Clinicians › Shoulder
Shoulder Arthroscopy
What shoulder arthroscopy is, what it's used for, and how to prepare and recover.
For patients: a plain-language version of this topic is available. See the patient guide.
Overview¶
Shoulder arthroscopy is a commonly performed procedure generally considered safe, with rare morbidity and mortality [3, 44]. The overall 30-day complication rate is approximately 1.0%, with readmission rates remaining below 1% [5, 80]. While complications are not necessarily less prevalent or devastating than those associated with open techniques, they differ in nature [2]. The most frequent adverse event is a return to the operating room, which accounts for 29% of all complications [5]. Risk factors for adverse events include increasing age and higher ASA scores [80]. In patients aged 60 years or older, the 30-day postoperative complication rate is 1.6%, a figure higher than previously reported for the overall shoulder arthroscopy population [42]. The typical patient demographic in the US consists primarily of older, white, male adults [12].
Postoperative pain is relatively low, and the efficacy of the procedure is long-lasting regarding pain symptoms [13]. Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experience favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery and progression to clinically relevant osteoarthritis [6]. Arthroscopic revision of failed open anterior shoulder stabilization provides satisfactory results in selected populations [14], and revision arthroscopic anterior stabilization can yield satisfactory outcomes in appropriately selected patients who have failed previous capsulolabral repair [28, 29]. Considering new technical possibilities, most cases of anterior shoulder instability are suitable for arthroscopic reconstruction, though further studies are necessary to validate continued efficacy [35]. Proper evaluation of bone loss best determines surgical indications and outcomes for shoulder instability [71].
Current guidelines for thromboprophylaxis in shoulder arthroscopy lack consensus and require patient-specific considerations [41]. Surgeons must recognize mixed neuropathy presenting clinically as an anterior interosseous nerve palsy following the procedure to ensure appropriate intervention or referral [1]. The literature remains controversial, with conclusions often unsupported due to bias and limitations; no clinical guidelines are definitive pending higher levels of evidence [4]. When comparing open and arthroscopic rotator cuff repair outcomes, surgeons must carefully interpret data, as differences in complications may be influenced by selection bias and narrowing indications for open repair [45]. A criteria-based testing protocol for return to play following arthroscopic shoulder stabilization is strongly recommended [46]. Arthroscopic shoulder procedures are increasingly performed in ambulatory surgery centers, although reimbursements for these procedures declined during the study period from 2013 to 2022 [216].
Anatomy & Pathophysiology¶
Bony Anatomy¶
The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [87]. The articular head is spherical with a diameter of 37 to 57 mm [87]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [87], while the superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [96]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [87]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [96]. The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [98] and inclined approximately 130 degrees with respect to the humeral shaft [87]. The average neck-shaft angle is 45 degrees, with a range of 30 to 50 degrees [96].
The anatomic neck is located at the junction of the articular surface and the tuberosities [87], directly below the humeral head, and serves as an attachment for the shoulder capsule [98]. The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [87]; it is more distal than the anatomic neck and is more often involved in fractures [98]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [87], while the lesser tuberosity serves as the attachment site for the subscapularis tendon [87]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [96]. Humeral articular malposition of more than 4 mm leads to increased subacromial contact [96], and an offset of 8 mm in any direction significantly decreases passive range of motion [96].
The glenoid is a convex structure of shallow depth shaped like an inverted pear [87]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [96]. The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [98]. It is anteverted on the chest wall approximately 30 degrees relative to the body [98], and the glenoid is retroverted approximately 5 degrees relative to the scapular body [98]. Os acromiale results from incomplete fusion of secondary ossification centers, most commonly between the mesoacromion and meta-acromion [98]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch [87].
The clavicle is the first bone to ossify in the body at 5 weeks of gestation [98]. The medial epiphysis of the clavicle is the last to fuse, occurring at 25 years of age [98]. The proximal humerus has three ossification centers: the humeral head, greater tuberosity, and lesser tuberosity [89]. The humeral head ossification center is present at birth, the greater tuberosity appears by 1 to 3 years of age, and the lesser tuberosity appears by 5 years of age [93]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [93]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis [93]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to adult values by 11 years of age [93]. The humeral head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [98].
Vascular Supply¶
The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches of the axillary artery [87]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [87]. Its ascending branch 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 [87]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [89]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [89]. This terminal anterolateral branch is known as the artery of Laing or arcuate artery [87]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [87], although additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [87].
The posterior humeral circumflex artery travels with the axillary nerve and enters the quadrilateral space posteriorly [87]. Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [93]. The transverse humeral ligament is an important stabilizer of the biceps tendon [98].
Joints and Ligaments¶
The shoulder joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints [97]. The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [89]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability of the sternoclavicular joint [98].
The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [89]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [89]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [89]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint [98]. The conoid ligament is located approximately 45 mm from the acromioclavicular joint and is stronger than the trapezoid ligament [98].
The glenohumeral joint has the greatest range of motion in the body [98]. Static restraints include articular anatomy, the glenoid labrum, glenohumeral ligaments, capsule, and negative intraarticular pressure [98]. Dynamic stabilizers include the rotator cuff and biceps tendon [98]. The fibrocartilaginous glenoid labrum deepens the socket by 50% and provides a bumper to translation [98]. The glenoid labrum increases the depth of the socket by 50% around the humeral head [97]. The glenoid articular surface and labrum combine to create a socket approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [97]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [97].
The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction [97]. It is the primary stabilizer to anterior and posterior stress in 0 degrees of abduction [97] and restrains external rotation and inferior translation of the adducted or slightly abducted arm [98]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [89]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction [97] and has little effect when the arm is in 90 degrees of abduction [97]. It is absent in up to 30% of shoulders [98]. The middle glenohumeral ligament restrains anterior translation with the arm abducted to 45 degrees [98] and is a primary static restraint against anterior translation with the arm in external rotation and 45 degrees of abduction [89].
The inferior glenohumeral ligament is composed of an anterior band, a posterior band, and a thinner intervening axillary pouch [97]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [97]. The anterior band of the inferior glenohumeral ligament restrains anterior and inferior translation with the arm externally rotated and abducted to 90 degrees [98] and is a primary static restraint against anterior-inferior dislocation in 90 degrees of abduction and external rotation [89]. The posterior band of the inferior glenohumeral ligament restrains posterior and inferior translation with the arm internally rotated and abducted to 90 degrees [98] and is a primary static restraint against posterior-inferior translation in internal rotation and adduction [89].
The coracohumeral ligament restrains inferior translation and external rotation of the adducted arm [98]. It restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [89]. The coracohumeral ligament originates from the base and lateral border of the coracoid process just below the origin of the coracoacromial ligament [100] and inserts on the greater tuberosity [100]. It has a static suspensory function for the humeral head in the glenoid cavity when the arm is in the dependent position [100]. With abduction, the coracohumeral ligament relaxes and loses its ability to support the humerus [100]. The superior glenohumeral ligament and coracohumeral ligament form a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [89].
The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [89]. It contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [89]. Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [89]. Contracture of the rotator interval is seen with adhesive capsulitis [89]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency [98] and is the arthroscopic landmark for a complete release of the rotator interval for adhesive capsulitis [98]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [98].
The shoulder capsule is large and has twice the surface area of the humeral head [100]. It typically accepts approximately 28 to 35 mL of fluid [100]. In patients with adhesive capsulitis, the shoulder capsule accepts only 5 mL or less of fluid [100]. The capsule is lined by synovium and extends from the glenoid neck to the anatomic neck and proximal shaft of the humerus [100]. The capsule is reinforced by the tendons of the rotator cuff muscles on all sides except the inferior portion [100]. The rotator cuff tendons blend into the capsule over varying lengths, averaging approximately 2.5 cm [100]. The transverse humeral ligament consists of transverse fibers of capsule extending between the greater and lesser tuberosities to contain the long head of the biceps tendon [100].
The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [89]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to it [89]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and infraspinatus muscles [89]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [89]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus muscle [89].
Muscles and Nerves¶
The rotator cuff consists of four muscles: the subscapularis, supraspinatus, infraspinatus, and teres minor [88]. The teres major is not a rotator cuff muscle [88]. The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [88]. The infraspinatus and teres minor are external rotators of the humerus [88]. The subscapularis is an internal rotator of the humerus [88]. The deltoid and pectoralis major muscles, along with the rotator cuff, cause predictable displacement of fractures around the proximal humerus [88].
The subscapularis is the largest and strongest of the rotator cuff tendons [126]. It is responsible for active internal rotation of the humerus and contributes to shoulder stability [126]. The subscapularis forms the anterior portion of the transverse plane force couple of the rotator cuff [126].
The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [92]. It passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction [92]. The axillary nerve enters the quadrilateral space posteriorly [92] and splits into anterior and posterior branches within the quadrangular space [92]. The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [92]. Posterior deltoid muscle innervation varies, with supply from both branches in 89.1% of cases [92]. The posterior branch of the axillary nerve supplies the teres minor muscle and terminates as the superior lateral brachial cutaneous nerve [92].
In the anterior deltopectoral approach, the axillary nerve can be palpated by sweeping a finger inferiorly across the subscapularis muscle tendon interface [92]. In the anterolateral deltoid splitting approach, the axillary nerve crosses approximately 5 cm inferior to the anterolateral acromial corner [92]. In the posterior deltoid splitting approach, the axillary nerve is approximately 7 cm from the posterior acromial corner [92]. The brachial plexus and axillary artery are anterior to the coracoid process of the scapula and humeral head [88]. Nerves innervating muscles around the shoulder include the axillary, suprascapular, subscapular, and musculocutaneous nerves [88]. The brachial plexus is prone to injury when the proximal humerus is injured in fractures or dislocations [93]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [93].
Bursae and Synovial Structures¶
The subacromial bursa and subscapular bursa are the two bursae of particular clinical importance in the shoulder region [90]. The subscapular bursa lies between the subscapularis tendon and the neck of the scapula [90]. It communicates with the joint cavity between the superior and middle glenohumeral ligaments [90]. The subscapular bursa protects the tendon of the subscapularis at the point where it passes [90].
