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This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Diagnostic arthroscopy in the beach-chair position can effectively identify and characterize intra-articular shoulder pathologies when properly executed [1].
• Adopting refined techniques is crucial for addressing complex shoulder pathologies effectively as shoulder arthroscopy continues to evolve [2].
• Current guidelines for thromboprophylaxis in shoulder arthroscopy lack consensus and need patient-specific considerations [3].
• Arthroscopic Instruments represented the most frequent category among the top 100 most-cited shoulder arthroscopy patents [4].
• The arthroscopic suspensionplasty technique is relatively simple, with low morbidity for a surgeon with experience in shoulder arthroscopy and rotator cuff surgery using common devices [5].
• Supine-position shoulder arthroscopy using the anterior portal as the initial approach serves as a safer, more cost-effective, and more accessible complementary approach for shoulder arthroscopy positioning and is worthy of routine clinical application [6].
• Resident involvement in shoulder arthroscopy procedures is not associated with increased risk for medical or surgical 30-day postoperative complications [7].
• Strong consideration should be given to performing arthroscopy prior to open Latarjet if a preoperative MRI is not obtained or if a preoperative MRI identifies additional intra-articular pathology [8].
• Earlier Orthopaedic Surgeon evaluation of workers' compensation patients with shoulder injuries was associated with a higher return to full duty after shoulder arthroscopic surgery [9].
• Lateral decubitus positioning is safe and effective for arthroscopic treatment of various shoulder pathologies with appropriate technique [10].
• Dynamic anterior glenohumeral capsular ligament tensioning during arthroscopic shoulder stabilization is considered a reliable surgical technique for traumatic anterior instability of the dominant shoulder in athletes who wish to return to overhead-throwing sports [17].

Anatomy & Pathophysiology

Bony Anatomy

• The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [33].
• The articular head of the humerus is spherical with a diameter of 37 to 57 mm [33].
• The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [33].
• Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [33].
• The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [33].
• The bicipital groove lies between the greater and lesser tuberosities and serves as a pathway for the long head of the biceps tendon [33].
• The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [33].
• The anatomic neck of the proximal humerus is located at the junction of the articular surface and the tuberosities [33].
• The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [33].
• The greater tuberosity is located in a posterior-superior location with respect to the humeral shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [33].
• The lesser tuberosity is located on the anterior aspect of the proximal humerus and serves as the attachment site for the subscapularis tendon [33].
• The glenoid is a convex structure of shallow depth shaped like an inverted pear [33].
• The glenoid cavity is a shallow socket, approximately one third the size of the humeral head [34].
• The neck-shaft angle measures an average of 135 degrees [34].
• The humeral head is retroverted an average of 30 degrees [34].
• The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [35].
• The glenoid averages 5° of retroversion in relation to the axis of the scapular body [35].
• The subchondral bone of the glenoid is relatively flat, and the articular concavity is augmented by cartilage and a circumferential labrum [35].
• The acromion has three ossification centers: the metacromion (base), the mesoacromion (middle), and the preacromion (tip) [35].
• Failure of fusion of the acromial ossification centers results in os acromiale [35].
• The clavicle is the first bone to ossify, occurring in the fifth week of gestation [35].
• The clavicle is the only long bone to ossify by intramembranous ossification [35].
• The medial (sternal) epiphysis of the clavicle is the last ossification center to fuse, at age 20 to 25 years [35].
• The proximal humerus has three centers of ossification: the humeral head (4 to 6 months), the greater tuberosity (1 to 3 years), and the lesser tuberosity (3 to 5 years) [35].
• The ossification centers of the proximal humerus fuse to the shaft at age 17 to 20 years [35].
• Ossification of the scapular body begins at the eighth week of gestation [35].

Vascular Supply

• The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [33].
• The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [33].
• The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [33].
• The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing (also known as the arcuate artery) [33].
• The ascending branch of the anterior humeral circumflex artery courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [33].
• Injury to the arcuate artery may result in osteonecrosis of the humeral head [33].
• Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [33].
• The major blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [34].
• The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [35].
• The anterolateral ascending branch of the anterior humeral circumflex artery travels proximally in the lateral aspect of the intertubercular groove [35].
• The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [35].

