Clinicians › Shoulder

Assessment & Imaging

Clinical evaluation and imaging protocols for shoulder pathology, focusing on glenoid morphology and soft tissue integrity to guide surgical planning.

130 citationsUpdated Sep 2026

Overview¶

Shoulder imaging relies on a combination of modalities to assess glenoid morphology, version, and humeral head subluxation [1]. While MRI provides CT-equivalent measurements of glenoid retroversion, concavity, and bony stability ratio after anterior dislocation [15], 3-D CT remains the most reliable modality for quantifying glenoid bone loss, with regular CT serving as the second most reliable option [19]. For patients with glenohumeral osteoarthritis, the combined use of CT and MRI is recommended for preoperative planning, as CT underestimates rotator cuff pathology [23]. MRI is the preferred strategy for detecting symptomatic full-thickness supraspinatus tears based on cost-effectiveness [47], and the integrity of Kaplan fibers should be routinely reviewed on MRI scans [20]. The glenoid track concept assessment is encouraged as a routine part of preoperative evaluation for arthroscopic anterior stabilization [59], and the SHART test is suggested for addition to conventional imaging [29].

In proximal humeral fractures, CT diagnostics allow significantly better assessment of relevant structures than conventional diagnostics [4]. Multiple radiographic views are needed to evaluate greater tuberosity displacement appropriately [56], though three-dimensional fluoroscopy requires further clinical studies to establish its role in determining intra-articular screw penetration [136]. For sternoclavicular joint injuries, CT is the imaging modality of choice and the gold standard for evaluating posterior dislocations [2, 13]. Spine imaging requires an understanding of specific indications, advantages, and disadvantages for radiographs, CT, and MRI depending on the pathology [7]. Advanced imaging techniques, including CT and three-dimensional reconstructions, augment plain radiographs to guide treatment decisions for acetabular fractures [30].

Postoperative imaging protocols vary by indication. For patients experiencing pain or limited range of motion following primary anatomic or reverse total shoulder arthroplasty, ongoing assessment using additional X-rays, CT scans, or other diagnostic tests is recommended [3]. However, routine PACU radiographs in the absence of a specific indication may result in poor-quality images [22], and there is low utility for obtaining immediate postoperative radiographs in the PACU for uncomplicated primary reverse shoulder arthroplasty with osteoarthritis or rotator cuff tear arthropathy [151]. Radiology reports of routine immediate postoperative radiographs rarely identified postoperative complications, with a rate of 0.2% [11]. Routine radiographs provide low utility in guiding treatment for asymptomatic pediatric patients following scoliosis surgery [10].

Anatomy & Pathophysiology¶

Bony Anatomy¶

The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [78]. The articular head is spherical with a diameter of 37 to 57 mm [78]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [78]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [78]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [78]. The anatomic neck is located at the junction of the articular surface and the tuberosities [78]. The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [78]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [78]. The lesser tuberosity serves as the attachment site for the subscapularis tendon [78].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [78]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch [78]. The scapula is triangular when viewed anteroposteriorly, with its base situated superiorly and its apex inferiorly [80]. The glenoid is connected with the flat body of the scapula by the scapular neck [80]. The coracoid process curves forwards from the superior surface of the scapular neck [80]. The scapular spine ends in a flattened bony process, the acromion, which curves forwards [80]. The highest concentration of bony mass in the scapula is found in the glenoid, the scapular neck, and the lateral border of the scapular body [80]. Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar and the spinal pillar [80]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [80]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [80]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [80]. The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [80].

The clavicle is the first bone to ossify, occurring at the fifth week of gestation [81]. The clavicle is the only long bone to ossify by intramembranous ossification [81]. The medial epiphysis of the clavicle is the last ossification center to fuse, occurring at age 20 to 25 years [81]. The primary blood supply to the clavicle is periosteal, with no nutrient artery present [81]. The scapula has only one true diarthrodial articulation, the acromioclavicular joint [81]. Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [81]. Ossification of the scapular body begins at the eighth week of gestation [81]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [81]. Failure of fusion of the acromial ossification centers results in os acromiale [81].

The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [81]. The glenoid averages 5 degrees of retroversion in relation to the axis of the scapular body [81]. The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [81]. The humeral head averages 19 degrees of retroversion and 41 degrees of inclination [81]. The humeral shaft extends from the level of the insertion of the pectoralis major muscle proximally to the supracondylar ridge distally [79]. The glenoid cavity is a shallow socket, approximately one-third the size of the humeral head [79]. The neck-shaft angle of the proximal humerus measures an average of 135 degrees [79]. The humeral head is retroverted an average of 30 degrees [79].

The articular surface of the humeral head is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [90]. The radius of curvature of the humeral head is approximately 25 mm [90]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [90]. The average neck-shaft angle is 45 degrees, with a range of 30 to 50 degrees [90]. The superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [90]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [90]. The glenoid diameter ranges from 18 to 30 mm superiorly and 21 to 35 mm inferiorly in the anteroposterior direction [90]. The superoinferior height of the glenoid ranges from 30 to 48 mm [90]. The glenoid inclination averages 4.2 degrees, with a range of -7 to 20 degrees [90]. The humeral head inclination ranges from 30 to 55 degrees [90]. The glenoid version averages 1.5 degrees of retroversion, with a range of 10.5 degrees anteversion to 9.5 degrees retroversion [90]. The glenoid surface area ranges from 4 to 6 mm [90]. The humeral head surface area ranges from 11 to 19 mm [90]. The glenoid cartilage thickness is 2.16 mm [90]. The humeral head cartilage thickness is 1.44 mm [90]. The glenoid radius of curvature ranges from 22 to 28 mm [90]. The humeral head radius of curvature ranges from 23 to 28 mm [90]. The medial humeral offset ranges from 4 to 14 mm [90]. The posterior humeral offset ranges from -2 to 10 mm [90].

The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [93]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [93]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [93]. Os acromiale is incomplete fusion of secondary ossification centers, most commonly between the mesoacromion and meta-acromion [93]. The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [93]. Head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [93]. The anatomic neck is located directly below the humeral head and serves as an attachment for the shoulder capsule [93]. The surgical neck is more distal than the anatomic neck and is more often involved in fractures [93]. The transverse humeral ligament is an important stabilizer of the biceps tendon [93].

The formation of the humerus begins with the appearance of the cartilage anlage by the fifth week of gestation [85]. The primary ossification center for the humerus appears at about the sixth week [85]. By birth, the entire humeral diaphysis is completely ossified [85]. The proximal humerus is primarily cartilaginous at birth [85]. Ossification centers for the proximal humerus can be detected with ultrasonography as early as the 38th week of gestation [85]. The ossification center for the humeral head is usually present at birth [85]. The greater tuberosity ossification center appears by 1 to 3 years of age [85]. The lesser tuberosity ossification center appears by 5 years of age [85]. Proximal humeral ossification centers fuse by 5 to 7 years of age to form the humeral head [85]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [85]. Mean humeral retroversion is around 26 degrees in healthy adults [85]. Humeral retroversion averages 65 degrees in infants and young children [85]. Humeral retroversion approaches adult values by 11 years of age [85]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis [85]. The proximal humeral physis accounts for approximately 40% of the growth of the entire upper extremity [85]. Less than 75% of proximal humeral growth occurs before 2 years of age [85]. More than 85% of proximal humeral growth occurs by 8 years of age [85].