Classification¶
Wright and Cofield: This classification divides periprosthetic humeral fractures associated with shoulder arthroplasty into three categories based on fracture location relative to the stem. Type A fractures propagate proximally from the distal stem, type B fractures are centered over the distal stem, and type C fractures are located distal to the tip of the stem [223].
DeOrio and Cofield: This system categorizes rotator cuff tear size into four tiers. Small tears measure <1 cm, medium tears measure 1 cm to <3 cm, large tears measure 3 cm to <5 cm, and massive tears measure >5 cm [270].
Rockwood: This classification differentiates rotator cuff tears into four groups based on chronological appearance. Acute tears present <6 weeks after the onset of symptoms or trauma, subacute tears present ≥6 weeks and <6 months, chronic tears present ≥6 months and <1 year, and inveterate tears present >1 year [271].
Snyder: This classification system considers four types of rotator cuff lesions. The evidence specifies C1 lesions as having a size ≤1 cm and C2 lesions as having a width between 2 cm and 3 cm [271].
Goutallier: This scale classifies muscle fatty degeneration of the rotator cuff into five stages. G-0 indicates no fatty degeneration, G-1 indicates muscle > fat, G-2 indicates muscle = fat, G-3 indicates muscle < fat, and G-4 indicates complete replacement of muscle tissue with fat tissue [271].
Visual Clarity Grading: This system for shoulder arthroscopy defines three grades based on the extent of the obscured field of view. Grade 1 is defined as <1/3 of the field of view obscured, Grade 2 as 1/3 to <2/3 of the field of view obscured, and Grade 3 as >2/3 of the field of view obscured [249].
Clinical Presentation¶
History and Physical Examination Principles¶
The clinical evaluation initiates the doctor-patient relationship with the goal of establishing a reasonable management plan rather than merely securing a diagnosis [54]. Outcomes are determined by four factors: the patient, the specific shoulder problem, the procedure selected, and the physician rendering treatment [54]. A "no touch" approach involves asking patients to demonstrate difficult actions and describe their subjective sensations during these movements [54]. If a shoulder problem is not apparent on history, physical examination, and plain radiographs, or if the patient is not an excellent surgical candidate, nonoperative management is likely recommended [54]. 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 [140]. While most physical examination tests are sensitive for a wide range of shoulder conditions, very few are specific to a single disorder [140]. A 2012 systematic review and meta-analysis concluded that using any single test to establish a pathognomonic diagnosis could not be recommended [140]. Combinations of shoulder tests provided better diagnostic accuracy than single tests, but only marginally so [140].
The history should define the mechanism of injury, including arm position, force magnitude, and point of force application [139]. Injury with the arm in extension, abduction, and external rotation favors anterior dislocation [139]. Electoshock, seizures, or a fall on the flexed and adducted arm are commonly associated with posterior dislocation [139]. For recurrent instability, the history defines the initial injury, the position or action resulting in instability, duration of dislocation, and reduction methods [139]. The history should solicit evidence of neurologic or rotator cuff problems after previous instability episodes and document previous treatments and their effectiveness [139]. Patients typically present with a history of trauma for shoulder instability [153]. Note should be made of age at first dislocation, increasing ease of dislocation, frequency of recurrence, duration of symptoms, and the patient's ability to self-reduce the dislocation [153].
A failed arthroscopic stabilization procedure often starts with the failure to identify red flags in the patient’s history and physical examination that might preclude a successful arthroscopic repair [112]. Risk factors associated with treatment failure for shoulder instability include age, gender, presence of osseous Bankart, and/or large Hill-Sachs 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 [112]. A thorough history and physical examination should allow the examiner to understand the etiology, direction, degree, and frequency of a patient’s shoulder instability [112]. Radiographs and MRI are used as adjuncts to diagnosis, to determine whether a patient is a candidate for arthroscopic stabilization, and for preoperative planning [112]. MRI has proven to be useful in identifying capsulolabral avulsions (HAGL and reverse HAGL lesions) and rotator cuff pathology, which is common in patients over 40 years old with glenohumeral dislocation [112]. Computed tomography allows for a more precise quantification of bone loss compared to plain radiography [112]. Glenoid bone loss greater than 18% to 25% of the glenoid surface area increases risk of failure of nonoperative and operative management that does not address the bone loss [112].
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 [112]. The pattern of instability can be determined during examination under anesthesia without being affected by patient apprehension or guarding [112]. The axial load test or load-and-shift test is conducted during examination under anesthesia, and translation is noted in the anterior, inferior, and posterior directions [112]. Grade 1+ instability corresponds to the translation of the humeral head to the edge of the glenoid [112]. Grade 2+ instability corresponds to the humeral head being subluxated over the glenoid rim but reducing spontaneously [112]. Grade 3+ instability corresponds to a frank dislocation of the humeral head over the glenoid rim that does not reduce spontaneously [112].
Diagnostic arthroscopy is critical for finalizing the surgical plan and includes evaluation of the glenoid labrum, capsular redundancy and tissue quality, size of the humeral Hill-Sachs defect, anterior-inferior bony defects of the glenoid, osteochondral loose bodies, and glenohumeral ligament detachment [112]. Arthroscopic inspection of the intra-articular and bursal surfaces of the rotator cuff should be performed, particularly in older patients who tend to have a high prevalence of concomitant rotator cuff pathology [112]. Approximately 20% to 25% of patients with instability undergoing arthroscopy have associated loose bodies, rotator cuff tears, biceps tendon pathology, or SLAP lesions [112]. Lesions such as loose bodies, rotator cuff tears, biceps tendon pathology, or SLAP lesions may compromise the surgical outcome if unrecognized or untreated [112]. Arthroscopic examination can clarify the diagnosis in ambiguous cases [112].
Specific Clinical Findings by Condition¶
An acutely dislocated shoulder is usually very painful, and muscles are in spasm in an attempt to stabilize the joint [139]. In an anterior dislocation, the humeral head may be palpable anteriorly [139]. The posterior and lateral aspect of the shoulder shows a hollow beneath the acromion [139]. The arm is held in slight abduction [139]. Passive and active motions are limited by pain [139]. 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 [139].
Recognition of a posterior dislocation may be impaired by the lack of a striking deformity and by the fact that the shoulder is held in the traditional sling position of adduction and internal rotation [139]. Classic features of posterior dislocation include limited external rotation of the shoulder, often to <0 degrees [139], limited elevation of the arm, often to <90 degrees [139], posterior prominence and rounding of the shoulder in comparison to the normal side [139], flattening of the anterior aspect of the shoulder [139], and prominence of the coracoid process on the dislocated side [139]. Asymmetry of the shoulder contours can often best be visualized by viewing the shoulders from above while standing behind the patient [139]. Motion is limited in posterior dislocation 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 [139]. 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 [139]. Atrophy will be present with long-standing disuse of the muscles about the shoulder, accentuating the flattening of the anterior portion, prominence of the coracoid, and fullness of the posterior portion [139]. The injury may be misdiagnosed as a frozen shoulder in the interval before the diagnosis of posterior dislocation is made [139].
The hallmark of a frozen shoulder is the corresponding loss of both passive and active ROM [144]. Practitioners that are not experienced with shoulder pathology often miss the diagnosis of frozen shoulder because they do not test ROM and instead move directly to more provocative maneuvers to assess the rotator cuff [144]. A complete cervical examination, including neurologic testing of the extremities, should be performed when evaluating a frozen shoulder [144]. The shoulder should be inspected for signs of trauma or previous surgery, which may provide clues for the diagnosis of acquired stiffness [144]. Important landmarks, such as the acromioclavicular joint and bicipital groove, are palpated for tenderness in the evaluation of a frozen shoulder [144]. ROM, both active and passive, should be tested in all planes and recorded as objectively as possible for a frozen shoulder [144]. It is essential to differentiate glenohumeral motion from humeroscapular motion as many patients with glenohumeral stiffness can compensate with scapulothoracic motion [144]. 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) in the evaluation of a frozen shoulder [144]. Provocative tests for impingement, acromioclavicular joint pathology, labral tears, instability, and biceps pathology may also be indicated depending on the history and clinical suspicion for a frozen shoulder [144].
Patients in the freezing phase of a frozen shoulder have achy discomfort at rest and severe pain with attempted movements, especially sudden movements [144]. Difficulty with sleeping is an almost universal complaint in the freezing phase of a frozen shoulder [144]. During the frozen phase, the pain tends to abate, but motion becomes severely limited in all planes [144]. In the final stage of a frozen shoulder, ROM slowly returns and residual discomfort generally resolves as motion improves [144]. Return of flexibility in a frozen shoulder can take months to years [144]. Motion restrictions often persist after a frozen shoulder, are generally mild, and do not cause significant impairment [144].
The apprehension-relocation test (Fowler test) is the most sensitive test for shoulder instability [153]. In the apprehension-relocation test, the arm is placed into abduction and external rotation, and the patient experiences a sense of instability that is relieved when the examiner places a posterior force on the arm [153]. The load-and-shift test can be used to classify degrees of instability on the basis of distance of humeral head translation [153]. In the load-and-shift test, 1+ corresponds to 0 to 1 cm of translation to before glenoid rim [153]. 2+ corresponds to 1 to 2 cm of translation to glenoid rim [153]. 3+ corresponds to greater than 2 cm translation or over glenoid rim [153]. An evaluation of generalized laxity should be performed during the physical examination for shoulder instability [153]. The specificity of the anterior apprehension test, the relocation test, and the surprise test for anterior shoulder instability exceeds 95% [140]. For anterior shoulder instability, glenohumeral translation (apprehension), and not pain, is used as the sine qua non for diagnosis [140].
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 [140]. 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 [140]. 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 [140]. The costoclavicular maneuver is used to cause compression of the subclavian vessels in the costoclavicular space [140]. In the costoclavicular maneuver, a backward and downward bracing of the shoulders is performed, and obliteration of the radial pulse is considered a positive test [140]. The bony apprehension test is a reliable screen for large bony lesions associated with instability of the shoulder [127]. Large bony lesions associated with shoulder instability are rare but often require open surgery to prevent recurrent instability [127]. Neither clinical examination nor MR arthrogram is accurate or reliable in identifying patients with intra-articular causes of hip pain as determined by intra-articular anesthetic injection [127].