Joints and Ligaments

• Normal shoulder motion is approximately two-thirds glenohumeral and one third scapulothoracic [35].
• The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [35].
• The posterior sternoclavicular joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [35].
• The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [35].
• The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior (horizontal) translation of the clavicle [35].
• The coracoclavicular ligaments (conoid: medial; trapezoid: lateral) are the primary stabilizers to superior (vertical) translation of the distal clavicle [35].
• The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [35].
• The superior shoulder suspensory complex is composed of the glenoid, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the acromioclavicular joint, and the acromion [35].
• The superior strut of the superior shoulder suspensory complex comprises the middle clavicle [35].
• The inferior strut of the superior shoulder suspensory complex comprises the lateral scapular border/spine of the scapula [35].
• The rotator cuff stabilizes the glenohumeral joint via joint compression [35].
• Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [35].
• The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [35].
• The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [35].
• The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [35].
• Laxity of the rotator interval results in inferior laxity (the sulcus sign) [35].
• Contracture of the rotator interval is seen with adhesive capsulitis [35].
• The coracohumeral ligament restricts external rotation in adduction [35].
• The coracohumeral ligament is a static restraint to inferior and posterior translation in adduction and external rotation [35].
• The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [35].
• With the coracohumeral ligament, the superior glenohumeral ligament forms a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [35].
• The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [35].
• The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90° of abduction and external rotation (position of apprehension) [35].
• The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [35].
• The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [35].
• The suprascapular artery runs superior to the superior transverse scapular ligament, and the nerve runs deep to the ligament [35].
• Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [35].
• The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [35].
• Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [35].

Muscles and Nerves

• The rotator cuff consists of four muscles: the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [34].
• The teres major is not a rotator cuff muscle [34].
• The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [34].
• The infraspinatus and teres minor are external rotators of the humerus [34].
• The subscapularis is an internal rotator of the humerus [34].
• The deltoid and pectoralis major muscles, along with the rotator cuff, cause predictable displacement of fractures around the proximal humerus [34].
• The subscapularis is the largest and strongest of the rotator cuff tendons [43].
• The subscapularis is responsible for active internal rotation of the humerus and contributes to the stability of the shoulder [43].
• As a component of the dynamic stabilization mechanism of the glenohumeral joint, the subscapularis forms the anterior portion of the transverse plane “force couple” of the rotator cuff [43].
• The subscapularis serves to balance the forces generated across the joint to maintain glenohumeral congruency throughout movement [43].
• The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [38].
• The axillary nerve passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction [38].
• The axillary nerve is adjacent to the inferior capsule before entering the quadrilateral space posteriorly [38].
• The axillary nerve splits into the anterior and posterior branches within the quadrangular space [38].
• The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [38].
• In 2.3% of cases, the posterior deltoid muscle receives supply only from the anterior branch of the axillary nerve [38].
• In 8.5% of cases, the posterior deltoid muscle receives supply only from the posterior branch of the axillary nerve [38].
• In 89.1% of cases, the posterior deltoid muscle receives supply from both branches of the axillary nerve [38].
• The posterior branch of the axillary nerve branches to supply the teres minor muscle and then terminates as the superior lateral brachial cutaneous nerve [38].
• In the anterior deltopectoral approach, the axillary nerve can be palpated by sweeping a finger inferiorly across the subscapularis muscle tendon interface [38].
• In the anterolateral deltoid splitting approach, the axillary nerve crosses approximately 5 cm inferior to the anterolateral acromial corner [38].
• In the posterior deltoid splitting approach, the axillary nerve is approximately 7 cm from the posterior acromial corner [38].