Joints and Ligaments¶

The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [81]. The posterior sternoclavicular joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [81]. The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [81]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [81]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [81]. The rotator cuff stabilizes the glenohumeral joint via joint compression [81]. Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [81]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [81].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [81]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [81]. Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [81]. Contracture of the rotator interval is seen with adhesive capsulitis [81]. The coracohumeral ligament restricts external rotation in adduction [81]. The coracohumeral ligament is a static restraint to inferior and posterior translation in adduction and external rotation [81]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [81]. The superior glenohumeral ligament forms a pulley with the coracohumeral ligament that provides restraint against medial subluxation of the long head of the biceps tendon [81]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45 degrees of abduction [81]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90 degrees of abduction and external rotation [81]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [81].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [81]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to the ligament [81]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [81]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [81]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [81].

The shoulder joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints [91]. The glenoid is encircled by the labrum, which increases the depth of the socket by 50% around the humeral head [91]. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [91]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [91]. The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction [91]. The superior glenohumeral ligament is the primary stabilizer to anterior and posterior stress in 0 degrees of abduction [91]. Tightening of the rotator interval decreases posterior and inferior translation [91]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction [91]. The middle glenohumeral ligament has little effect when the arm is in 90 degrees of abduction [91]. The inferior glenohumeral ligament is composed of an anterior band, a posterior band, and a thinner intervening axillary pouch [91]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [91].

The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion [91]. The infraspinatus and teres minor fuse near their musculotendinous junctions [91]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [91]. The roof of the biceps sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor [91]. The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [91]. The coracohumeral ligament is deep to the tendinous insertion of the cuff and blends with the capsule and supraspinatus tendon to form part of the roof of the biceps sheath [91].

The fibrocartilaginous glenoid labrum deepens the socket by 50% and provides a bumper to translation [93]. Labral anatomic variants include the sublabral foramen and the Buford complex [93]. The Buford complex is characterized by the absence of the anterosuperior labrum and a cordlike middle glenohumeral ligament [93]. The sternoclavicular joint involves double gliding with an articular disc [93]. The sternoclavicular joint rotates 30 degrees with shoulder motion [93]. The acromioclavicular joint is a plane or gliding joint with a fibrocartilaginous disc [93]. The posterior and superior acromioclavicular ligaments are considered the strongest [93]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint [93]. The conoid ligament is located approximately 45 mm from the acromioclavicular joint [93]. The conoid ligament is posteromedial and stronger than the trapezoid ligament [93]. The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [81].

Classification¶

Glenoid Morphology and Instability¶

Walch: The modified Walch classification represents an improvement over the original system, though automated computer-based analysis of CT scans may be required to further enhance its value [41]. Inter-rater agreement between x-ray images and consensus MRI for the Walch classification is fair-to-moderate, which is lower than previously reported reliability using CT scans [52]. Conversely, intraobserver agreement using the Walch classification based on axillary radiographs was substantial and compared favorably with agreement based on CT scans [147]. MRI is comparable to CT for determination of glenoid version but does not accurately distinguish between Walch B2 and C classifications [205].

Glenoid Bone Loss: Significant differences in bone loss measurement between imaging modality, measurement method, and observers may lead to differences in treatment in up to 34% of cases [5]. A new classification of glenoid bone loss for planning glenoid component implantation before revision arthroplasty has good intra- and inter-observer reliability and good correlation between results from plain radiographs and CT images [120].

Kim: The interobserver reliability of Kim's classification for posterior shoulder instability is fair [61].

FEDS: There are 16 categories within the FEDS classification for glenohumeral instability that are clinically significant [140].

Hill–Sachs Lesion (HSL): With the exception of the Hill–Sachs interval, CT and MRI show no significant differences in the diagnostic value of the HSL measurement regardless of the measurement technique [149]. All measurement techniques for HSL, with the exception of the Franceschi and Calandra classifications, provided good to very good intra- and inter-rater reliabilities with both CT and MRI [149].

General Imaging Reliability: Interobserver and intraobserver agreement for assessing glenoid morphology, glenoid version, and humeral head subluxation is comparable between MRI and CT [1].

Proximal Humerus Fractures¶

AO/OTA: Overall interobserver agreement within levels of training when evaluating the AO/OTA classification for proximal humeral fractures was fair to substantial (0.281 to 0.713) [213]. The highest levels of agreement among attending surgeons and senior residents for AO/OTA classification was with 2-D CT imaging, while junior residents had the highest agreement when 3-D CT imaging was used [213]. Between levels of training, the highest levels of agreement were between attending surgeons and senior residents for all imaging modalities, with 2-D CT producing agreement superior to that with 3-D CT or radiographs [213]. When comparing junior residents with reviewers who have more clinical experience, the highest levels of agreement for AO/OTA classification were seen with 3-D CT [213].

Boileau: The Boileau classification of proximal humerus fracture sequelae had poor interobserver reliability even when using a three-dimensional evaluation of the deformity [60].

Artificial Intelligence: Despite rigorous training methodology based on CT imaging with multi-rater consensus to serve as the reference standard, artificial intelligence-driven classification of proximal humerus fractures is insufficient for clinical implementation [128].

Imaging Strategy: Optimum patient care for proximal humeral fractures might require the development of new imaging modalities rather than new classification systems [24].

Rotator Cuff and Muscle Fatty Infiltration¶

Goutallier: The correlation between the semi-quantitative MRI-based Goutallier Classification system and MR spectroscopic fat measurement is weak [58]. Intraobserver and interobserver reliability of the Goutallier scores was determined using multijudge k coefficient of agreement, with the 3-grade scale showing significantly better agreement than the 5-tiered system [212]. The level of agreement between CT horizontal, coronal, and sagittal image plans for supraspinatus fatty degeneration was best when evaluated on horizontal CT images [212]. The horizontal plane produced the most reliable (good to moderate agreement) results for both intraobserver and interobserver values using the 5-tiered system of Goutallier (k 0.687 and 0.498) and the 3-tiered system (k 0.772 and 0.593) [212]. The poorest intraobserver and interobserver agreement for supraspinatus fatty degeneration was found using sagittal images [212].

Euler and Ideberg: The established classifications by Euler and Ideberg for glenoid fractures are not capable of providing similar reliability [154].

Measurement Limitations: Clinical scores using a single image slice do not represent 3-dimensional muscle measurements [49].

Other Classifications and Imaging Reliability¶

SLAP Lesions: Classification of superior labrum anterior to posterior (SLAP) lesions using MRa resulted in significant disagreement between and within raters [104].

Acromial Morphology: The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease [50].

Elbow Osteoarthritis: The CT-based staging system for primary elbow osteoarthritis showed almost perfect interobserver and intraobserver agreement and high correlation with visual analogue scale scores compared to plain radiograph-based classifications [98].

Lateral Scapula Suspension System (LSSS): The proposed classification system for lateral scapula suspension system (LSSS) failure demonstrated satisfactory agreement and accuracy among experienced surgeons [142]. Complete disruptions (S2) in the lateral scapula suspension system are relatively common and associated with increased risk of neurovascular injury [142].

Scaphoid Fractures: The 'long axis' measurement for acute scaphoid fractures has clear potential benefits over traditional classification systems which should be explored in future clinical research [57].