The diagnosis of a stiff shoulder depends on awareness of the problem, with the history and physical examination being paramount [30]. The history and physical examination are paramount in the diagnosis of a stiff shoulder, and ancillary studies may also be helpful in certain circumstances [30]. It is important to understand the natural history of a stiff shoulder so that patients are well informed and can actively participate in decision-making [30].
The evaluation of the overhead athlete requires the close integration of history and physical examination findings while utilizing a systematic approach [160]. Many of the traditional examination tests of the shoulder have not been validated or critically evaluated to a significant extent and should therefore be used only as an adjunct to a wider global assessment [160]. A sport-specific approach should be used when evaluating the shoulder in an athlete [160]. In throwers, a detailed history with the chronology of symptoms is essential [160]. Pitchers commonly complain of loss of pitch control and loss of velocity and also describe symptoms distant from the shoulder joint [160]. A preseason examination is critical to document baseline shoulder stability, strength, and ROM, which can be used as a reference when evaluating a mid-season injury [160]. Instability often exists in throwing athletes, but they do not present with symptoms of frank subluxation or dislocation [160]. Pain during cocking in throwers is often a result of instability or internal impingement with a type II SLAP lesion [160]. Pain during follow-through in throwers arises from rotator cuff or posterior capsular problems [160]. Swimmers will often complain of pain during the catch or the recovery, when the shoulder is more often in the provocative impingement position [160]. In swimmers, instability is often the principal culprit, exacerbating symptoms of impingement [160]. Determining the onset of symptoms is critical for athletes presenting with gross instability, as traumatic and atraumatic instability are treated differently [160]. Symptoms elicited with the arm in adduction and internal rotation may suggest posterior instability [160]. Symptoms reproduced by holding objects with the arms at the sides often indicate inferior instability [160]. The location of pain or instability, its duration, and response to prior treatment should be noted for all athletes [160].
Patient age, speed of onset, and duration of symptoms as well as the possibility of a precipitating injury should be ascertained to help determine the contribution of the biceps to shoulder pain [158]. A young athlete with pain only on throwing or heavy use raises the suspicion of a SLAP tear [158]. An elderly individual with a degenerative tendon related to concomitant cuff tears, such as chronic impingement and rotator cuff tears, presents differently from a young athlete with biceps pathology [158]. Inspection may reveal the loss of biceps muscle contour following LHBT rupture [158]. Palpation can help distinguish the location of pain, which is typically felt more anteriorly in the shoulder over the bicipital groove with the arm in internal 10-degree rotation [158]. Lesions more proximal to the bicipital groove may not reveal tenderness on palpation [158]. O’Brien’s active compression test and O’Driscoll’s dynamic labral shear test are considered the most useful for SLAP pathology [158]. Where there is coexisting pathology involving the subacromial space, acromioclavicular joint, and rotator cuff, other tests have poor specificity and are not conclusive for biceps pathology [158]. It is crucial to formally assess cuff integrity, including of the subscapularis that is intimately related to the LHBT [158]. Ultrasound scan is useful to assess for tendinopathy, partial tears, and subluxation but is user dependent and does not visualize the intra-articular portion or the superior labrum [158]. MRI provides distinct advantages in the younger, more active patient where more subtle lesions may be present [158]. MRI enhanced with a gadolinium arthrogram is the investigation of choice if there is any clinical concern about SLAP pathology [158].
In patients with persistent shoulder pain after sprain or contusion, arthroscopy revealed a broad spectrum of intraarticular findings [138]. The diagnostic performance of MRI and ultrasonography may be similar for detection of any rotator cuff tears [161]. The sensitivity of ultrasonography may be much lower than that of MRI for detecting partial thickness tears [161]. CT is the first-line imaging modality for the evaluation of glenoid bone loss and Hill-Sachs lesions [161]. MRI can also be used to identify Hill-Sachs lesions, glenoid bone loss and for the evaluation
Investigations¶
Diagnostic Arthroscopy¶
Diagnostic shoulder arthroscopy remains the gold standard for diagnosing shoulder pathology [15]. A reliable, systematic approach is essential for consistent and complete evaluation of the glenohumeral joint [15]. This technique allows for efficient, consistent, and effective evaluation in both novice and expert hands, particularly when performed in the beach-chair position [18]. Arthroscopy enhances the ability to evaluate the glenohumeral joint by revealing significant information regarding labral tears, rotator cuff status, and biceps tendon lesions that may otherwise be undetectable [62]. It serves as an invaluable diagnostic tool to confirm clinical and radiographic abnormalities, identify associated intra-articular and extra-articular pathologic conditions, and treat various lesions without the morbidity of open surgical repair and reconstruction [17].
In the post-arthroplasty setting, shoulder arthroscopy is most frequently used as a diagnostic tool [9]. It is a helpful adjunct for evaluating painful anatomic total shoulder arthroplasty by providing information on periprosthetic infection, cuff tears, implant wear, and loosening [50]. These findings support the use of arthroscopy as an adjunctive diagnostic tool in select patients with unresolved pain following shoulder arthroplasty [7]. The high rate of articular pathologies in operated shoulders makes arthroscopy invaluable for diagnosing and treating these conditions simultaneously with hardware removal [36].
During open Latarjet procedures, diagnostic imaging may not reliably correlate with arthroscopic findings from both a bony and soft-tissue perspective [258]. Among patients undergoing arthroscopy at the time of open Latarjet, most required an additional procedure, including extensive debridement (89.1%), that would not have been performed with a Latarjet alone [26]. Excluding extensive debridements, an additional arthroscopic procedure was required in 9.2% of cases [26]. Among patients requiring additional arthroscopic procedures who had a preoperative MRI, the MRI identified pathology in only 1 case (0.5%) [26]. While the space between the biceps tendon and supraspinatus can serve as a reliable adjunct for verification, it should not replace a full arthroscopic evaluation [273].
Imaging Modalities¶
Plain radiography: Standardized plain films are almost always sufficient to garner the necessary information, and they provide data that cannot be obtained from CT scans [52]. The standard shoulder series should include orthogonal views: a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [105]. The first key view is the AP in the plane of the scapula, taken so the x-ray beam passes through the glenohumeral joint [52]. The second key view is the axillary view, taken with the arm in the functional position of elevation in the plane of the scapula, oriented so both the spinoglenoid notch and scapular neck are visible [52]. Referred to as the “truth view,” it demonstrates glenohumeral relationships in the functional position of elevation [52]. The axillary view is necessary for evaluating glenohumeral joint instability and enables determination of humeral head position in the glenoid fossa [105]. It may also detect occult, locked posterior shoulder dislocation in patients exhibiting a lack of passive external rotation [105]. The scapular Y view visualizes the coracoacromial arch and can reveal coracoacromial spurs, which are closely associated with rotator cuff pathology [105].
Normal radiographic measurements include an acromiohumeral distance of 7 to 14 mm, a symmetric superior and inferior glenohumeral joint space width, and a coracoclavicular distance of 1.1 to 1.3 cm [105]. Type III acromial morphology correlates with the presence of rotator cuff disease, although no direct causal relationship has been demonstrated [105]. The standardized axillary view enables measurement of posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side [52]. Posterior subluxation can be measured as the position of the center of the humeral head in relation to the plane of the scapula, the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [52]. The point of contact reflects the degree of centering of the net humeral joint reaction force on the glenoid [52]. Malcentering of this force leads to posterior instability, posterior glenoid wear, and “rocking horse” loosening of prosthetic glenoid components [52].
MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [104]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of joint surfaces [104]. T2-weighted MRI provides better visualization of full-thickness rotator cuff tears [104]. MR arthrography is considered the benchmark for evaluating labral tears and is rarely indicated for rotator cuff pathology [104]. For full-thickness rotator cuff tears, MRI sensitivity is 100%, specificity is 68%, positive predictive value is 85%, negative predictive value is 100%, and accuracy is 89% [105]. In a community practice, radiologists miss approximately 50% of subscapularis tears on MRI, while a shoulder surgeon misses 28.6% [254]. Preoperative MRI scans interpreted by orthopaedic surgeons using a described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies [165].
CT: CT imaging is frequently used to evaluate fractures, assess bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [104]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in shoulder instability [105]. CT scans have the disadvantage of being taken with the arm in the adducted position [52]. In a community practice, information gained from a CT scan did not alter treatment decision-making in three-quarters of vignettes among surgeons experienced in managing anterior shoulder instability [250].
Ultrasonography: Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating skeletal and soft-tissue structures [104]. It provides immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [104]. It can measure the subacromial space and detect atrophy of rotator cuff muscles [104]. However, it is highly operator-dependent and less useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [104]. For full-thickness rotator cuff tears, ultrasonography sensitivity is 98%, specificity is 80%, positive predictive value is 90%, negative predictive value is 95%, and accuracy is 94% [105].
Other Considerations: 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 to the patient [52]. Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions necessary for patient care [52].
Post-Arthroplasty Imaging¶
Routine radiographic evaluation of a glenohumeral arthroplasty should consist of recommended views for evaluating component position and glenoid articulation [108]. Humeral stem lucencies, migration, and humeral head height with respect to the greater tuberosity can be easily followed with anteroposterior views in internal and external rotation [108]. Axillary lateral and apical oblique views can reveal glenoid wear or humeral component instability [108]. Radiographic evaluation of the glenoid component should routinely consist of a true anteroposterior view, an axillary lateral view, or an apical oblique view [108]. The presence of lucent lines about a keeled or pegged component should be noted at the first postoperative visit, along with the seating of the component on the native glenoid [108]. Fluoroscopic positioning of radiographs is a more accurate method for identifying glenoid component radiolucent lines but exposes the patient to a large amount of radiation and is time-consuming [108]. Occasionally, a limited CT scan provides useful information regarding glenoid wear or humeral component malposition in painful shoulder arthroplasty [108]. CT of a cemented pegged polyethylene glenoid component is more sensitive than radiography in identifying the size and number of peg lucencies [108]. MRI and ultrasonography have been reported as useful for identifying rotator cuff tendon tears in painful shoulder arthroplasty [108]. MRI with metal-artifact reduction fast spin-echo (FSE) and multiaquisition variable-resonance image combination (MAVRIC) sequencing can reveal synovitis, periprosthetic osteolysis, and supraspinatus tendon tears [108].