Bursae and Synovial Structures

• The subacromial bursa and subscapular bursa are two bursae in the shoulder region with particular clinical importance [36].
• The subscapular bursa lies between the subscapularis tendon and the neck of the scapula [36].
• The subscapular bursa communicates with the joint cavity between the superior and middle glenohumeral ligaments [36].
• The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [36].
• The subscapular bursa is linked to the coracoid process by a suspensory ligament [36].
• In 28% of specimens dissected by Colas and colleagues, the subscapular bursae merged with the subcoracoid bursae, forming a unique wide bursa in this region [36].
• The subscapular bursa often houses loose bodies in the shoulder [36].
• The subscapular bursa is a region in which synovitis of the shoulder may be most intense, where small fringes, or villi, can project into the joint cavity [36].
• A soft tissue sheath consistently covers the long head of the biceps tendon to the level of the proximal margin of the pectoralis major tendon and contributes to the roof of the bicipital tunnel [36].
• The fibro-osseous bicipital tunnel consists of three distinct anatomic zones [36].
• Zone 1 of the bicipital tunnel represents the traditional bony bicipital groove beginning at the articular margin and ending at the distal margin of the subscapularis tendon [36].
• Zone 2 of the bicipital tunnel extends from the distal margin of the subscapularis tendon to the proximal margin of the pectoralis major tendon and represents a “no man’s land” because it is not viewable from arthroscopy above or from subpectoral exposure below [36].
• Zone 3 of the bicipital tunnel is distal to the proximal margin of the pectoralis major tendon and represents the subpectoral region [36].
• DePalma and colleagues described six common variations or types of recesses in the anterior capsule [36].
• Type 1 anterior capsule recess (30.2%) has one synovial recess above the middle glenohumeral ligament [36].
• Type 2 anterior capsule recess (2.0%) has one synovial recess below the middle glenohumeral ligament [36].
• Type 3 anterior capsule recess (40.6%) has one recess above and one below the middle glenohumeral ligament [36].
• Type 4 anterior capsule recess (9.0%) has one large recess above the inferior ligament, with the middle glenohumeral ligament being absent [36].
• Type 5 anterior capsule recess (5.1%) has the middle glenohumeral ligament manifested as two small synovial folds [36].
• Type 6 anterior capsule recess (11.4%) has no synovial recesses, although all the ligaments are well defined [36].
• DePalma believed that if the capsule arises at the labrum or glenoid border of the scapula, few, if any, recesses would be present [36].
• DePalma believed that if the capsule begins farther medially on the scapula or glenoid neck, the synovial recesses are larger and more numerous [36].
• DePalma believed that the end result of such recesses was a thin, weakened anterior capsule that could predispose the shoulder to instability [36].
• The rotator interval is defined as the region between the superior border of the subscapularis and the anterior border of the supraspinatus [36].
• The rotator interval includes the region of the superior glenohumeral ligament and coracohumeral ligament, in addition to the middle glenohumeral ligament [36].
• Plancher and colleagues found the average area of the rotator interval to be 20.96 mm [36].
• Dynamic testing has shown that the subscapularis and supraspinatus dimensions as well as the total area of the rotator interval decrease significantly with internal rotation and open with external rotation [36].

Pathophysiology and Biomechanics

• Stability and function of the glenohumeral joint is provided by the interaction of structures that promote a near global range of motion and purposeful function [33].
• External loads transferred to the shoulder girdle are initially offset by joint surface anatomy, joint volume, atmospheric pressure, and joint fluid cohesion and adhesion [33].
• Moderate and large loads are counterbalanced by

Periprosthetic Fractures

• Periprosthetic fractures associated with shoulder arthroplasty can occur around the glenoid or the humeral stem [60].
• Periprosthetic fracture around the glenoid component is rare and typically occurs intraoperatively [60].
• Most periprosthetic fractures associated with shoulder arthroplasty occur on the humeral side [60].
• Humeral periprosthetic fractures can occur both during and after surgery [60].
• Women and patients with a poor morbidity index score are at substantial risk for humeral periprosthetic fractures [60].
• The Wright and Cofield classification divides periprosthetic humeral fractures into three categories [60].
• Type A fractures propagate proximally from the distal stem [60].
• Type B fractures are centered over the distal stem [60].
• Type C fractures are located distal to the tip of the stem [60].

Clinical Presentation

History and Physical Examination Principles

• A failed arthroscopic stabilization procedure often begins with the failure to identify red flags in the patient’s history and physical examination that might preclude a successful arthroscopic repair [42].
• The history should define the mechanism of injury, including the position of the arm, the amount of force applied, and the point of force application [46].
• Injury with the arm in extension, abduction, and external rotation favors anterior dislocation [46].
• Electoshock, seizures, or a fall on the flexed and adducted arm are commonly associated with posterior dislocation [46].
• For recurrent instability, the history defines the initial injury, the position or action that results in instability, how long the shoulder stays out, whether radiographs are available with the shoulder out of joint, and what means have been necessary to reduce the shoulder [46].
• The history also solicits evidence of neurologic or rotator cuff problems after previous episodes of shoulder instability [46].
• Previous treatment of recurrent instability, as well as the effectiveness of this treatment, should be documented [46].
• A thorough history and physical examination should allow the examiner to understand the etiology, direction, degree, and frequency of a patient’s shoulder instability [42].
• Imaging studies must be interpreted in light of a thorough history and physical examination and must not be used as a stand-alone method to direct patient care [48].
• Most physical examination tests are sensitive for a wide range of shoulder conditions, but very few are specific to the presence of a single disorder [48].
• The use of any single test to establish a pathognomonic diagnosis could not be recommended, and combinations of shoulder tests provided better accuracy only marginally [48].
• Treatment should begin with a dialogue between the surgeon and the patient regarding the diagnosis, the probable natural history of the condition if untreated, and the potential risks and benefits of different treatment options [47].
• The likely outcomes are discussed in light of the patient’s expectations and the surgeon’s personal experience in treating the patient’s condition [47].