Larsen: Larsen’s classification system was used to classify glenohumeral joint destruction into 6 grades (grades 0-5) in shoulders with rheumatoid arthritis [209]. The severity of greater tuberosity destruction was classified into 3 grades: mild (depth < 5 mm), moderate (depth 5-10 mm), and severe (depth ≥10 mm) [209].

Trochlear Dysplasia: Inconsistent repeatability of the Dejour classification of trochlear dysplasia is due to the variability of imaging modalities [208]. High heterogeneity due to differences in imaging protocols, classification groupings, and statistical methods to assess observer agreement made pooling of results for quantitative statistical analysis impossible in the systematic review of trochlear dysplasia classifications [208].

Other Considerations: Consensus was reached for five elements in the x-ray report, twenty in the MRA report, nine in the CT report, and two elements regarding MRA views and settings for anterior shoulder instability [16].

Clinical Presentation¶

General Principles & History¶

The comprehensive history and physical examination constitute the initial interactions required to deliver a correct diagnosis and subsequent treatment recommendations [14]. The evaluation begins with elucidating an accurate history, including symptom location, severity, onset, duration, quality and character, aggravating or alleviating factors, and previous related treatments [14]. Caution should be taken attributing symptoms to underlying medical diagnoses as symptoms can often be multifactorial [14]. In the acutely injured patient, specific attention should be given to the mechanism of injury and associated injuries [14]. By completing a comprehensive history, the provider can often develop an appropriate differential diagnosis, which can be further narrowed by the examination [14].

Symptoms can often be similar for spinal and appendicular musculoskeletal etiologies, with cervical spine symptoms mimicking shoulder problems, brachial plexopathies, and peripheral compressive neuropathies [14]. Lumbar spine symptoms are often very similar to those originating from the hip, sacroiliac joint, or even vascular insufficiencies [14]. Patients with myelopathy may present with vague symptoms that could be mistaken for other systemic or neurologic disorders [14].

Imaging plays an important role in the evaluation of musculoskeletal symptoms, ranging from traumatic injury to tumor characterization to treatment follow-up [8]. An understanding of available imaging modalities and their indications is critical to ensure the correct study is performed and the clinical question is answered [8]. Multiple image-guided interventions are available to aid in diagnosis and therapy [8]. While imaging and other studies may assist medical assessors in making a diagnosis, the presence of a morphological variation from 'normal' in an imaging study does not confirm the diagnosis [38]. To be of diagnostic value, imaging studies must be concordant with clinical symptoms and signs [38]. An imaging test is useful to confirm a diagnosis, but an imaging study alone is insufficient to qualify for a DRE category, excepting spinal fractures [38]. Clinicians should always correlate the findings of MRI with the patients' medical history and clinical presentation in clinical decision making [12].

Shoulder Imaging¶

For patients experiencing pain or limited range of motion following primary anatomic and reverse total shoulder arthroplasty, ongoing assessment using additional X-rays, computed tomography scans, or other diagnostic tests is recommended for effective monitoring [3]. CT diagnostics allowed a significantly better assessment of relevant structures than conventional diagnostics in proximal humeral fractures [4]. Significant differences in bone loss measurement between imaging modality, measurement method, and observers may lead to differences in treatment in up to 34% of cases in glenohumeral instability [5]. Regular CT was the second most reliable and reproducible modality when quantifying glenoid bone loss [19].

Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning for unilateral shoulder pain [6]. The quality of shoulder MRI images and their usefulness are markedly affected by the type of equipment employed, with high-field-strength systems typically providing superior image quality compared to low-field-strength open systems [9]. MRI provides CT-equivalent measurements of glenoid retroversion, concavity, and BSSR after anterior shoulder dislocation [15]. These findings support MRI as a viable modality for assessing key bony stability parameters, potentially reducing the need for supplemental CT in many clinical scenarios [15]. Conventional 3.0-Tesla nonenhanced magnetic resonance imaging findings contribute to achieving an accurate clinical diagnosis of the anteroinferior capsulolabral complex in patients with traumatic anterior shoulder instability [121].

All parameters related to history taking, physical exam and imaging studies for traumatic anterior shoulder instability should be considered according to the patient's age and the number of dislocation episodes [18]. The West Point view is a good screening tool for classic anteroinferior bony Bankart lesions, while CT should be added when the view is equivocal or difficult to obtain [113]. There was high variability in what the imaging modality was being tested for regarding Hill-Sachs lesions, including utility for diagnosis, confirmation of size, and/or determination of status as on or off track [27].

Critical shoulder angle (CSA) on plain radiographs has good diagnostic performance for rotator cuff tears [17]. Plain radiographs rarely alter the diagnosis or affect management in the setting of atraumatic shoulder pain, particularly in patients younger than 50 years [25]. The clinical utility of the lateral scapular view may need to be reassessed in the initial evaluation of nontraumatic shoulder conditions [45]. Further clinical trials using more accurate diagnostic MRI tools are required to better define anatomical differences between partial-thickness rotator cuff tears and healthy patients [124].

Imaging abnormalities of the acromioclavicular joint and subacromial space are common in asymptomatic shoulders [21]. Surgical decision-making for acromioclavicular arthritis should rely on focused history and clinical examination rather than MRI scans [28]. The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography should be taken into consideration when using a CT scan to assess a patient with symptomatic SCJ pathology [26].

Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps [94]. Needle diagnostic arthroscopy had better ability to rule in a diagnosis but slightly worse ability to rule out a diagnosis compared with MRI [96]. The SLAP diagnosis appears to be a clinical impression; however, the criteria described within the literature vary among the evaluation areas and differ from the results of the survey [107]. Conventional 1.5-T MRI is specific but not sensitive for diagnosing superior labrum anterior–posterior tears, while 1.5-T MRA is sensitive but not specific [109]. The positive predictive value is poor for both MRI and MRA, while the negative predictive value is acceptable for both in diagnosing superior labrum anterior–posterior tears [109]. The decision to operate for superior labrum anterior–posterior tears must be balanced with the clinical scenario, physical exam findings, and imaging results together, as none of these modalities in isolation provides sufficient diagnostic accuracy [109].

Assessments of fatty infiltration and muscle atrophy from a single magnetic resonance image slice are not predictive of 3-dimensional measurements [49]. Anatomic variations of the pectoralis minor tendinous insertion can be detected preoperatively on high-quality MRI, but its clinical impact needs further elucidation [122]. Synthesis of detailed findings from multiple studies could define patterns of pathological MRI findings allowing for associations of imaging findings to risk factors including specific activities in manual wheelchair users [53].

Most incidental findings on routine preoperative computed tomography for shoulder arthroplasty are pulmonary in nature, and overall, half of the patients with incidental findings were recommended for further follow-up [51]. 18F-FDG PET/CT is clinically relevant in diagnostically challenging cases, such as the first phase of frozen shoulder, which can be difficult to distinguish from subacromial impingement [127]. With the increasing availability of 4D CT, this imaging modality may be of use in helping diagnose unusual causes of shoulder pain in patients who have otherwise normal imaging [129]. Surgery and histologic examination for elastofibroma dorsi should be performed only when there are significant symptoms or when MRI findings are controversial [106].

Spine Imaging¶

Magnetic resonance is an excellent modality for imaging pathologic processes in the pediatric spine, allowing high-resolution views of osseous and soft-tissue structures [48]. Findings of MRI abnormalities in asymptomatic individuals represent roentgenographic abnormalities only, and any clinical decisions concerning the treatment of pain in the thoracic spine usually require additional studies [119].