Clinical Evaluation¶
The clinical evaluation is the beginning of the doctor-patient relationship, with the goal of carrying out an evaluation that leads to a reasonable management plan [54]. If the problem is not apparent on history, physical examination, and plain radiographs, or if the patient does not appear to be an excellent surgical candidate, nonoperative management is likely to be recommended [54]. This recommendation remains valid even if MRIs show “acromioclavicular arthrosis,” “labral fraying,” a “humeral avulsion of the glenohumeral ligament (HAGL)” lesion, or “supraspinatus tendinosis” [54]. The physical exam seeks tangible findings such as loss of passive or active ROM, a palpable defect in the rotator cuff, minimal resistance to anterior translation of the humeral head pressed into the glenoid, palpable subacromial crepitus, muscle atrophy, loss of the biceps reflex, or an obvious “clunk” on cross-body adduction [54]. Tests described for evaluating shoulder problems are rarely capable of discriminating between these problems [54].
Epidemiology and Context¶
Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese [21]. Early perioperative complications are uncommon in patients undergoing shoulder arthroscopy [21]. Experience with arthroscopy has led to an explosion of interest and expertise in the technical skills that have made arthroscopic surgery the mainstay of surgical management for a wide range of shoulder conditions [16]. The majority of the most-cited articles in shoulder arthroscopy are case series and descriptive studies originating from the United States [34]. Shoulder Arthroscopy, Third Edition is highly recommended as a must-read for every shoulder surgeon [10]. Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology [11].
The Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group was formed to conduct large multicenter studies on conditions of the shoulder [31]. The group consists of 16 fellowship-trained orthopaedic surgeons and research personnel from nine academic and private practice sites in the United States [31]. Initially formed to identify research questions related to rotator cuff disease treatment, the group has expanded its scope to include other shoulder pathology [31]. To study rotator cuff disease, the group developed and standardized imaging protocols, assembled validated patient-oriented outcome forms, and conducted validation studies on the classification of rotator cuff tears based on MRI and arthroscopy videotapes as well as radiographic findings associated with rotator cuff disease [31]. MOON Shoulder Instability is an offshoot of MOON Shoulder, focusing on patients undergoing surgical treatment for shoulder instability [31].
Treatment¶
General Principles and Safety¶
Shoulder arthroscopy is one of the most common orthopedic procedures and serves as the mainstay of surgical management for a wide range of shoulder conditions, including rotator cuff tears, shoulder instability, and labral pathology [23] [16] [22]. Advances in modern arthroscopy have contributed significantly to greater flexibility and efficacy in addressing shoulder pathology [22]. The advantages of arthroscopy include less invasive approaches, improved visualization, decreased risk of many postoperative complications, and faster recovery [22]. A thorough understanding of anatomic principles in conjunction with proper patient positioning and portal selection and placement are essential for successful arthroscopic shoulder surgery [22]. The literature describes the evolution of shoulder arthroscopy from a marginalized technique to the standard of care, emphasizing the 'burden of craft' and the necessity for surgeons to selectively embrace technological advancement while honoring the surgeon's craft [120]. Shoulder arthroscopy continues to evolve, and the revolution represented by its development remains in skilled hands, with the expectation that it will continue to evolve [24]. As shoulder arthroscopy continues to evolve, adopting such refined techniques will be crucial for addressing complex shoulder pathologies effectively [19].
Visualization and Technique: The literature provides an evidence-based review of methods and techniques to optimize visualization during arthroscopic shoulder surgery, emphasizing that a thorough understanding of the supporting literature is essential to interpret the clinical utility of each technique [8]. This review examines the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy [20]. The described technique allows for efficient, consistent, and effective evaluation of the shoulder joint for the novice and expert alike [18]. It serves as a safer, more cost-effective, and more accessible complementary approach for shoulder arthroscopy positioning and is worthy of routine clinical application [121].
Complications and Evidence Quality: Shoulder arthroscopy has a 1.0% thirty-day complication rate, with the most common complication being return to the operating room (29% of all complications) [5]. Pain after shoulder arthroscopy is relatively low and the efficacy of the intervention is long-lasting in terms of pain symptom [13]. Shoulder arthroscopy literature remains controversial, conclusions are often unsupported due to bias and limitations, and no clinical guidelines are definitive pending higher levels of evidence [4]. Shoulder arthroscopy is increasingly used to manage a wide range of pathologies in the pediatric population, but special considerations regarding anatomy, anesthetic technique, equipment, and patient positioning are required [37].
Anesthesia and Pain Management¶
Regional anesthesia should become the standard practice for all arthroscopic shoulder surgeries due to its physiological and clinical advantages, including reduced intraoperative bleeding, improved surgical visualization, and enhanced patient safety and recovery [151]. Interscalene block remains the most consistent technique for reducing postoperative opioid requirements after shoulder arthroscopy [159]. Performing an ISB in arthroscopic shoulder surgery provides effective analgesia in the postoperative period [141]. Interscalene block can provide effective anesthesia for arthroscopic shoulder surgery [211]. The interscalene regional block provided more pain relief than infusion pumps immediately after arthroscopic shoulder surgery [214].
Adjuncts and Multimodal Analgesia: The initial 24 h after surgery plays a key role in controlling pain after arthroscopic shoulder surgery [72]. The concomitant use of suprascapular nerve block and general anesthesia was highly effective in patients undergoing ambulatory shoulder arthroscopy [187]. Combining SSNB and ANB is an effective and safe technique for intraoperative anesthesia and postoperative analgesia for certain procedures of shoulder arthroscopic surgery [190]. The SSNB and ANB were considered to provide safe and effective analgesia in terms of early postoperative pain in arthroscopic shoulder surgery [204]. Nerve block adjuncts may prolong postoperative block time and improve pain control, while there is no evidence to support the use of subacromial infusions or patient-controlled analgesia [213]. Subacromial continuous infusion of local anesthetic does not provide a clinically significant benefit compared with placebo as part of a multimodal analgesia regime after arthroscopic subacromial surgical procedures [156]. Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared to standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks [172]. Our results have to be confirmed for other arthroscopic shoulder procedures [47].
Preoperative Considerations¶
This study adds to the evidence suggesting caution when administering injections in the immediate postoperative period after shoulder arthroscopy [32]. The editorial concludes that shoulder arthroscopy should be avoided within 4 weeks of a pre-operative steroid injection unless there is strong justification, and that a cautious, individualized approach should be used before offering corticosteroid injections to patients anticipated to undergo subsequent shoulder arthroscopy [170]. Thromboembolic complications are extremely rare after shoulder arthroscopy, with no current guidelines for prophylactic treatment [74].
Instability and Stabilization¶
Indications: Arthroscopic anterior labral repair and capsulorrhaphy (also know as arthroscopic Bankart repair) is the most commonly performed procedure for recurrent anterior instability of the shoulder [25]. Considering new technical possibilities, most cases of anterior shoulder instability are suitable for arthroscopic reconstruction, but further studies are necessary to validate continued efficacy [35]. At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability [70]. Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery [192]. When nonsurgical treatment of atraumatic shoulder stability is not effective, inferior capsular shift is the treatment of choice [194]. Early arthroscopic stabilization by anterior capsule-labrum reinsertion after initial anterior shoulder dislocation is associated with a low 10-year recurrence rate of 35% compared to non-operative management [202]. Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis [6].
Surgical Approach / Technique: The procedure has been refined significantly over the past 30 years but continues to have a rate of failure from recurrent instability that is higher than open repairs [25]. Identification of the underlying cause(s) for failure of the index procedure is the key to planning revision surgery [25]. A thorough understanding of the pathomechanics of shoulder instability and the risk factors for failure of arthroscopic capsulorrhaphy allows for a systematic evaluation of the patient with recurrent instability after surgery [25]. Understanding normal shoulder anatomy and biomechanics is the first step in recognizing the etiology of anterior shoulder instability [25]. Stability of the glenohumeral joint is conferred by a complex combination of structural and functional elements [25]. Concavity of the glenoid is established by the shape of the bone and is deepened by the attached labrum [25]. Compression of the humeral head into this glenoid concavity achieved by the synchronized actions of the shoulder muscles creates the functional stability [25]. Stability is further supported by the capsular ligaments, especially the inferior glenohumeral ligament, at the extremes of motion [25]. These mechanisms establish joint stability while allowing for a large range of motion necessary for complex upper extremity tasks [25]. Disruptions to this complex balance from loss of any one of these components can lead to instability [25].
Implant Selection: Successful shoulder stabilization can be achieved with fewer than 3 anchors, and a single anchor is usually sufficient [79]. However, use of knotless anchors may be a significant risk factor for subsequent dislocation 2 years after arthroscopic shoulder stabilization surgery [239]. The use of a knotless all-suture anchor with suture tape provides an advancement in arthroscopic shoulder stabilization surgery [243]. Arthroscopic thermal capsulorrhaphy neither enhanced nor impaired the outcomes of arthroscopic labral repair with biodegradable tacks in patients with primary recurrent anterior shoulder instability [253].
Alignment / Balancing Strategy: The Delphi method is a structured communication technique used to allow a panel of experts to achieve a consensus in a systematic manner, resulting in an international consensus statement on shoulder instability covering diagnosis, nonoperative management, surgical options, rehabilitation, and clinical follow-up [27]. Overall, 77% of statements reached unanimous or strong consensus, covering patient history evaluation, prognostic factors for nonoperative management, and Bankart repair steps [237]. Despite the absence of evidence-based guidelines, there exists minimal variability in recommendations between North American and European shoulder surgeons regarding return to play criteria [43]. Based on our findings, we strongly recommend the utilization of a criteria based testing protocol for return to play following arthroscopic shoulder stabilization [46].