Anterior Dislocation

• An acutely dislocated shoulder is usually very painful, and muscles are in spasm in an attempt to stabilize the joint [46].
• The humeral head may be palpable anteriorly in an acutely dislocated shoulder [46].
• The posterior and lateral aspect of the shoulder shows a hollow beneath the acromion in an acutely dislocated shoulder [46].
• The arm is held in slight abduction in an acutely dislocated shoulder [46].
• Passive and active motions are limited by pain in an acutely dislocated shoulder [46].
• Assessment of the neurovascular status of the upper extremity and charting of the findings before reduction is an essential part of the physical examination of an anteriorly dislocated shoulder [46].

Posterior Dislocation

• Recognition of a posterior dislocation may be impaired by the lack of a striking deformity of the shoulder and by the fact that the shoulder is held in the traditional sling position of adduction and internal rotation [46].
• Limited external rotation of the shoulder, often to <0 degrees, is a classic feature of posterior dislocation [46].
• Limited elevation of the arm, often to <90 degrees, is a classic feature of posterior dislocation [46].
• Posterior prominence and rounding of the shoulder in comparison to the normal side is a classic feature of posterior dislocation [46].
• Flattening of the anterior aspect of the shoulder is a classic feature of posterior dislocation [46].
• Prominence of the coracoid process on the dislocated side is a classic feature of posterior dislocation [46].
• Asymmetry of the shoulder contours can often best be visualized by viewing the shoulders from above while standing behind the patient [46].
• Motion is limited because the head of the humerus is fixed on the posterior glenoid rim by muscle forces, or the head might actually be impaled on the glenoid rim [46].
• With the passage of time, the posterior rim of the glenoid can further impact the fracture of the humeral head and produce a deep hatchet-like defect or a V-shaped compression fracture, which engages the head even more securely [46].
• Patients with old, unreduced posterior dislocations of the shoulder can have 30 to 40 degrees of glenohumeral abduction and some humeral rotation as a result of enlargement of the groove [46].
• With long-standing disuse of the muscles about the shoulder, atrophy will be present, which accentuates the flattening of the anterior portion of the shoulder, the prominence of the coracoid, and the fullness of the posterior portion of the shoulder [46].
• In the interval before the diagnosis of posterior dislocation of the shoulder is made, the injury may be misdiagnosed as a frozen shoulder for which vigorous therapy may be mistakenly instituted in an attempt to restore range of motion [46].

Frozen Shoulder

• The hallmark of a frozen shoulder is the corresponding loss of both passive and active ROM [49].
• A major reason why practitioners that are not experienced with shoulder pathology miss the diagnosis is that they do not test ROM, instead moving directly to more provocative maneuvers to assess the rotator cuff, which are often positive in frozen shoulder patients [49].
• A complete cervical examination should be performed, including neurologic testing of the extremities, when diagnosing a frozen shoulder [49].
• The shoulder should be inspected for signs of trauma or previous surgery, which may provide clues for the diagnosis of acquired stiffness [49].
• Important landmarks, such as the acromioclavicular joint and bicipital groove, are palpated for tenderness [49].
• ROM, both active and passive, should be tested in all planes and recorded as objectively as possible, and repeated in the contralateral shoulder [49].
• It is essential to differentiate glenohumeral motion from humeroscapular motion as many patients with glenohumeral stiffness can compensate with scapulothoracic motion [49].
• Differentiating glenohumeral from humeroscapular motion is best done by examining the patient in the supine position with the arm free so that the scapula is being compressed against the chest wall through gravity, or by stabilizing the scapula with one hand while passively moving the arm with the other [49].
• Strength testing of the rotator cuff is performed using standard manual motor testing as well as special tests (belly press, lift-off, lag signs, hornblower’s sign) [49].
• Provocative tests for impingement, acromioclavicular joint pathology, labral tears, instability, and biceps pathology may also be indicated depending on the history and clinical suspicion [49].
• Patients in the freezing phase have what is often described as achy discomfort at rest and severe pain with attempted movements, especially sudden movements [49].
• Difficulty with sleeping is an almost universal complaint in the freezing phase [49].
• Generally, patients limit their use of the affected extremity as discomfort worsens, resulting in loss of function [49].
• Many patients are encouraged to immobilize their shoulders, which exacerbates the problem [49].
• The freezing phase generally lasts between 2 and 9 months [49].
• During the frozen phase, the pain tends to abate, but motion becomes severely limited in all planes [49].
• Even simple tasks, such as turning off the light and washing hair, become chores during the frozen phase [49].
• Sleeping is usually problematic during the frozen phase [49].
• A frozen shoulder is diagnosed in most patients when they enter the frozen stage [49].
• Although it can last between 3 and 12 months, the frozen stage can become refractory and last longer [49].
• In the thawing stage, ROM slowly returns [49].
• As motion improves in the thawing stage, residual discomfort generally resolves [49].
• Return of flexibility in the thawing stage can take months to years [49].
• Motion restrictions often persist after the thawing stage [49].
• Generally, these persistent restrictions are mild and do not cause significant impairment, but patients should be counseled about this at an early stage [49].

