresses and results in pain and severe debilitating osteoarthritis.

Treatment decisions for AVN are ultimately up to the patient and are based on his or her lifestyle and goals. If you are suffering with hip pain, talk with your primary care doctor about a referral to an orthopedic surgeon

Maintaining Angiogenesis Can Prevent Glucocorticoid Induced Osteonecrosis

Angiogenesis is a key component of bone repair. … Angiogenesis is regulated by a variety of growth factors, notably vascular endothelial growth factor (VEGF), which are produced by inflammatory cells and stromal cells to induce blood vessel in-growth.

Wouldn’t it be great if there wa a way many could keep their blood vessels healthy and avoid or lower risk of developing Osteonecrosis?

Research and links below discuss just that.

#angiogenesis and bone repair in steroid-induced osteonecrosis

#Osteonecrosis #AvascularNecrosis


Angiogenesis in Bone Regeneration What It Is

Angiogenesis and Bone Repair For Osteonecrosis Info and Links

Maintaining Angiogenesis Prevents Glucocorticoid Induced Osteonecrosis

Genetic association of angiogenesis- and hypoxia-related gene polymorphisms with osteonecrosis of the femoral head

How people can develop Osteonecrosis in Jaw.

Link below.

Osteonecrosis of the Jaw and Angiogenesis inhibitors: A Revival of a Rare but Serous Side Effect.

Photo credit and website listed below.

Bringing new life to damaged bone: The importance of angiogenesis in bone repair and regeneration photo linked to this site

Tracking Pain – With A Journal

While each person’s experience with Osteonecrosis is different, I want to make sure you have the right information and support you need to live life your best life in spite of osteonecrosis.

There are ways I was able to control my pain, lower overall inflammation in my body which helped my pain.

Also did you know that for many people statins helped as well?

It was time I stopped just being a patient , and I became an advocate and patient leader. It was time to take a personal approach to my health many doctors didn’t understand how I felt, some often seemed as if I was exaggerating or making it up.

This pain wasn’t in my head, and if anything I’m downplaying my pain vs telling you doctors how terrible it is on a constant and daily basis.

Let’s face it when we have chronic pain we don’t always want to cook all day . But I found out trying to save time and energy by grabbing a pizza or burger isn’t helping my pain.

The more junk fats like fast food, processed garbage I removed from my life over time the better I was feeling.

It’s not a cure or a easy fix.

But it’s not hard and it’s delicious.

I’m the main cook in our family. So I prepared meals that have less and no meat more often.

From meatless Monday to now meatless M-W-S

And it was a great success , soon we only ate meat or chicken 1x a week and fish 1x -2 x a week.

We did eat eggs .

Before I knew it some weeks we didn’t eat meat or poultry at all.

We did have fish like cod , tuna, haddock ,crab,shrimp or tuna steaks.

We didn’t care for salmon much.

I also started a pain journal it had what I ate- what I did – my stress level- pain level

Whether you’ve been battling pain for more than a decade or you’re just starting to deal with consistent aches pains and stiff soreness, a pain journal can help you document what you are feeling from day to day.

Your pain journal is where you write down everything relating to your chronic pain what kind of pain you have, what level of pain you are experiencing, what you were doing when you were in pain, what you ate and so on.

Chronic Pain Journal Helps

This information is useful both for you and your doctor. It can be used to help identify patterns of pain, such as time of day or level of stress, or pain triggers from certain activities.

A pain journal can also show what doesn’t increase your pain, which can help you make better decisions about how you spend your day. At the very least, it can be a good reference when memory doesn’t serve you (for example, if you’re not sure how to answer when your doctor asks if your pain is worse after lunch).

Usually pain journal are set up like this.

• Give your pain a scale rating. Most pain scales use the 0-10 rating system, with 0 representing no pain and 10 representing the worst imaginable pain. Your pain will usually fall somewhere in between.

• Use pain descriptor words. Is your pain burning? Stabbing? Tingling? Pulsating? Constant? Using pain descriptor words in your journal can help you track changes and patterns in your pain quality.

• It can also help doctors pinpoint your type of pain.

• Track the time of day pain occurs. Do you hurt more in the morning or the evening? How are your afternoons?

• Write down what you ate and drank that day. Foods and beverages may contribute to or worsen the pain you are experiencing. Jot down everything you ingested food and beverages everyday.You will see a pattern.

• Describe your mood. It’s also important to note your mental state and how you feel when experiencing pain. Are you depressed? Anxious? Fatigued? Obviously, the pain might be triggering these emotions, and your doctor may recommend you see a mental health specialist to deal with the feelings that arise as a result of your chronic pain.

• Note what you are doing when your pain begins. Did you just get out of bed, or had you been sitting for a while when your pain started? Were you exercising or overusing certain muscles in your body? Write down how you feel after activities, such as walking the dog or playing with the kids.

• Look at elements that might contribute to your pain. Think about the external factors that may add to the pain, such as if you suffer from stiff joints; does this happen when it’s raining or cold outside

• Note if you take pain medication does it help? Does it ease pain, take it away do nothing .

It seems like a lot of work but actually it takes just a few days to get it down.

And it’s a valuable tool.

Often a lot of what we eat makes pain worse. Because it causes inflammation in the body.

Basic inflammation is normal chronic inflammation is not.