Sternoclavicular Joint Imaging¶

Timely recognition and treatment are essential to prevent devastating consequences in sternoclavicular joint injuries, and computed tomography is the imaging modality of choice for evaluation [2].

Investigations¶

General Principles: Imaging is integral to the evaluation of musculoskeletal symptoms, ranging from traumatic injury to tumor characterization and treatment follow-up [8]. Understanding available modalities and their specific indications is critical to ensure the correct study is performed and the clinical question is answered [8]. The primary purposes of shoulder imaging are to establish the diagnosis, determine the severity of pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition to the patient [37]. Because the shoulder is a three-dimensional structure that cannot be represented by a single planar view, critical relationships such as the degree of centering of the humeral head change with arm position [111]. Pathology may involve numerous bones and soft tissues, and overlying structures or metallic implants can complicate imaging [111]. Surgeons must adopt a judicious approach that yields necessary information while resisting the temptation to "overimage," obtaining only the scans or reconstructions necessary for patient care unless a specific research protocol is in place [37, 111].

Plain radiography: Standardized plain films are almost always sufficient for shoulder assessment, and proper radiographic technique is as important as surgical technique [37]. Conventional radiographs are appropriate for patients presenting with shoulder pain, history of trauma, dislocation, night pain, or chronic shoulder pain [125]. Initially, patients are usually asked to have AP and lateral plain radiographs related to their chief report [123]. At least two X-ray views should be obtained: an anteroposterior (AP) in the plane of the glenoid and an axillary projection with the arm in abduction [105]. The standard shoulder series should include orthogonal views, including a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [125].

The first key view is the AP in the plane of the scapula, taken so the x-ray beam passes through the glenohumeral joint [37]. This view shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, joint space narrowing, medial displacement of the humerus, bone quality, loose bodies, and humeral head collapse or deformity [37]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile [125]. The AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [125]. The AP view is aligned with the body [131].

The second key view is the axillary view, taken with the arm in the functional position of elevation in the plane of the scapula [37]. It is oriented so that both the spinoglenoid notch and the scapular neck are visible [37]. The axillary view demonstrates a different perspective of humeral anatomy, amount of glenoid bone, shape of the glenoid, its version in relation to the plane of the scapula, and the relationship of the humeral head to the glenoid fossa [37]. Referred to as the "truth view," it demonstrates glenohumeral relationships in the functional position of elevation [37]. Joint space narrowing is most evident on this view compared to images made with the arm at the side [37]. It can show posterior subluxation or "functional decentering" not evident in images taken with the arm at the side [37]. The degree of posterior subluxation can be measured as the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [37]. The point of contact reflects the degree of centering of the net humeral joint reaction force on the glenoid [37]. Malcentering of this force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [37].

When taken properly, standardized anteroposterior and axillary views indicate the thickness of the cartilage space between the humerus and the glenoid, relative positions of the humeral head and glenoid, presence of osteophytes, degree of osteopenia, and extent of bony deformity and erosion [37]. Many "axillary views" sent for consultation are taken without standardization, making it impossible to determine important features of the glenohumeral joint [37]. The axillary view is necessary for evaluation of glenohumeral joint instability and enables determination of the humeral head position in the glenoid fossa [125]. It may detect occult, locked posterior shoulder dislocation in a patient who exhibits a lack of passive external rotation [125]. It is helpful in evaluation of glenoid morphology in glenohumeral osteoarthritis and provides good visualization of the coracoid process, acromion, and distal clavicle [125]. An axillary view must be obtained in patients who are able to abduct the arm to evaluate for anterior or posterior humeral head subluxation or dislocation [131]. It is centered on the epicenter of the humeral head and the glenoid and provides an unambiguous view of anteroposterior glenohumeral alignment [131]. Clinical concerns of anterior or posterior glenohumeral subluxation/dislocation and osseous Bankart lesions can best be evaluated with this view [131].

The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs associated with rotator cuff pathology [125]. It is a reliable alternative for evaluation of glenohumeral subluxation and dislocation [125]. It can show scapular body abnormalities such as osteochondroma or fracture and acromial shape [125]. If the patient is unable to abduct their arm due to the acuity of injury, a scapular "Y" view must be obtained to evaluate the relationship of the humeral head to the glenoid [131]. In a comparison of 75 consecutive patients with suspected shoulder dislocations, the axillary and scapular "Y" view resulted in the same diagnosis in 69 patients (92%) [131]. 81% of patients preferred the scapular "Y" view because of less pain [131]. Radiology technicians preferred the scapular "Y" view due to the ease of obtaining the image compared to the axillary view [131].

Normal measurements include an acromiohumeral distance of 7 to 14 mm, a symmetric glenohumeral joint space width superiorly and inferiorly, and a coracoclavicular distance of 1.1 to 1.3 cm [125]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked) [125]. Type III acromial morphology has been shown to have a correlation with the presence of rotator cuff disease, although no direct causal relationship has been demonstrated [125]. The Neer classification of acromial morphology has shown relatively poor interobserver reliability [125].

Patients presenting with shoulder instability and dislocations are initially imaged with standard radiographs [131]. Radiographs provide an overview of the bony anatomy, orientation of the humeral head in relation to the glenoid, and initial assessment for both bony Bankart and Hill–Sachs lesions [131]. Anteroposterior (AP), Grashey (true AP view), Y, and axillary views are typically obtained for shoulder instability [131]. The Grashey view (true AP view) is oriented to the scapula with the radiographic beam centered onto the glenohumeral joint line [131]. In a systematic review of posterior shoulder dislocations, a missed initial diagnosis occurred in 73% of patients (150) due to the lack of an axillary view, Y view, or computed tomography (CT) imaging [131]. Of the 150 patients with missed initial diagnosis of posterior dislocation, almost all (147/150 or 98%) had only AP or lateral views of the shoulder [131]. When axillary or Y-view radiographs were made subsequently, the diagnosis of posterior dislocation was confirmed in 100% of patients [131].

Special radiographic views assist in identifying pathology related to shoulder instability and other conditions. A Velpeau view can be obtained in patients who are guarding, done with the patient in the sling and the radiographic plate positioned posteriorly and under the shoulder [131]. A modified axillary view has been proposed by positioning the patient sitting on the radiographic table with the hand of the affected side on the table and the arm abducted 60 degrees [131]. Another modified axillary view is obtained with the patient leaning slightly forward, with the plate positioned behind the patient and the radiographic beam aiming down about 45 degrees toward the plate [131]. The modified axillary view with the patient leaning slightly forward provides greater comfort for the patient especially in the setting of acute traumatic dislocation [131]. Special radiographic views that can assist in identifying pathology related to shoulder instability include the Stryker Notch, West Point, and the Bernageau profile views [131]. The Serendipity view is indicated for the sternoclavicular joint and is taken with the patient supine, 40° cephalic tilt view centered on sternum [125]. The West point view is indicated for anterior glenoid bone loss and is taken with the patient prone with the involved shoulder raised above table level, centered on axilla with beam directed 25° downward and 25° medial [125]. The Zanca view is indicated for the AC joint and is taken as an AP with 10° cephalic tilt centered over AC joint, with patient supine, using only one-half the voltage of a routine shoulder AP view [125]. The Stryker notch view is indicated to evaluate Hill–Sachs lesion after dislocation and is taken with the patient supine, the affected arm placed on the top of the head with fingers toward the back of the head, beam centered over coracoid process with 10° cephalic tilt [125]. The Apical oblique view is indicated to evaluate for glenoid rim fracture in instability and is taken with the patient seated, cassette placed posterior and parallel to the spine of the scapula, beam directed 45° to the plane of the thorax and 45° caudally [125].