Instability Examination

• Risk factors associated with treatment failure (recurrent instability or functional deficits) include age, gender, presence of osseous Bankart, and/or large Hill-Sachs (cortical depression in the posterolateral humeral head) lesions, participation in competitive collision or forced overhead sports, hypermobility, time lapse between dislocation and reduction, and the number of instability episodes prior to operation [42].
• An examination under anesthesia is critical to the success of arthroscopic stabilization, and is more sensitive for determining both the degree and direction of instability [42].
• The pattern of instability can be determined without getting affected by patient apprehension or guarding during examination under anesthesia [42].
• The axial load test or load-and-shift test is conducted during examination under anesthesia and the translation noted in the anterior, inferior, and posterior directions [42].
• Grading reflects the degree of humeral head translation anterior and posterior to the glenoid rim [42].
• Grade 1+ corresponds to the translation of the humeral head to the edge of the glenoid [42].
• Grade 2+ corresponds to the humeral head being able to be subluxated over the glenoid rim but reducing spontaneously [42].
• Grade 3+ corresponds to a frank dislocation of the humeral head over the glenoid rim that does not reduce spontaneously [42].
• The specificity of the anterior apprehension test, the relocation test, and the surprise test exceeds 95% for anterior shoulder instability [48].
• Operationally, glenohumeral translation (apprehension), and not pain, is used as the sine qua non for diagnosis of anterior shoulder instability [48].
• The best physical examination signs for rotator cuff disorders include weakness in external rotation, a positive drop-arm sign, and a painful arc of motion [48].
• When weakness in external rotation, a positive drop-arm sign, and a painful arc of motion are positive in a patient older than 60 years of age, there was a 91% chance of a full-thickness rotator cuff tear [48].
• None of the five clinical tests evaluated for SLAP lesions provided diagnostic utility to aid decision-making, either as stand-alone examination tools or when used in clusters [48].

Investigations

Imaging Modalities and Protocols

• The purpose of shoulder imaging is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [24].
• Standardized plain films are almost always sufficient to garner the information needed for shoulder evaluation [24].
• CT scans may offer increased precision in the measurement of glenoid version, but this precision does not necessarily improve the quality of the surgery or the clinical outcome [24].
• The first key radiographic view is the anteroposterior (AP) view in the plane of the scapula, taken so that the x-ray beam passes through the glenohumeral joint [24].
• The AP view in the plane of the scapula shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, narrowing of the joint space, degree of medial displacement of the humerus, quality of bone, presence of loose bodies, and humeral head collapse or deformity [24].
• The second key radiographic view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula [24].
• The axillary view is referred to as the "truth view" because it demonstrates glenohumeral relationships in the functional position of elevation [24].
• CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [24].
• The standardized axillary view can show posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [24].
• The degree of posterior subluxation can be measured by the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [24].
• The point of contact of the humeral articular surface on the glenoid articular surface reflects the degree of centering of the net humeral joint reaction force on the glenoid [24].
• Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [24].
• MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [40].
• T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [40].
• T2-weighted MRI provides better visualization of full thickness rotator cuff tears [40].
• MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [40].
• CT arthrography is indicated when MRI or MR arthrography is contraindicated, such as in patients with pacemakers or vascular clips [40].
• Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [40].
• Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [40].
• Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [40].
• Ultrasonography can evaluate impingement in various positions and motions due to real-time imaging capabilities [40].
• Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [40].
• A robust approach to shoulder imaging must recognize that the shoulder is a three-dimensional structure that cannot be represented by a single planar view [39].
• Critical relationships, such as the degree of centering of the humeral head, change with the position of the arm [39].
• Shoulder pathology may be found in a large number of different bones and soft tissues [39].
• Overlying and superimposed structures as well as metallic implants may complicate imaging the structures of interest [39].
• Surgeons need to develop a judicious approach to imaging that yields necessary information while avoiding the tendency to "over-image" [39].