Other Considerations: The hypothesis that shoulders showed a higher proportion or degree of OA following operative treatment compared to non-operative treatment is not supported by the data [235]. Recent randomized trials and systematic reviews have not shown the superiority of modern arthroscopic techniques compared with open repairs for shoulder instability [38]. There was no difference between open and arthroscopic repair in terms of patient quality of life [38]. Open repair resulted in a significantly lower risk of recurrence [38]. Secondary outcome data from this trial suggest that open surgical repair may be recommended to reduce the risk of recurrent instability in younger male patients with a Hill-Sachs lesion [38]. 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 [38]. The available evidence indicates that arthroscopic approaches are not as effective as open approaches in preventing recurrent instability or enabling patients to return to work [38]. It is not uncommon for us to see shoulders in which suture anchors were misplaced and have given rise to secondary degenerative joint disease or “anchor arthropathy” [38]. Use of intra-articular infusion of local antibiotics via a pain pump after arthroscopic instability repairs results in a risk of a most severe complication: glenohumeral chondrolysis [38]. Although arthroscopic stabilization spares the incision of the subscapularis, the healing time for a labral reattachment is likely to be the same as the time to heal a subscapularis tenotomy; healing of both proceeds concurrently so the time to return to activity should not be different with the two approaches [38].
Pathomechanics and Specific Pathologies: Traumatic anterior instability usually affects shoulders that are not lax, enabling the applied force to avulse the labrum from the anteroinferior glenoid [38]. The capsule of these shoulders is not excessively stretchy, and an anatomic repair usually suffices to manage the instability; additional capsular tightening or shifting can result in a stiff shoulder [38]. Lax shoulders may be dislocatable but typically do not have labral avulsions; thus the management of relatively less-traumatic instability in more stretchy shoulders may require some combination of labral augmentation and capsular tightening with great care to avoid excessive and asymmetrical tightening [38]. The goal is always a flexible and stable shoulder [38]. While bone transfers surely have a role in cases where a third of the glenoid is missing and in patients whose anatomic repairs have failed, the routine use of bone transfers does not seem advisable because of the increased risk of arthritis, screw-related problems, damage to the subscapularis, and difficulty in revision [38]. We are now seeing these same complications with the Latarjet procedure, whether done open or arthroscopically [38]. While this chapter advocates “regional anesthesia with an interscalene block combined with general anesthesia,” it seems that this exposes the patient to the risks of both types of anesthetic and might be overkill, especially in view of the minimally invasive nature of arthroscopic surgery and the potentially serious complications of interscalene blocks [38]. Nerve injuries can be forever [38]. The management of shoulders with the AMBRI type of instability continues to be an interesting challenge [38]. By definition, compared to the TUBS type of instability, it is more a constitutional than a traumatic entity [38]. Fortunately, most many cases can be managed nonoperatively by patient education and rehabilitation [38]. When surgery is considered, the surgeon needs to recognize that the capsule is likely to be more stretchy than usual and the labrum is likely to be more compressible than usual; this combination allows the humeral head to translate due to failure of the concavity compression mechanism [38]. Rather than risking overtightening of the shoulder with capsular plication that may result in a stiff, redundant shoulder, the surgeon has the opportunity to use the redundant capsule to augment the labrum, creating a deeper stabilizing concavity [38]. In managing shoulders with the AMBRI type of instability, rotator interval closure may be another useful adjunct [38].
Revision and Historical Context: Arthroscopic revision stabilization of the shoulder can result in satisfactory outcomes in patients who have failed previous capsulabral repair [261]. More than 150 operations and many modifications have been devised to treat traumatic recurrent anterior instability of the shoulder [75]. There is no single best procedure [75]. Factors that have been stressed as important in achieving a successful result are adequate exposure and accurate surgical technique [75]. The pathologic condition should be defined, and a procedure should be done that corrects this condition most anatomically [75]. Ideally, the procedure for recurrent instability should include the following factors: (1) low recurrence rate, (2) low complication rate, (3) low reoperation rate, (4) does no harm (arthritis), (5) maintains motion, (6) is applicable in most cases, (7) allows observation of the joint, (8) corrects the pathologic condition, and (9) is not too difficult [75]. Operative procedures can be done open or arthroscopically with comparable results [75]. When the appropriate procedure is accomplished to restore the anatomy, outcomes of Bankart repairs are affected by what Balg and Boileau described as the Instability Severity Index Score (ISIS) [75]. At present, our preferred surgical procedures are arthroscopic Bankart or capsular plication procedures as indicated [75]. When an open procedure is desired, we prefer the Jobe capsulolabral reconstruction or Neer capsular shift for anterior instability and a glenoid-based shift for posterior instability [75]. For glenoid bony defects that cannot be repaired, we reconstruct the anterior defects with a Latarjet procedure and use an autograft iliac crest extracapsular bone graft posteriorly [75]. Moderately sized (20% to 30%) humeral head defects are treated with an arthroscopic remplissage procedure and Bankart repair, and larger defects (35% to 45%) are treated indirectly by increasing the glenoid arc using a Latarjet procedure or by allograft repair of the defect [75]. In a contact or collision athlete any significant Hill-Sachs lesion is treated [75]. Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides, whereas stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder [73].
Rotator Cuff and Subacromial Decompression¶
Indications: Following nonoperative treatment for at least 6 weeks, SAD is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff [157].
Surgical Approach / Technique: Advances in arthroscopic equipment and increased surgeon familiarity with shoulder arthroscopy have made arthroscopic surgery the preferred method of rotator cuff repair for many shoulder surgeons [206]. It offers numerous advantages over traditional open repair techniques [206]. More thorough visualization, diagnosis, and treatment of lesions within the joint are facilitated, which is critical because a high prevalence of concomitant intra-articular pathology has been reported in patients undergoing rotator cuff repair [206]. Arthroscopy allows a more comprehensive assessment of intra
Complications¶
General Safety and Risk Factors: Complication rates after shoulder arthroscopy are generally low, ranging between 1% and 2%, with readmission rates under 1% [80]. While some literature reports an overall self-reported surgical complication rate of 7.9% [183], arthroscopic procedures are widely considered safe with very low complication rates [293]. Surgeons must learn from complications through careful review of etiology and prevention [286]. Most existing data are limited to single-institution case series with conflicting findings [23]. Patients aged 60 years or older have a 30-day postoperative complication rate of 1.6%, which is higher than the overall population [42]. Although up to 43% of patients are obese, early perioperative complications are uncommon [21]; however, a BMI >40 confers a statistically significant but slightly increased risk of 30-day complications [292]. Resident involvement does not increase the risk of medical or surgical 30-day complications [64]. Increased procedure time is associated with significantly higher rates of superficial surgical site infections and overnight hospital stays [289].
Infection: The risk of infection following shoulder arthroscopy is 0.21%, consistent with other large series [68]. Cutibacterium acnes infections occur at a very low rate of 0.22% [296]. In revision shoulder arthroscopy, the rate of P. acnes infection is higher than previously published and should be considered in cases of refractory postoperative pain and stiffness [299]. The incidence of unexpected positive cultures is significantly higher in revision arthroscopic shoulder stabilization procedures than in primary surgeries [285]. Arthroscopic rotator cuff repair reduces the risk of infection compared with open techniques [294]. No study compares infection rates between patients who receive and those who do not receive perioperative antibiotics in routine shoulder arthroscopic procedures [279]. Postoperative infection risk is greatest when corticosteroid injections are given within 2 weeks of surgery, with a lesser increased risk for injections given within 2–4 weeks [288]. In general, shoulder arthroscopic surgery has a low rate of reoperation in the acute period [278].
Thromboembolism: Postoperative deep venous thrombosis (DVT) and pulmonary embolism (PE) are unusual but potentially fatal consequences of arthroscopic shoulder surgery. Reported prevalence varies, with one series noting 0.31% [134], another 0.24% [150], and a third 0.15% [152]. The rate of symptomatic VTE is low, approximately 0.3% at 3 months [163]. While rare, VTE occurs following shoulder arthroscopy [182] and accounts for a certain number of postoperative complications [193]. One study reveals a substantially higher rate of VTE than previously recognized [189]. The overall VTE incidence is low at 0.24%, with risk factors including a body mass index greater than 30 and hypertension [169]. Oral contraceptive use at the time of surgery is not associated with an increased risk of VTE [231]. Awareness and early detection are the best approaches to managing thromboembolic disease [251].
Neurological and Mechanical Complications: Misplaced suture anchors can cause secondary degenerative joint disease or "anchor arthropathy" [38]. Intra-articular infusion of local antibiotics via a pain pump after arthroscopic instability repairs results in a risk of glenohumeral chondrolysis [38]. Nerve injuries from interscalene blocks can be permanent [38]. The incidence of neurovascular complications in open stabilization surgery is reported as 1% to 8% [232]. Subscapularis rupture and neurologic injury are exceedingly rare in arthroscopic stabilization [232]. Most cases of early osteoarthritis after arthroscopic stabilization are associated with anchor complications or chondrolysis from thermal capsulorrhaphy [232]. Absorbable suture anchors can displace, break, and cause chondral injury or synovitis [232]. Infection rarely complicates arthroscopic stabilization procedures [232]. When failure of arthroscopic stabilization is excluded, the surgical complication rate is low, and complications are generally less common than in open stabilization and self-limited or resolved with nonoperative measures [232].
Stiffness / Arthrofibrosis: The incidence of secondary frozen shoulder following simple arthroscopic shoulder surgery is just over 5% [282]. Stiffness can complicate shoulder stabilization surgery, especially with overtightening of the soft tissues and prolonged immobilization [232]. To avoid overtightening and loss of external rotation, capsulolabral reconstructions must be tensioned in 30 to 45 degrees of external rotation and 30 degrees of abduction [232].