Plain radiographs are often the only required studies needed for assessing acute shoulder trauma, including fractures or dislocations [123]. Arthritis, calcific tendinitis, and osteolysis of the distal clavicle can be observed on plain radiograph [123]. The critical shoulder angle (CSA) on plain radiographs has good diagnostic performance for rotator cuff tears [17]. Radiographs provide better reproducibility and accuracy for CSA measurement compared to MRI [46]. The inter-rater agreement between x-ray images and consensus MRI for Walch classification is fair-to-moderate, which is lower than previously reported reliability using CT scans [52]. AHDs measured on radiograph and MRI should not be used interchangeably in early Hamada grades to assess outcomes of superior capsule reconstruction and similar procedures [31]. Routine immediate postoperative radiographs rarely identified postoperative complications (0.2%) [11]. Routine PACU radiographs, in the absence of a specific indication, may result in poor-quality images [22]. For patients experiencing pain or limited range of motion, ongoing assessment using additional X-rays, computed tomography scans, or other diagnostic tests is recommended for effective monitoring [3]. The SHART test (shoulder hyperabduction radiological test) is suggested to be added to conventional preoperative imaging techniques [29].

Computed Tomography (CT): CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [125]. CT imaging is frequently used to evaluate fractures of the shoulder, to assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [123]. CT is helpful for planning fracture surgery and shoulder joint replacement [105]. Computed tomography is a useful imaging modality for evaluating osseous Hill-Sachs lesions [153]. The authors recommend the combined use of CT and MRI for preoperative planning in patients with glenohumeral osteoarthritis [23]. CT is the gold standard for closed reduction of posterior sternoclavicular dislocations, making it the most reliable method until further research establishes other modalities [13]. Timely recognition and treatment of sternoclavicular joint injuries are essential to prevent devastating consequences [2]. Although CT scans may offer a few degrees of increased precision in the measurement of glenoid version, this precision does not necessarily improve the quality of the surgery or the clinical outcome [37]. There is information that can be gathered from properly taken plain films that cannot be obtained from CT scans [37]. Three-dimensional reconstructions can reveal fine details of the shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty [37]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [37]. Based on CT, 3 of 21 cases of spinal osteoblastoma were considered Enneking stage 1, 12 cases as stage 2, and 6 cases as stage 3 [63]. Consistency between CT and MRI for Enneking staging of spinal osteoblastoma was reached in 6 of 19 cases (31.6%) [63]. The staging based on MRI was higher than that on CT in the other cases for spinal osteoblastoma [63].

Magnetic Resonance Imaging (MRI): MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [123]. MRI is useful to identify osteonecrosis of the humeral head, or a bone tumour [105]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [105]. T1-weighted MRI can reveal Hill–Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [123]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [123]. Traditional magnetic resonance imaging (MRI) is a diagnostic tool to complement both physical examination and standard radiographs in the management of patients with anterior shoulder instability [114]. The quality of images and their usefulness are markedly affected by the type of equipment employed, with high-field-strength systems typically providing superior image quality compared to low-field-strength open systems [9].

Treatment¶

Non-Operative¶

Conservative management remains the primary pathway for specific shoulder and scapular pathologies. Non-operative treatment with a sling for a couple of weeks, followed by early motion, is indicated for the majority of scapular fractures [207]. Similarly, nearly 90 per cent of fractures of the glenoid cavity can be treated non-operatively with a good or excellent result [70]. For patients with frozen shoulder but without suspicion of an additional pathology, routine use of shoulder MRI scans may not be indicated [174].

Operative¶

Indications: Surgical intervention is dictated by specific radiographic and clinical thresholds. In glenoid fractures, commonly used indications for surgery include glenohumeral instability, intra-articular involvement of more than 25%, and/or a glenoid surface step of more than 5 mm [207]. Fractures involving the glenoid are more likely to require surgical treatment than other scapular fractures [207]. For extra-articular scapular neck fractures, a displacement of the glenoid > 40°, or a 1 cm translation usually indicates surgery to regain the mechanical axis [207]. Augmented capsular plication is indicated for patients with symptomatic atraumatic sternoclavicular joint instability confirmed by MRI imaging that have failed appropriate nonoperative treatment [194].

Imaging Strategy: Computed tomography is the imaging modality of choice for the evaluation of sternoclavicular joint injuries [2] and is the gold standard for the evaluation of posterior sternoclavicular dislocations [13]. For preoperative planning in patients with glenohumeral osteoarthritis, the combined use of CT and MRI is recommended, as CT underestimates rotator cuff pathology [23]. Advanced imaging techniques, including CT and three-dimensional reconstructions, augment the information obtained from plain radiographs to guide treatment decisions in acetabular fractures [30]. 3D CT imaging is effective and reproducible in determining Hill-Sachs lesion size [130]. MRI is a viable modality for assessing key bony stability parameters such as glenoid retroversion, concavity, and BSSR after anterior shoulder dislocation, potentially reducing the need for supplemental CT in many clinical scenarios [15].

Diagnostic Modalities: Plain radiographs are an excellent starting point for most bone tumors [34]. MRI is often helpful for soft-tissue tumors, bone masses with a soft-tissue component, and any malignant tumor [34]. MRI is the preferred strategy for the detection of symptomatic full-thickness supraspinatus tendon tears based on cost-effectiveness criteria, although the decision between MRI and ultrasound is likely dependent on additional factors such as available resources and workflow [47]. High-field-strength MRI systems typically provide superior image quality compared to low-field-strength open systems [9]. An understanding of the available imaging modalities and indications for each is critical to ensure that the correct study is performed and the clinical question is answered in musculoskeletal evaluation [8].

Measurement and Assessment: Radiographs provide better reproducibility and accuracy for critical shoulder angle (CSA) measurement compared to MRI [46]. On nonstandard anteroposterior radiographs, the diagnostic efficacy of the acromion index (AI) was better than that of the critical shoulder angle (CSA) for predicting rotator cuff tears [148]. Acromiohumeral distances (AHDs) measured on radiograph and MRI should not be used interchangeably in early Hamada grades to assess outcomes of superior capsule reconstruction and similar procedures [31]. The glenoid track concept method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization [59]. The SHART (shoulder hyperabduction radiological test) is suggested to be added to conventional preoperative imaging techniques [29].

Postoperative and Specialized Imaging: For patients experiencing pain or limited range of motion following primary anatomic and reverse total shoulder arthroplasty, ongoing assessment using additional X-rays, computed tomography scans, or other diagnostic tests is recommended [3]. The radiology reports of routine immediate postoperative radiographs rarely identified postoperative complications after shoulder arthroplasty, with a rate of 0.2% [11]. The lack of clinically meaningful change from routine postoperative radiography does not justify the per-patient expense, as almost all postoperative radiographs were read as normal and did not alter postoperative management in primary total shoulder arthroplasty [33]. Lesser tuberosity osteotomy (LTO) healing after total shoulder replacement is best assessed on radiographs; if nondisplaced or displaced nonunions are suspected, computed tomography can be a helpful additional examination [199]. A conventional antero-posterior radiograph cannot provide any predictive information on the clinical status of the patient with cuff tear arthropathy [200].