Diagnostic Arthroscopy and Positioning

• When properly executed, diagnostic arthroscopy in the beach-chair position can effectively identify and characterize intra-articular shoulder pathologies [1].
• Lateral decubitus positioning presents technical challenges including increased theoretical risk to the musculocutaneous and axillary nerves, risk of traction injury to the brachial plexus, and limitations in range of motion that make procedures like rotator cuff repair more challenging [22].
• Supine-position shoulder arthroscopy using the anterior portal as the initial approach serves as a safer, more cost-effective, and more accessible complementary approach for shoulder arthroscopy positioning [6].
• The supine-position shoulder arthroscopy approach is worthy of routine clinical application [6].

Preoperative Assessment and Clinical Considerations

• The authors recommend strong consideration of performing arthroscopy prior to open Latarjet if a preoperative MRI is not obtained or if a preoperative MRI identifies additional intra-articular pathology [8].
• The diagnosis of a stiff shoulder depends on awareness of the problem, with history and physical examination being paramount and ancillary studies helpful in certain circumstances [18].
• It is important to understand the natural history of shoulder stiffness so that patients are well informed and can actively participate in decision-making [18].

Treatment

Positioning and Setup

• The beach-chair position offers an intuitive anatomic view with the advantage of shoulder maneuverability [13].
• Lateral decubitus positioning is safe and effective for arthroscopic treatment of various shoulder pathologies when appropriate technique is used [10].
• The supine position using the anterior portal as the initial approach serves as a safer, more cost-effective, and more accessible complementary approach for shoulder arthroscopy positioning worthy of routine clinical application [6].
• A high-low positioned bag technique for fluid management in shoulder arthroscopy is a simple, effective, and cost-efficient approach [14].

Diagnostic Arthroscopy

• Arthroscopy can serve as both a diagnostic and therapeutic tool for patients who have pain after shoulder arthroplasty [20].
• Failure of standard investigations to identify the cause of pain after shoulder arthroplasty is an indication for diagnostic arthroscopy [20].
• In a series of nine cases, arthroscopic examination for more than 2 mm of motion at the interface correctly diagnosed all five loose glenoid components [20].
• Serial radiographs correctly predicted glenoid loosening in only two of six patients, while arthrography did so in only one out of three cases [20].

Instability and Stabilization

• Recent randomized trials and systematic reviews have not shown the superiority of modern arthroscopic techniques compared with open repairs for shoulder instability [19].
• Open repair resulted in a significantly lower risk of recurrence compared to arthroscopic repair in terms of patient quality of life [19].
• Arthroscopic and open repair techniques for the treatment of recurrent traumatic shoulder instability yield comparable results if the procedure is selected on the basis of the pathologic findings at the time of surgery [19].
• Available evidence indicates that arthroscopic approaches are not as effective as open approaches in preventing recurrent instability or enabling patients to return to work [19].
• Misplaced suture anchors can give rise to secondary degenerative joint disease or "anchor arthropathy" [19].
• Use of intra-articular infusion of local antibiotics via a pain pump after arthroscopic instability repairs results in a risk of glenohumeral chondrolysis [19].
• The healing time for a labral reattachment is likely to be the same as the time to heal a subscapularis tenotomy, so the time to return to activity should not be different with the two approaches [19].
• For traumatic anterior instability, an anatomic repair usually suffices, and additional capsular tightening or shifting can result in a stiff shoulder [19].
• For lax shoulders with relatively less-traumatic instability, management may require a combination of labral augmentation and capsular tightening with care to avoid excessive and asymmetrical tightening [19].
• The routine use of bone transfers for glenohumeral instability in the absence of major glenoid bone loss is not advisable due to increased risk of arthritis, screw-related problems, damage to the subscapularis, and difficulty in revision [19].
• For AMBRI type instability, the surgeon can use the redundant capsule to augment the labrum to create a deeper stabilizing concavity rather than risking overtightening with capsular plication [19].
• Dynamic anterior glenohumeral capsular ligament tensioning is considered a reliable surgical technique for traumatic anterior instability of the dominant shoulder in athletes who wish to return to overhead-throwing sports [17].
• Higher resilience scores were associated with improved patient-reported outcomes following shoulder stabilization [16].
• Operative procedures for recurrent anterior instability can be done open or arthroscopically with comparable results [28].
• Preferred surgical procedures for anterior instability include arthroscopic Bankart or capsular plication procedures as indicated [28].
• Moderately sized (20% to 30%) humeral head defects are treated with an arthroscopic remplissage procedure and Bankart repair [28].
• Larger humeral head defects (35% to 45%) are treated indirectly by increasing the glenoid arc using a Latarjet procedure or by allograft repair of the defect [28].