Other Considerations: With a follow-up of 97%, about one third of stabilized shoulders experienced at least one redislocation after 8 to 10 years [83]. The incidence of complications following the primary Latarjet procedure for shoulder instability varies from 0% to 25.7% [110]. Graft fracture and graft migration were observed in 19.2% of cases following the Bristow-Latarjet procedure [267]. Failure following major trauma to the operated shoulder without indication of impending hardware loosening or fracture was observed in 11.5% of cases following the Bristow-Latarjet procedure [267]. The early graft failure rate after Latarjet procedure is 4.7%, and the nerve injury rate is 3.2% [264]. Two-thirds of graft failures after Latarjet procedure required reoperation, and half of nerve injuries required reoperation [264]. In a cohort of patients returning to sports after arthroscopic anterior stabilization, there were no infections, cases of shoulder stiffness, or neuropathies in the early postoperative period [201]. Seven patients had recurrence after surgery [201]. Five patients had a subsequent dislocation requiring manual reduction, and 2 had a subsequent subluxation episode [201]. Four of these patients had traumatic instability events after return to sports participation (2 contact and 2 noncontact athletes) [201]. One patient had a dislocation during a seizure episode [201]. These 5 patients subsequently underwent open revision procedures [201]. Postoperative complications after arthroscopic remplissage procedures included persistent tenosynovitis of the long head of the biceps tendon and ipsilateral ulnar nerve palsy, with a rate of 0.9% (2 of 212) [242]. The rate of postoperative complications after Weber osteotomy procedures was 29% (53 of 184), including pain, hematoma, infection, nonunion, delayed union, reoperations related to hardware and other noneinstability-related causes, and internal rotation deficit [242]. The rate of postoperative complications after humeral allograft reconstructions was 74%, including spontaneous avascular necrosis and collapse, persistent pain, clicking, catching, stiffness, and flattening [242]. The rate of postoperative complications after humeral arthroplasty was 19%, comprising rerupture of the subscapularis tendon after redislocation, humeral diaphyseal fracture distal to the implant after a fall, scapular notching, loosening of the glenoid and humeral components, humeral fracture, infection, pain from glenoid wear, brachial plexus injury, axillary nerve injury, adhesive capsulitis, and subacromial impingement [242]. Shoulder arthroscopy in the year prior to shoulder arthroplasty is associated with an increased risk of complications, including revision and aseptic loosening [49]. Care should be taken to avoid damage to the metal or polyethylene surfaces when performing arthroscopy after arthroplasty [39]. A 30-degree arthroscope should be used and turned away from the humeral head or glenosphere (for reverse shoulder arthroplasty) to avoid the “mirror effect” that can distort anatomy and confuse the surgeon [39]. In a series of 203 cases of TSA, 3% had impingement refractory to conservative management [39]. Arthroscopic SAD yielded excellent or good results in five of six patients with impingement syndrome after TSA [39].
Recovery¶
Light activity (weeks): The evidence provided does not specify a typical week range for light activities such as desk work, driving, or light ADLs. However, earlier return to light duty is associated with earlier return to full duty after shoulder arthroscopic surgery in patients with a Workers' Compensation claim [114].
Full activity (months): The evidence provided does not specify a typical month range for full activity, including manual work or sport.
Complete recovery / outcome plateau (months): The evidence provided does not specify a typical month range for complete recovery or outcome plateau.
Rehabilitation protocol: There is no clear consensus regarding optimal post-operative rehabilitation following arthroscopic shoulder stabilisation [146]. Patient engagement and rehabilitation are emphasized as important components in the management of patients undergoing contemporary arthroscopic procedures [197]. Exergames can be used effectively in the rehabilitation of patients following arthroscopic shoulder surgery [174]. Arthroscopic capsular release with manipulation and a well-programmed rehabilitation program can avoid any delay of surgery and limitation of motion after cuff repair in patients with concomitant moderate shoulder stiffness [191].
Functional milestones: Achieving 69.5% of maximal ASES score improvement or 75% of maximal SANE score improvement is indicative of achieving patient satisfaction after arthroscopic rotator cuff repair [297].
Other Considerations: The initial 24 hours after surgery plays a key role in controlling pain after arthroscopic shoulder surgery [72]. Caution is suggested when administering corticosteroid injections in the immediate postoperative period after shoulder arthroscopy due to potential effects on postoperative infection risk [32].
Earlier orthopaedic surgeon evaluation of Workers' Compensation patients with shoulder injuries was associated with a higher return to full duty after shoulder arthroscopic surgery [173]. The duration of sick leave after arthroscopic shoulder surgery in Germany does not exceed sick leave duration in other countries [240].
A substantial number of athletes do not meet expected goals for operative shoulder function and strength compared with the contralateral shoulder at 6 months postoperatively [81]. The utilization of a criteria-based testing protocol for return to play following arthroscopic shoulder stabilization is recommended to improve recurrence rates [46]. Professional elite goalkeepers requiring shoulder surgery for different causes demonstrated a high rate of return to play despite the persistence of mild symptoms [236]. Patients can have a high expectation of return to wildlife sports following shoulder surgery [246]. High school football players who returned to competitive play after arthroscopic shoulder stabilization surgery experienced a higher rate of recurrent instability that was dependent on their years of eligibility remaining [280]. Following arthroscopic shoulder labral surgery, most Major League Baseball pitchers and positional players were able to return to play successfully but experienced shorter careers thereafter [283]. Female patients had a lower postoperative return to sport and shoulder scores after the modified Latarjet procedure compared with literature reports [281]. Active-duty patients undergoing double-pulley remplissage for shoulder instability without glenoid bone loss demonstrated an overall return to active-duty rate of 91.67% [247].
With a follow-up of 97%, about one third of the stabilized shoulders experienced at least least one redislocation after 8 to 10 years following arthroscopic shoulder stabilization using suture anchors [83]. Twenty years postoperatively, arthroscopic Bankart repair was associated with good to excellent shoulder function, low pain levels and high patient satisfaction [295]. Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment [78]. Arthroscopic partial repair may produce initial improvement in selected outcomes at 2-year follow-up, but about half of the patients were not satisfied with their outcomes, which had deteriorated over time [290].
Resident involvement in shoulder arthroscopy was not associated with increased risk of adverse events, increased operative time, or readmission within 30 days [244]. Early results of total shoulder arthroplasty for young patients with shoulder chondrolysis following arthroscopic shoulder surgery show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients [84].
Patient compliance with electronic patient-reported outcome measure (PROM) data collection decreased over time, with the lowest percentage of patients completing electronic surveys at the traditional 2-year follow-up for shoulder arthroscopy [241].
Key Evidence¶
- [L4] Recognizing this complication and providing appropriate intervention or referral are important for any surgeon performing shoulder arthroscopies. [1] (10.1016/j.jse.2016.04.037)
- [L4] Complications of arthroscopic shoulder surgery are not necessarily less prevalent or devastating than those associated with open techniques, though they differ in nature. [2] (10.5435/jaaos-22-07-410)
- [L5] Shoulder arthroscopy is a commonly performed procedure with low risks. [3] (10.1016/j.jhsa.2015.01.002)
- [L5] The editorial states that shoulder arthroscopy literature remains controversial, conclusions are often unsupported due to bias and limitations, and no clinical guidelines are definitive pending higher levels of evidence. [4] (10.1016/j.arthro.2012.07.001)
- [L4] Shoulder arthroscopy has a 1.0% thirty-day complication rate, with the most common complication being return to the operating room (29% of all complications). [5] (10.1016/j.arthro.2014.12.011)
- [L4] Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis. [6] (10.1016/j.jseint.2024.05.015)
- [L4] These findings support the use of arthroscopy as an adjunctive diagnostic tool in select patients with unresolved pain following shoulder arthroplasty. [7] (10.1016/j.jse.2026.07.016)
- [L4] The article provides an evidence-based review of methods and techniques to optimize visualization during arthroscopic shoulder surgery, emphasizing that a thorough understanding of the supporting literature is essential to interpret the clinical utility of each technique. [8] (10.5435/jaaos-d-23-01025)
- [L4] Shoulder arthroscopy in patients after arthroplasty is most frequently used as a diagnostic tool; however, it has utility in treating a number of predetermined pathologies. [9] (10.1016/j.jse.2015.09.013)
- [L5] Shoulder Arthroscopy, Third Edition is highly recommended as a must-read for every shoulder surgeon. [10] (10.1016/j.arthro.2014.07.021)
- [L5] Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology. [11] (10.5435/jaaos-d-15-00258)
- [L4] Patients undergoing shoulder arthroscopy in the US are primarily older, white, male adults. [12] (10.1177/17585732261420111)
- [L4] Pain after shoulder arthroscopy is relatively low and the efficacy of the intervention is long-lasting in terms of pain symptom. [13] (10.1016/j.otsr.2011.02.003)
- [L4] Arthroscopic revision of failed open anterior shoulder stabilization provides satisfactory results in a selected patient population. [14] (10.1016/j.arthro.2009.04.073)
- [Paper] Diagnostic shoulder arthroscopy is the gold standard for diagnosis of shoulder pathology, and a reliable systematic approach is key to consistent and complete evaluation of the glenohumeral joint. [15] (10.1016/j.eats.2018.12.003)
- [L5] Experience with arthroscopy has led to an explosion of interest and expertise in the technical skills that have made arthroscopic surgery the mainstay of surgical management for a wide range of shoulder conditions. [16] (10.1016/j.mporth.2009.08.008)
- [L5] Arthroscopy of the shoulder may be invaluable as a diagnostic tool to confirm clinical and radiographic abnormalities, to identify associated intra-articular and extra-articular pathologic conditions, and to treat a variety of these lesions without the attendant morbidity of open surgical repair and reconstruction. [17] (10.1016/s0278-5919(20)30081-8)