Soft Tissue and Ultrasound: The efficacy of determination of rotator cuff tears will increase after the introduction of shoulder ultrasonography performed by orthopedic surgeons [139]. The use of ultrasound guidance significantly improves the success rate in acromioclavicular joint injection and is recommended for therapeutic ACJ injections in routine clinical practice [143]. An NO-MRI scan and an NO-MRI arthrogram provide a good assessment of the structural soft-tissue injuries associated with acute and chronic sternoclavicular joint injuries and provide a reliable guide to further clinical management [198]. A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists [190].

Other Considerations: Glenoid morphology can be normalized during the intermediate to long-term postoperative period after arthroscopic repair of chronic osseous Bankart lesions, even in shoulders with a smaller fragment [64]. Kinematic changes in symptomatic rotator cuff tears might be associated with the development of symptoms [54]. The correlation between the semi-quantitative MRI-based Goutallier Classification system and MR spectroscopic fat measurement of the supraspinatus muscle is weak [58]. A systematic review identified significant heterogeneity in both the imaging modality and method used to measure glenoid bone loss in clinical studies [156]. Equalization of grade 0 and grade 1 laxity in the shoulder laxity examination improves both intra- and interobserver reproducibility, but caution is recommended when determining diagnosis and treatment based on this examination [150]. The clinical utility of the lateral scapular view in the initial evaluation of nontraumatic shoulder conditions may need to be reassessed [45]. Orthopaedic surgeons should develop a systematic approach to interpreting the entire image and create a discrete plan with radiologists on managing incidental findings on radiographs [191]. Improved use of MRI with sedation through a careful pre-MRI evaluation and interdisciplinary communication results in shortened MRI duration, a reduced rate of preliminary scanning, and a shortened period of hospitalization in children with musculoskeletal infections [117].

Complications¶

Nerve palsy: Three-dimensional analysis of baseplate screw penetration in reverse total shoulder arthroplasty identifies a risk of iatrogenic suprascapular neuropathy by screw violation [72]. Clinical outcomes of reverse total shoulder arthroplasty at a minimum follow-up of 1 year were similar in high- and lower-risk groups for iatrogenic suprascapular neuropathy [72].

Other Considerations: Routine immediate postoperative radiographs rarely identified postoperative complications in 0.2% of cases [11]. Most incidental findings on routine preoperative computed tomography for shoulder arthroplasty are pulmonary in nature [51]. Half of the patients with incidental findings on routine preoperative computed tomography for shoulder arthroplasty were recommended for further follow-up [51]. The natural history of first-time shoulder dislocations is bound up with arthropathy [67]. Muscle atrophy and fatty infiltration are irreversible phenomena that continue even after successful rotator cuff repair [68]. Muscle atrophy and fatty infiltration do not have a significant influence on the functional outcome at short-term follow-up after rotator cuff repair [68]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for radial head arthroplasty [204]. A large number of missing or inadequate radiographs led to repeat radiation exposure in a cohort of patients with adolescent idiopathic scoliosis [185].

Recovery¶

Postoperative Imaging Utility: Routine immediate postoperative radiographs rarely identify postoperative complications, with a rate of 0.2% [11]. The lack of clinically meaningful change from routine radiography does not justify the per-patient expense, as almost all postoperative radiographs were read as normal and did not alter postoperative management [33]. CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery, with prevalence increasing more than two-fold from 6 months to 5 years post-surgery [62].

MRI and Soft Tissue Assessment: Surgical decision-making should rely on focused history and clinical examination rather than MRI scans for predicting symptomatic acromioclavicular arthritis [28]. Muscle atrophy and fatty infiltration are irreversible phenomena that continue even after successful repair; however, they do not have a significant influence on the functional outcome at short-term follow-up after cuff repair [68]. The immediate postoperative time point should be considered as the baseline to monitor the true changes of fatty infiltration after repair [229]. Early after surgery (1-3 months), worse clinical outcomes correlated with higher signal intensity on the proximal cuff tendon [214]. Enhancement patterns in intratendinous tissue increased at 1 or 2 months postoperatively and decreased at 3 months [76]. Reduced perfusion was associated with limited range of motion and below-average outcome in deltoid muscle integrity assessment after reverse shoulder arthroplasty [217].

CT and Specific Measurements: The significant differences in bone loss measurement between imaging modality, measurement method, and observers may lead to differences in treatment in up to 34% of cases [5]. On-track and off-track assessments using 2D CT and 2D MRI demonstrated inconsistent results; therefore, the additional information provided by 2D CT may be of significant value for clinical decision-making [232]. Even with a longitudinal protocol, most radiographs are of insufficient quality for Critical Shoulder Angle measurement [66]. Short term results show that pre-arthroplasty CT scanning of the shoulder does not influence revision rates [75]. These findings raise concern for glenoids at risk of loosening, but further follow-up is needed to determine the long-term clinical impact of these findings regarding implant position [65]. These findings may support the potential role of SPECT/CT in early detection of stress-related changes in symptomatic patients after reverse total shoulder arthroplasty [233].

Clinical Correlation and History: All parameters related to history taking, physical exam and imaging studies should be considered according to the patient's age and the number of dislocation episodes [18]. The natural history of the first time shoulder dislocations is bound up with arthropathy [67]. The age of the patient at the time of the initial dislocation is the most consistent and significant factor influencing prognosis, with recurrence rates of 83% in patients under twenty years and 12% in patients over fifty years [230]. Glenoid ossification and fusion progress in a predictable and chronological manner, which can mimic Bankart lesions on MRI [231].