Rotator Cuff and Biceps Pathology

• The arthroscopic suspensionplasty technique for hemiplegic shoulder painful inferior subluxation is relatively simple, with low morbidity for a surgeon with experience in shoulder arthroscopy and rotator cuff surgery using common devices [5].
• Arthroscopic rotator cuff repair has evolved from arthroscopic-assisted mini-open approaches to all-arthroscopic approaches [53].
• The goal of rotator cuff repair remains secure fixation to the humerus with a relatively tension-free repair that respects biology and biomechanics [53].
• Improved instrumentation has been the greatest advancement facilitating approaches to repairing cuff tendons through cannulas [53].
• The role of biceps tendon transfer remains to be determined, with options including tenotomy and tenodesis at the top of the groove, below the groove but above the pectoralis, and subpectoral [55].
• Tenotomy is preferred for low-demand elderly and sedentary patients, usually in the setting of rotator cuff repair [55].
• Tenodesis at the top of the groove is preferred for active patients undergoing rotator cuff repair [55].
• For younger patients with isolated biceps tendon or partial-thickness tears, either an arthroscopic infragroove suprapectoral tenodesis or an open subpectoral biceps tenodesis may be performed depending on intraoperative findings [55].

Post-Arthroplasty Arthroscopy

• When performing arthroscopy after arthroplasty, care should be taken to avoid damage to the metal or polyethylene surfaces [20].
• A 30-degree arthroscope should be used and turned away from the humeral head or glenosphere to avoid the "mirror effect" that can distort anatomy and confuse the surgeon [20].
• Arthroscopic removal of an all-polyethylene glenoid component for conversion of a failed total shoulder arthroplasty to a hemiarthroplasty is a novel technique considered only when glenoid loosening occurs in a patient with a large rotator cuff defect or associated medical comorbidity that precludes a revision arthroplasty [20].
• In a series of 203 cases of total shoulder arthroplasty, 3% had impingement refractory to conservative management, and arthroscopic subacromial decompression yielded excellent or good results in five of six patients [20].
• Arthroscopic procedures for painful shoulder arthroplasties include subacromial decompression, distal clavicle excision, capsular release, mini-open rotator cuff repairs, biceps tenodesis or debridement, and loose body or suture granuloma removal [20].
• Biceps tendon pathology in the post-arthroplasty shoulder can involve bowstringing over the humeral head component, leading to pain and degeneration [20].

Complications and Safety

• Overall, complications of shoulder arthroscopy are low [12].
• Most of the literature describing complications of shoulder arthroscopy is limited to single-institution case series with conflicting data in several areas [12].
• Surgeons must have a thorough understanding of the potential arthroscopic complications in shoulder surgery to prevent, recognize, and manage them when they occur [12].

General Principles and Evolution

• Shoulder arthroscopy is currently one of the most common orthopedic procedures [12].
• Many conventional shoulder procedures previously performed with open techniques are now accomplished arthroscopically [12].
• Early proponents of the trend towards arthroscopic shoulder management suggested that the technique is associated with fewer complications compared with open surgery [12].
• Adopting refined techniques such as posterior-to-anterior cannula-guided subacromial access will be crucial for addressing complex shoulder pathologies effectively [2].

Complications

General Complication Profile

• Early proponents of arthroscopic shoulder management suggested that the technique is associated with fewer complications compared with open surgery [12].

Intraoperative and Technical Complications

• Dermal burns are a complication associated with shoulder arthroscopy [21].
• This complication is more common than originally thought [21].
• When performing arthroscopy after shoulder arthroplasty, care should be taken to avoid damage to the metal or polyethylene surfaces [20].
• Visual damage to the humeral head can occur after arthroscopic excision of loose glenoids [20].