- [L5] The described technique allows for efficient, consistent, and effective evaluation of the shoulder joint for the novice and expert alike. [18] (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. [19] (10.1016/j.eats.2025.103901)
- [L5] The purpose of this review is to examine the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy. [20] (10.5397/cise.2022.01291)
- [L3] Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon. [21] (10.1016/j.arthro.2016.03.022)
- [L5] [22] (10.5435/00124635-201306000-00003)
- [L5] Shoulder arthroscopy continues to evolve, and the revolution represented by its development remains in skilled hands, with the expectation that it will continue to evolve. [24] (10.1016/j.arthro.2009.06.015)
- [L4] [26] (10.1177/23259671261415839)
- [L5] The Delphi method is a structured communication technique used to allow a panel of experts to achieve a consensus in a systematic manner, resulting in an international consensus statement on shoulder instability covering diagnosis, nonoperative management, surgical options, rehabilitation, and clinical follow-up. [27] (10.1016/j.arthro.2021.11.052)
- [L4] Revision arthroscopic anterior stabilization of the shoulder can result in satisfactory outcomes in appropriately selected patients who have failed previous capsulolabral repair. [28] (10.1016/j.jse.2014.11.034)
- [Paper] Revision arthroscopic anterior stabilization of the shoulder can result in satisfactory outcomes in appropriately selected patients who have failed previous capsulolabral repair. [29] (10.1007/s00402-015-2294-7)
- [L3] This study adds to the evidence suggesting caution when administering injections in the immediate postoperative period after shoulder arthroscopy. [32] (10.1177/0363546518825348)
- [L5] The majority of the most-cited articles in shoulder arthroscopy are case series and descriptive studies originating from the United States. [34] (10.1016/j.asmr.2020.09.011)
- [L5] Considering new technical possibilities, most cases of anterior shoulder instability are suitable for arthroscopic reconstruction, but further studies are necessary to validate continued efficacy. [35] (10.1007/s00402-002-0423-6)
- [L4] The high rate of articular pathologies in operated shoulders makes arthroscopy an invaluable tool to diagnose and treat them at the same time of hardware removal. [36] (10.1007/s00590-017-1938-4)
- [L5] Shoulder arthroscopy is increasingly used to manage a wide range of pathologies in the pediatric population, but special considerations regarding anatomy, anesthetic technique, equipment, and patient positioning are required. [37] (10.5435/00124635-201307000-00004)
- [L4] Current guidelines for thromboprophylaxis in shoulder arthroscopy lack consensus and need patient-specific considerations. [41] (10.2106/jbjs.rvw.23.00228)
- [L3] Patients 60 years or older who underwent shoulder arthroscopy have a low overall 30-day postoperative complication rate of 1.6%, which is higher than previously reported for the overall shoulder arthroscopy population. [42] (10.1016/j.arthro.2016.05.035)
- [L4] Despite the absence of evidence-based guidelines, there exists minimal variability in recommendations between North American and European shoulder surgeons regarding return to play criteria. [43] (10.1016/j.jse.2021.01.026)
- [L2] Morbidity and mortality are rare events after elective shoulder arthroscopy, and the procedure should generally be considered safe. [44] (10.1016/j.jse.2013.06.022)
- [L5] Shoulder surgeons must carefully interpret literature comparing open and arthroscopic rotator cuff repair outcomes, as differences in complications may be influenced by selection bias and narrowing indications for open repair. [45] (10.1016/j.arthro.2017.11.026)
- [L3] Based on our findings, we strongly recommend the utilization of a criteria based testing protocol for return to play following arthroscopic shoulder stabilization. [46] (10.1177/2325967120s00381)
- [L1] Our results have to be confirmed for other arthroscopic shoulder procedures. [47] (10.1213/01.ane.0000125112.83117.49)
- [L3] Shoulder arthroscopy in the year prior to shoulder arthroplasty is associated with an increased risk of complications, including revision and aseptic loosening. [49] (10.1177/17585732231176269)
- [L5] Diagnostic arthroscopy is a helpful tool for evaluating painful anatomic total shoulder arthroplasty by providing information on periprosthetic infection, cuff tears, implant wear, and loosening. [50] (10.1016/j.xrrt.2025.06.011)
- [L4] Shoulder arthroscopy can enhance the ability to evaluate the glenohumeral joint and reveal significant information that would otherwise be undetectable, particularly regarding labral tears, rotator cuff status, and biceps tendon lesions. [62] (10.1177/036354659001800506)
- [L3] Resident involvement in shoulder arthroscopy procedures is not associated with increased risk for medical or surgical 30-day postoperative complications. [64] (10.5435/jaaosglobal-d-20-00138)
- [L3] The risk of infection following shoulder arthroscopy was 0.21%, similar to reported numbers from other large series. [68] (10.1177/2325967117s00362)
- [L4] At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. [70] (10.1016/j.jse.2021.07.016)
- [L5] Proper evaluation of bone loss best determines shoulder instability surgical indications and outcomes. [71] (10.1016/j.arthro.2021.01.004)
- [L2] The initial 24 h after surgery plays a key role in controlling pain after arthroscopic shoulder surgery. [72] (10.1007/s00167-012-1950-5)
- [L3] Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides, whereas stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder. [73] (10.1177/03635465231156181)
- [Case_report] Thromboembolic complications are extremely rare after shoulder arthroscopy, with no current guidelines for prophylactic treatment. [74] (10.1016/j.otsr.2009.03.016)
- [L3] Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment. [78] (10.1016/j.jse.2023.05.029)
- [L3] Successful shoulder stabilization can be achieved with fewer than 3 anchors, and a single anchor is usually sufficient. [79] (10.1016/j.jse.2013.08.010)
- [L3] Complication rates after shoulder arthroscopy are low (between 1% and 2%) and readmission rates are less than 1%, with increasing age and higher ASA scores identified as risk factors for adverse events. [80] (10.1016/j.arthro.2016.11.010)
- [L4] A substantial number of athletes do not meet expected goals for operative shoulder function and strength compared with the contralateral shoulder at 6 months postoperatively. [81] (10.1016/j.jse.2020.04.035)
- [L4] With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. [83] (10.1177/0363546511415657)
- [L4] Early results of total shoulder arthroplasty show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients. [84] (10.1016/j.jse.2007.11.004)
- [L3] The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. [110] (10.1016/j.arthro.2023.05.024)
- [L3] Earlier return to light duty is associated with earlier return to full duty after shoulder arthroscopic surgery in patients with a Workers' Compensation claim. [114] (10.1016/j.asmr.2022.01.004)
- [L5] The article describes the evolution of shoulder arthroscopy from a marginalized technique to the standard of care, emphasizing the 'burden of craft' and the necessity for surgeons to selectively embrace technological advancement while honoring the surgeon's craft. [120] (10.1016/j.jse.2020.04.011)
- [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. [121] (10.1002/atn2.70109)
- [L5] [127] (10.1016/j.arthro.2008.07.001)
- [L4] Postoperative DVT and PE are unusual and potentially fatal consequences of arthroscopic shoulder surgery with a low prevalence of 0.31%, but all patients in this series required hospitalization and subsequent anticoagulation. [134] (10.1016/j.arthro.2011.06.026)
- [Paper] In patients with persistent shoulder pain after sprain or contusion, arthroscopy revealed a broad spectrum of intraarticular findings. [138] (10.1007/s00402-014-2114-5)
- [L2] Performing of an ISB in arthroscopic shoulder surgery provides effective analgesia in the postoperative period. [141] (10.1080/08941939.2019.1576809)
- [L4] There is no clear consensus regarding optimal post-operative rehabilitation following arthroscopic shoulder stabilisation. [146] (10.1177/17585732231154889)
- [L4] Postoperative deep venous thrombosis and pulmonary embolism are unusual but serious and potentially fatal consequences of arthroscopic shoulder surgery with a low incidence of 0.24%. [150] (10.1016/j.arthro.2007.03.048)
- [L5] Regional anesthesia should become the standard practice for all arthroscopic shoulder surgeries due to its physiological and clinical advantages, including reduced intraoperative bleeding, improved surgical visualization, and enhanced patient safety and recovery. [151] (10.1016/j.arthro.2024.07.031)
- [L3] The results of this study show that although rare, VTE occurs following shoulder arthroscopy at a rate of 0.15%. [152] (10.1177/2325967114559506)
- [L1] Subacromial continuous infusion of local anesthetic does not provide a clinically significant benefit compared with placebo as part of a multimodal analgesia regime after arthroscopic subacromial surgical procedures. [156] (10.1016/j.jse.2019.11.010)
- [L5] Following nonoperative treatment for at least 6 weeks, SAD is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff. [157] (10.1016/j.arthro.2019.06.012)
- [L1] Interscalene block remains the most consistent technique for reducing postoperative opioid requirements after shoulder arthroscopy. [159] (10.1177/03635465261462708)
- [L2] The rate of symptomatic VTE in patients undergoing shoulder arthroscopy is low, being about 0.3% at 3 months. [163] (10.1177/1076029614567311)
- [L3] Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. [165] (10.1016/j.arthro.2012.04.142)
- [L1] The VTE incidence following shoulder arthroscopy is low at 0.24%. [169] (10.1016/j.asmr.2023.100815)
- [L5] The editorial concludes that shoulder arthroscopy should be avoided within 4 weeks of a pre-operative steroid injection unless there is strong justification, and that a cautious, individualized approach should be used before offering corticosteroid injections to patients anticipated to undergo subsequent shoulder arthroscopy. [170] (10.1016/j.arthro.2023.10.006)
- [L1] Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared to standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks. [172] (10.1016/j.jisako.2023.03.424)
- [L4] Earlier Orthopaedic Surgeon evaluation of WC patients with shoulder injuries was associated with a higher return to full duty after shoulder arthroscopic surgery. [173] (10.5435/jaaosglobal-d-24-00269)
- [L2] This randomized controlled trial demonstrates that exergames can be used effectively in the rehabilitation of patients following arthroscopic shoulder surgery. [174] (10.1016/j.jse.2021.08.019)
- [L2] The incidence rate of VTE after arthroscopic shoulder surgeries is relatively low. [182] (10.1186/s13018-023-03592-0)
- [L4] The overall self-reported surgical complication rate for arthroscopic shoulder procedures was 7.9%, which is higher than the rates reported in the literature. [183] (10.5435/jaaosglobal-d-18-00093)
- [L1] The concomitant use of suprascapular nerve block and general anesthesia was highly effective in patients undergoing ambulatory shoulder arthroscopy. [187] (10.1097/00000539-199706000-00024)