Key Evidence¶

[L4] Based on these data, a treating clinician may choose to utilize either an MRI or a CT to assess these parameters. [1] (10.1177/1758573218768507)
[L4] For patients experiencing pain or limited range of motion, ongoing assessment using additional X-rays, computed tomography scans, or other diagnostic tests is recommended for effective monitoring. [3] (10.1016/j.jse.2024.11.010)
[L2] CT diagnostics allowed a significantly better assessment of relevant structures than conventional diagnostics. [4] (10.1186/1471-2474-10-33)
[L3] The significant differences in bone loss measurement between imaging modality, measurement method, and observers may lead to differences in treatment in up to 34% of cases. [5] (10.1016/j.arthro.2019.06.025)
[L3] Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning. [6] (10.1016/j.jse.2019.04.001)
[L5] The quality of images and their usefulness are markedly affected by the type of equipment employed, with high-field-strength systems typically providing superior image quality compared to low-field-strength open systems. [9] (10.2106/00004623-199706000-00019)
[L4] Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. [10] (10.2106/jbjs.l.01357)
[L4] The radiology reports of routine immediate postoperative radiographs rarely identified postoperative complications (0.2%). [11] (10.1016/j.jse.2022.10.027)
[L1] Therefore, clinicians should always correlate the findings of MRI with the patients' medical history and clinical presentation in clinical decision making. [12] (10.1186/s12891-016-1236-z)
[L4] CT is the gold standard, making this the most reliable method until further research establishes other modalities. [13] (10.1016/j.jse.2011.07.015)
[L3] These findings support MRI as a viable modality for assessing key bony stability parameters, potentially reducing the need for supplemental CT in many clinical scenarios. [15] (10.1016/j.jse.2026.03.004)
[L5] Consensus was reached for five elements in the x-ray report, twenty in the MRA report, nine in the CT report, and two elements regarding MRA views and settings. [16] (10.1016/j.jseint.2024.03.012)
[L1] CSA on plain radiographs has good diagnostic performance for RCTs. [17] (10.1007/s00167-018-5247-1)
[L2] All parameters related to history taking, physical exam and imaging studies should be considered according to the patient's age and the number of dislocation episodes. [18] (10.1002/ksa.70336)
[L5] Regular CT was the second most reliable and reproducible modality. [19] (10.1007/s11999-012-2607-x)
[L5] The integrity of the Kaplan fibers should be routinely reviewed on MRI scans. [20] (10.1177/0363546520919986)
[L2] [21] (10.1186/s13018-024-05378-4)
[L3] Routine PACU radiographs, in the absence of a specific indication, may result in poor-quality images. [22] (10.1007/s11999-012-2551-9)
[L3] The authors recommend the combined use of CT and MRI for preoperative planning. [23] (10.1016/j.jse.2018.02.034)
[L4] Optimum patient care might require the development of new imaging modalities rather than new classification systems. [24] (10.2106/00004623-199609000-00012)
[L2] Plain radiographs rarely alter the diagnosis or affect management in the setting of atraumatic shoulder pain, particularly in patients younger than 50 years. [25] (10.5435/jaaos-d-16-00884)
[L3] This should be taken into consideration when using a CT scan to assess a patient with symptomatic SCJ pathology. [26] (10.1016/j.jse.2016.04.029)
[L1] [27] (10.1016/j.arthro.2020.08.005)
[L3] Surgical decision-making should rely on focused history and clinical examination rather than MRI scans. [28] (10.1177/1758573217724080)
[L2] We suggest adding the SHART test to conventional preoperative imaging techniques. [29] (10.1007/s00167-011-1438-8)
[L5] Advanced imaging techniques, including CT and three-dimensional reconstructions, augment the information obtained from plain radiographs to guide treatment decisions. [30] (10.5435/jaaos-d-15-00666)
[L3] AHDs measured on radiograph and MRI should not be used interchangeably in early Hamada grades to assess outcomes of superior capsule reconstruction and similar procedures. [31] (10.1016/j.jse.2019.10.020)
[L4] The lack of clinically meaningful change from routine radiography does not justify the per-patient expense, as almost all postoperative radiographs were read as normal and did not alter postoperative management. [33] (10.1016/j.jse.2016.11.035)
[L4] Although the modified Walch classification represents an improvement over the original classification, automated computer-based analysis of CT scans may be needed to further improve the value of this classification. [41] (10.1016/j.jse.2018.09.021)
[L3] The clinical utility of the lateral scapular view may need to be reassessed in this setting. [45] (10.1016/j.xrrt.2022.01.001)
[L3] Radiographs provide better reproducibility and accuracy for CSA measurement compared to MRI. [46] (10.1007/s00167-015-3587-7)
[L2] The results indicate that MRI is the preferred strategy based on cost-effectiveness criteria, although the decision between MRI and ultrasound for an imaging center is likely to be dependent on additional factors, such as available resources and workflow. [47] (10.1016/j.jse.2017.07.012)
[L5] Magnetic resonance is an excellent modality for imaging pathologic processes in the pediatric spine, allowing high-resolution views of osseous and soft-tissue structures. [48] (10.5435/00124635-200307000-00004)
[L2] Clinical scores using a single image slice do not represent 3-dimensional muscle measurements. [49] (10.1016/j.arthro.2015.06.035)
[L3] The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease. [50] (10.1016/j.jse.2011.09.028)
[L3] Most of these findings are pulmonary in nature, and overall, half of the patients with incidental findings were recommended for further follow-up. [51] (10.5397/cise.2023.00836)
[L3] The inter-rater agreement between x-ray images and consensus MRI is fair-to-moderate, which is lower than previously reported reliability using CT scans. [52] (10.1016/j.jse.2017.03.014)
[L4] However, synthesis of detailed findings from multiple studies could define patterns of pathological MRI findings allowing for associations of imaging findings to risk factors including specific activities. [53] (10.1155/2014/769649)
[L4] Kinematic changes in symptomatic RCTs might be associated with development of symptoms. [54] (10.1016/j.jse.2015.06.003)
[L5] Multiple radiographic views are needed to evaluate displacement of the greater tuberosity appropriately. [56] (10.2106/jbjs.c.01576)
[L4] The 'long axis' measurement has clear potential benefits over traditional classification systems which should be explored in future clinical research. [57] (10.1186/s12891-018-2236-y)
[L3] The correlation between the semi quantitative MRI based Goutallier Classification system and MR spectroscopic fat measurement is weak. [58] (10.1186/s12891-016-1216-3)
[L3] This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization. [59] (10.2106/jbjs.15.01099)
[L2] However, even using a three-dimensional evaluation of the deformity, the Boileau classification had a poor interobserver reliability. [60] (10.1177/17585732221150785)
[L4] The sensitivity, specificity, and reliability of magnetic resonance arthrogram for detecting these lesions are substantial, while the interobserver reliability of Kim's classification is fair. [61] (10.1016/j.arthro.2014.02.038)
[L3] CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery, with prevalence increasing more than two-fold from 6 months to 5 years post-surgery. [62] (10.1186/s12891-017-1420-9)
[L4] [63] (10.1186/s12891-020-03252-y)
[L4] Glenoid morphology can be normalized during the intermediate to long-term postoperative period, even in shoulders with a smaller fragment. [64] (10.2106/jbjs.n.01033)
[L2] These findings raise concern for glenoids at risk of loosening, but further follow-up is needed to determine the long-term clinical impact of these findings. [65] (10.1016/j.jse.2017.12.012)
[L2] Even with a longitudinal protocol, most radiographs are of insufficient quality for CSA measurement. [66] (10.1007/s11999-017-5249-1)
[Abstract] The natural history of the first time shoulder dislocations is bound up with arthropathy. [67] (10.1016/j.jse.2007.02.100)
[L4] Muscle atrophy and fatty infiltration are irreversible phenomena that continue even after successful repair; however, they do not have a significant influence on the functional outcome at short-term follow-up after cuff repair. [68] (10.1016/j.jse.2020.03.040)
[L4] Nearly 90 per cent of fractures of the glenoid cavity can be treated non-operatively with a good or excellent result. [70] (10.2106/00004623-199274020-00019)