Postoperative Complications and Risk Factors

• Resident involvement in shoulder arthroscopy procedures is not associated with increased risk for medical or 30-day postoperative surgical complications [7].
• Operative duration is an independent risk factor for lower-extremity deep vein thrombosis following shoulder arthroscopy [31].
• These findings highlight the need to reconsider VTE risk assessment in shoulder arthroscopy and support further research into risk-stratified prevention strategies [31].

Instability-Specific Complications

• Open repair resulted in a significantly lower risk of recurrence compared to arthroscopic repair in younger male patients with a Hill-Sachs lesion [19].
• Arthroscopic approaches are not as effective as open approaches in preventing recurrent instability or enabling patients to return to work [19].
• The routine use of bone transfers for glenohumeral instability is associated with an increased risk of arthritis, screw-related problems, damage to the subscapularis, and difficulty in revision [19].
• Nerve injuries from interscalene blocks can be permanent [19].

Recovery

• Higher resilience scores were associated with improved patient-reported outcomes following arthroscopic shoulder stabilization surgery [16].

Key Evidence

• [L5] When properly executed, diagnostic arthroscopy in the beach-chair position can effectively identify and characterize intra-articular shoulder pathologies. [1] (10.1016/j.eats.2024.103083)
• [L5] As shoulder arthroscopy continues to evolve, adopting such refined techniques will be crucial for addressing complex shoulder pathologies effectively. [2] (10.1016/j.eats.2025.103901)
• [L4] Current guidelines for thromboprophylaxis in shoulder arthroscopy lack consensus and need patient-specific considerations. [3] (10.2106/jbjs.rvw.23.00228)
• [Paper] Arthroscopic Instruments represented the most frequent category among the top 100 most-cited shoulder arthroscopy patents. [4] (10.1016/j.xrrt.2026.100828)
• [L5] The arthroscopic suspensionplasty technique is relatively simple, with low morbidity for a surgeon with experience in shoulder arthroscopy and rotator cuff surgery using common devices. [5] (10.1016/j.eats.2023.02.037)
• [Paper] It serves as a safer, more cost-effective, and more accessible complementary approach for shoulder arthroscopy positioning and is worthy of routine clinical application. [6] (10.1002/atn2.70109)
• [L3] Resident involvement in shoulder arthroscopy procedures is not associated with increased risk for medical or surgical 30-day postoperative complications. [7] (10.5435/jaaosglobal-d-20-00138)
• [L4] The authors recommend strong consideration of performing arthroscopy prior to open Latarjet if a preoperative MRI is not obtained or if a preoperative MRI identifies additional intra-articular pathology. [8] (10.1177/23259671261415839)
• [L4] Earlier Orthopaedic Surgeon evaluation of WC patients with shoulder injuries was associated with a higher return to full duty after shoulder arthroscopic surgery. [9] (10.5435/jaaosglobal-d-24-00269)
• [L5] With appropriate technique, lateral decubitus positioning is safe and effective for arthroscopic treatment of various shoulder pathologies. [10] (10.1016/j.eats.2024.103080)
• [L5] The beach-chair position offers an intuitive anatomic view with the advantage of shoulder maneuverability. [13] (10.1016/j.eats.2024.103082)
• [Paper] The high-low positioned bag technique for fluid management in shoulder arthroscopy is a simple, effective, and cost-efficient approach. [14] (10.1016/j.eats.2025.103852)
• [L4] Higher BRS scores were associated with improved PROs following shoulder stabilization. [16] (10.1177/2325967126s00528)
• [L5] Therefore, we consider this surgical technique to be reliable for traumatic anterior instability of the dominant shoulder in athletes who wish to return to overhead-throwing sports. [17] (10.1016/j.eats.2024.103069)
• [L4] [21] (10.1016/j.arthro.2011.06.005)
• [L5] However, it presents technical challenges including increased theoretical risk to the musculocutaneous and axillary nerves, risk of traction injury to the brachial plexus, and limitations in range of motion that make procedures like rotator cuff repair more challenging. [22] (10.1016/j.eats.2024.103081)
• [L2] These findings highlight the need to reconsider VTE risk assessment in shoulder arthroscopy and support further research into risk-stratified prevention strategies. [31] (10.1177/23259671261451735)

References

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[2] Subacromial Access in Shoulder Arthroscopy Using a Posterior‐to‐Anterior Cannula‐Guided Technique. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103901

[3] Venous Thromboembolism Chemical Prophylaxis in Patients Undergoing Shoulder Arthroscopy. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.23.00228

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