- [L2] This study reveals a substantially higher rate of VTE following shoulder arthroscopy than previously recognized. [189] (10.1177/23259671261451735)
- [L4] Combining SSNB and ANB is an effective and safe technique for intraoperative anesthesia and postoperative analgesia for certain procedures of shoulder arthroscopic surgery. [190] (10.1016/j.arthro.2008.01.019)
- [L3] Arthroscopic capsular release with manipulation and a well programmed rehabilitation program can avoid any delay of surgery and limitation of motion after cuff repair in patients with concomitant moderate shoulder stiffness. [191] (10.1016/j.arthro.2008.06.007)
- [L3] Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. [192] (10.1016/j.arthro.2021.03.047)
- [L4] While symptomatic VTEs are rare following shoulder arthroscopic procedures, surgeons must be aware that they still account for a certain number of postoperative complications. [193] (10.1016/j.xrrt.2022.05.003)
- [L5] When nonsurgical treatment of atraumatic shoulder stability is not effective, inferior capsular shift is the treatment of choice. [194] (10.5435/00124635-200903000-00002)
- [L5] The book is a treatise from a single centre that has evolved a particular way of teaching surgeons and treating patients, covering practical steps in contemporary arthroscopic procedures and emphasizing the importance of patient engagement and rehabilitation. [197] (10.1177/1758573214562292)
- [L4] [201] (10.1016/j.arthro.2013.09.008)
- [L2] Early arthroscopic stabilization by anterior capsule-labrum reinsertion after initial anterior shoulder dislocation is associated with a low 10-year recurrence rate of 35% compared to non-operative management. [202] (10.1016/j.otsr.2015.09.029)
- [L2] The SSNB and ANB were considered to provide safe and effective analgesia in terms of early postoperative pain in arthroscopic shoulder surgery. [204] (10.1016/j.jse.2011.04.022)
- [L3] Interscalene block can provide effective anesthesia for arthroscopic shoulder surgery. [211] (10.1016/j.jse.2006.01.009)
- [L1] Nerve block adjuncts may prolong postoperative block time and improve pain control, while there is no evidence to support the use of subacromial infusions or patient-controlled analgesia. [213] (10.1177/0363546520971757)
- [L2] The interscalene regional block provided more pain relief than infusion pumps immediately after arthroscopic shoulder surgery. [214] (10.1016/j.arthro.2007.07.021)
- [L5] Arthroscopic shoulder procedures are increasingly performed in ASCs, but reimbursements for these procedures declined during the study period (2013-2022). [216] (10.1016/j.xrrt.2025.09.001)
- [L4] Symptomatic deep venous thrombosis and pulmonary embolism are rare complications of arthroscopic shoulder surgery. [218] (10.1016/j.jse.2006.05.009)
- [L3] OCP use at the time of arthroscopic shoulder surgery is not associated with an increased risk of VTE. [231] (10.1177/2325967118822970)
- [L1] The hypothesis that shoulders showed a higher proportion or degree of OA following operative treatment compared to non-operative treatment is not supported by the data. [235] (10.1007/s00167-020-06263-3)
- [L4] Professional elite goalkeepers requiring shoulder surgery for different causes demonstrated a high rate of return to play despite the persistence of mild symptoms. [236] (10.1007/s00167-021-06637-1)
- [L5] Overall, 77% of statements reached unanimous or strong consensus, covering patient history evaluation, prognostic factors for nonoperative management, and Bankart repair steps. [237] (10.1016/j.arthro.2021.07.022)
- [L3] However, use of knotless anchors may be a significant risk factor for subsequent dislocation 2 years after arthroscopic shoulder stabilization surgery. [239] (10.1177/2325967119s00273)
- [L3] The duration of sick leave after arthroscopic shoulder surgery in Germany does not exceed sick leave duration in other countries. [240] (10.1007/s00402-016-2460-6)
- [L4] Patient compliance with PROMs decreased over time with the lowest percentage of patients completing electronic surveys at the traditional 2-year follow-up for shoulder arthroscopy. [241] (10.1016/j.asmr.2022.11.004)
- [L4] [242] (10.1016/j.arthro.2014.06.010)
- [L5] The use of a knotless all-suture anchor with suture tape provides an advancement in arthroscopic shoulder stabilization surgery. [243] (10.1016/j.eats.2025.103598)
- [L3] Resident involvement in shoulder arthroscopy was not associated with increased risk of adverse events, increased operative time, or readmission within 30 days. [244] (10.1177/2325967118816293)
- [L5] Patients can have a high expectation of return to wildlife sports following shoulder surgery. [246] (10.1016/j.jseint.2025.101432)
- [L4] Mid-term outcomes in this population of active-duty patients undergoing DPR for shoulder instability without glenoid bone loss demonstrate a statistically and clinically significant improvement in patient-reported outcomes, a significant decrease of pain and an overall return to active-duty rate of 91.67%. [247] (10.1016/j.arthro.2021.09.003)
- [L4] [249] (10.1016/j.jseint.2025.02.003)
- [L4] Information gained from a CT scan did not alter treatment decision-making in three-quarters of vignettes among surgeons experienced in the management of anterior shoulder instability. [250] (10.1177/03635465231163148)
- [Case_report] Awareness and early detection are the best approach to thromboembolic disease following shoulder arthroscopy. [251] (10.5397/cise.2021.00500)
- [L3] Arthroscopic thermal capsulorrhaphy neither enhanced nor impaired the outcomes of arthroscopic labral repair with biodegradable tacks in patients with primary recurrent anterior shoulder instability. [253] (10.1177/0363546504270563)
- [L3] In a community practice, radiologists miss approximately 50% of subscapularis tears on MRI examination, while a shoulder surgeon misses 28.6%. [254] (10.1016/j.asmr.2023.100825)
- [L4] Diagnostic imaging may not reliably correlate with diagnostic arthroscopic findings at the time of a Latarjet procedure from both a bony perspective and a soft-tissue perspective. [258] (10.1016/j.asmr.2021.09.014)
- [L3] Arthroscopic revision stabilization of the shoulder can result in satisfactory outcomes in patients who have failed previous capsulabral repair. [261] (10.1177/2325967115s00012)
- [L4] [264] (10.1016/j.arthro.2021.01.061)
- [L4] [267] (10.1007/s00264-018-4105-6)
- [L3] [270] (10.1177/0363546517702863)
- [L2] [271] (10.1007/s00167-011-1521-1)
- [L3] The space can be a reliable adjunct for verification but should not replace a full arthroscopic evaluation. [273] (10.1016/j.jse.2006.09.005)
- [L4] In general, shoulder arthroscopic surgery in this study population had a low rate of reoperation in the acute period. [278] (10.1177/0363546513510686)
- [L4] There is no study in the literature comparing infection rates between patients who receive and those who do not receive perioperative antibiotics in routine shoulder arthroscopic procedures. [279] (10.1055/s-0038-1636950)
- [L4] High school football players who returned to competitive play after arthroscopic shoulder stabilization surgery experienced a higher rate of recurrent instability that was dependent on their years of eligibility remaining. [280] (10.1177/23259671241239334)
- [L4] Female patients had a lower postoperative return to sport and shoulder scores after the modified Latarjet procedure compared with literature reports. [281] (10.1016/j.jse.2017.07.030)
- [L3] This large retrospective study found that the incidence of secondary frozen shoulder following simple arthroscopic shoulder surgery was just over 5%. [282] (10.1302/0301-620x.97b7.35387)
- [L3] Following arthroscopic shoulder labral surgery, most MLB pitchers and positional players were able to return to play successfully but experienced shorter careers thereafter. [283] (10.1016/j.asmr.2023.02.004)
- [L2] The incidence of unexpected positive cultures (UPCs) is significantly higher in revision arthroscopic shoulder stabilization procedures than in primary surgeries. [285] (10.1002/arj.70130)
- [L5] Arthroscopic and related surgery has a low complication rate, but surgeons must learn from complications that do occur through careful review and study of etiology and prevention. [286] (10.1016/j.arthro.2014.08.002)
- [L3] The postoperative infection risk is greatest when corticosteroid injections are given within 2 weeks of shoulder arthroscopy, whereas injections given within 2-4 weeks also portend increased risk, albeit to a lesser degree. [288] (10.1016/j.arthro.2023.08.073)
- [L3] Increased shoulder arthroscopy procedure time is associated with significantly increased rates of superficial surgical site infections and overnight hospital stays. [289] (10.1016/j.arthro.2017.08.243)
- [L4] Arthroscopic partial repair may produce initial improvement in selected outcomes at 2-year follow-up, but about half of the patients were not satisfied with their outcomes, which had deteriorated over time. [290] (10.1177/0363546515585122)
- [L3] Patients with a BMI >40 have a statistically significant but only slightly increased risk of 30-day complications after shoulder arthroscopy. [292] (10.1016/j.arthro.2018.10.136)
- [L3] Arthroscopic procedures are safe with very low complication rates. [293] (10.1016/j.arthro.2018.10.108)
- [L4] Arthroscopic rotator cuff repair reduced the risk of infection compared with open techniques. [294] (10.1016/j.arthro.2015.08.021)
- [L3] Twenty years postoperatively, arthroscopic Bankart repair was associated with good to excellent shoulder function, low pain levels and high patient satisfaction. [295] (10.1177/2325967124s00022)
- [L1] C acnes infections occur at a very low rate (0.22%) following shoulder arthroscopy. [296] (10.1016/j.jse.2019.12.032)
- [L4] Achieving 69.5% of maximal ASES score improvement or 75% of maximal SANE score improvement is indicative of achieving patient satisfaction after arthroscopic rotator cuff repair. [297] (10.1016/j.arthro.2020.02.047)
- [L2] The rate of P acnes infection in patients undergoing revision shoulder arthroscopy is higher than previously published and should be considered in cases characterized by refractory postoperative pain and stiffness. [299] (10.1016/j.jse.2015.03.008)
See Also¶
- Shoulder Instability
- Rotator cuff repair
- Fractures
- Os Acromiale
- Rotator Cuff
- Shoulder Arthroplasty
- Frozen Shoulder
- Rotator Cuff Disorders
- Total shoulder arthroplasty
- Latarjet Procedure
- Shoulder Arthritis
- Brachial Plexus Injury
- Reverse Shoulder Arthroplasty
- Capsular Release for Frozen Shoulder
References¶
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[9] Indications and outcomes of shoulder arthroscopy after shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.09.013
[10] Shoulder Arthroscopy, Third Edition. StephenJ. Snyder, RonaldP. Karzel, MarkH. Getelman, JosephP. Burns, MichaelS. Bahk, David M.Auerbach. Philadelphia: Lippincott Williams & Wilkins, 2014, 405 pp.. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.07.021
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[12] Epidemiological trends and indications of shoulder arthroscopy among 191,549 patients in the United States. Shoulder & Elbow. 2026. DOI: 10.1177/17585732261420111
[13] Pain after shoulder arthroscopy: A prospective study on 231 cases. Orthopaedics & Traumatology: Surgery & Research. 2011. DOI: 10.1016/j.otsr.2011.02.003
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