[L3] However, the clinical outcomes of RTSA at a minimum follow-up of 1 year were similar in the high- and lower-risk groups. [72] (10.1016/j.jse.2021.10.024)
[L3] Short term results shows that pre-arthroplasty CT scanning of the shoulder does not influence revision rates. [75] (10.1016/j.jse.2023.02.087)
[L4] Enhancement patterns in intratendinous tissue increased at 1 or 2 months postoperatively and decreased at 3 months. [76] (10.1177/0363546511420077)
[L1] [94] (10.1007/s00167-022-07154-5)
[L2] It had better ability to rule in a diagnosis but slightly worse ability to rule out a diagnosis compared with MRI. [96] (10.1016/j.arthro.2021.03.006)
[L4] The CT-based staging system showed almost perfect interobserver and intraobserver agreement and high correlation with visual analogue scale scores compared to plain radiograph-based classifications. [98] (10.1016/j.jse.2021.03.083)
[L4] Classification using MRa resulted in significant disagreement between and within raters. [104] (10.1016/j.jseint.2024.06.009)
[L4] Surgery and histologic examination should be performed only when there are significant symptoms or when MRI findings are controversial. [106] (10.1016/j.jse.2012.02.005)
[L4] The SLAP diagnosis appears to be a clinical impression; however, the criteria described within the literature vary among the evaluation areas and differ from the results of the survey. [107] (10.1016/j.arthro.2015.06.033)
[L2] [109] (10.1007/s00167-014-3109-z)
[L5] The West Point view is a good screening tool, while CT should be added when the view is equivocal or difficult to obtain. [113] (10.1177/03635465030310010301)
[L4] We emphasize that these findings represent roentgenographic abnormalities only, and any clinical decisions concerning the treatment of pain in the thoracic spine usually require additional studies. [119] (10.2106/00004623-199511000-00001)
[L4] It has good intra- and inter-observer reliability, as well as good correlation between the results of classification by plain radiographs and CT images. [120] (10.1302/0301-620x.98b3.36664)
[L4] These findings contribute to achieving an accurate clinical diagnosis. [121] (10.1016/j.jseint.2024.05.013)
[Case_report] This anatomic variation can be detected preoperatively on high-quality MRI, but its clinical impact needs further elucidation. [122] (10.1016/j.jse.2010.01.009)
[L2] Further clinical trials using more accurate diagnostic MRI tools are required to better define anatomical differences between partial-thickness tears and healthy patients. [124] (10.1186/s12891-023-06756-5)
[L2] This is clinically relevant in diagnostically challenging cases, for instance in the first phase of frozen shoulder, which can be difficult to distinguish from subacromial impingement. [127] (10.1007/s00167-020-05937-2)
[L3] Despite rigorous training methodology based on CT imaging with multi-rater consensus to serve as the reference standard, artificial intelligence-driven classification is insufficient for clinical implementation. [128] (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
[L4] The authors suggest that with the increasing availability of 4D CT, this imaging modality may be of use in helping diagnose unusual causes of shoulder pain in patients who have otherwise normal imaging. [129] (10.1177/1758573214533781)
[L5] The 3D CT imaging is effective and reproducible in determining lesion size. [130] (10.1016/j.jse.2017.09.007)
[L5] Further clinical studies are required to establish this modality. [136] (10.1016/j.jse.2013.12.007)
[L4] The efficacy of determination of rotator cuff tears will also increase after the introduction of shoulder ultrasonography. [139] (10.1186/s13018-017-0565-4)
[L4] There are 16 categories within the FEDS classification that are clinically significant. [140] (10.1016/j.jse.2018.08.014)
[L4] The proposed classification system for LSSS failure demonstrated satisfactory agreement and accuracy among experienced surgeons, with complete disruptions (S2) being relatively common and associated with increased risk of neurovascular injury. [142] (10.1016/j.injury.2013.03.001)
[L5] The use of US guidance significantly improves the success rate in ACJ injection, and we recommend it for therapeutic ACJ injections in routine clinical practice. [143] (10.1016/j.jse.2011.11.036)
[L3] In this study, intraobserver agreement using the Walch classification based on axillary radiographs was substantial and compared favorably with agreement based on CT scans. [147] (10.1016/j.jse.2017.02.015)
[L2] In contrast, on nonstandard AP films, the diagnostic efficacy of the AI was better than that of the CSA. [148] (10.1016/j.arthro.2019.03.050)
[L3] With regard to the intra- and inter-rater reliabilities, all measurement techniques analysed, with the exception of the Franceschi and Calandra classifications, provided good to very good reliabilities with both CT and MRI. [149] (10.1007/s00167-021-06695-5)
[L4] Equalization of grade 0 and grade 1 laxity improves both intra- and interobserver reproducibility, but caution is recommended when determining diagnosis and treatment based on this examination. [150] (10.1177/03635465990270040901)
[L4] However, there is low utility for obtaining an immediate postoperative radiograph in the PACU when indications include osteoarthritis or rotator cuff tear arthropathy. [151] (10.1016/j.jse.2021.02.018)
[L2] Computed tomography is a useful imaging modality for evaluating osseous Hill-Sachs lesions. [153] (10.1177/0363546514549543)
[L4] The established classifications by Euler and Ideberg are not capable of providing a similar reliability. [154] (10.1186/s12891-018-2016-8)
[L1] This systematic review has identified significant heterogeneity in both the imaging modality and method used to measure glenoid bone loss. [156] (10.1302/0301-620x.104b1.bjj-2021-0751.r1)
[L4] Therefore, routine use of shoulder MRI scans in patients with FS but without suspicion of an additional pathology may not be indicated. [174] (10.1016/j.jseint.2022.05.009)
[L4] A large number of missing or inadequate radiographs led to repeat radiation exposure in this cohort. [185] (10.5435/jaaos-d-17-00142)
[L4] A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. [190] (10.1007/s00167-014-3102-6)
[L3] Orthopaedic surgeons should develop a systematic approach to interpreting the entire image and create a discrete plan with radiologists on managing incidental findings. [191] (10.5435/jaaos-d-19-00236)
[L4] Undertaking an augmented capsular plication on patients with symptomatic atraumatic SCJ instability confirmed by MRI imaging that have failed appropriate nonoperative treatment provides a satisfactory result with regard to clinical outcomes and joint stability. [194] (10.1016/j.jse.2025.06.003)
[L4] An NO-MRI scan and an NO-MRI arthrogram provide a good assessment of the structural soft-tissue injuries associated with acute and chronic SCJ injuries and provide a reliable guide to further clinical management. [198] (10.1016/j.jseint.2025.09.001)
[L4] LTO healing is best assessed on radiographs; if nondisplaced or displaced nonunions are suspected, computed tomography can be a helpful additional examination. [199] (10.1016/j.jse.2013.12.010)
[L3] A conventional antero-posterior radiograph cannot provide any predictive information on the clinical status of the patient. [200] (10.1186/1749-799x-6-1)
[L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. [204] (10.1016/j.jse.2010.05.022)
[L3] [205] (10.1016/j.jse.2016.09.024)
[L5] [207] (10.1302/2058-5241.5.190057)
[L4] [208] (10.1007/s00167-023-07612-8)
[L3] [209] (10.1016/j.jse.2006.11.011)
[L3] [212] (10.1016/j.jse.2008.12.014)
[L3] [213] (10.2106/jbjs.m.00199)
[L4] Early after surgery (1-3 months), worse clinical outcomes correlated with higher signal intensity on the proximal cuff tendon. [214] (10.1177/0363546519899357)
[L4] Reduced perfusion was associated with limited range of motion and below-average outcome. [217] (10.1016/j.jse.2016.04.012)
[L3] The immediate postoperative time point should be considered as the baseline to monitor the true changes of fatty infiltration after repair. [229] (10.1007/s00167-017-4604-9)
[L4] The age of the patient at the time of the initial dislocation is the most consistent and significant factor influencing prognosis, with recurrence rates of 83% in patients under twenty years and 12% in patients over fifty years. [230] (10.2106/00004623-195638050-00001)
[L4] Glenoid ossification and fusion progress in a predictable and chronological manner. [231] (10.1016/j.arthro.2019.08.011)
[L3] On-track and off-track assessments using 2D CT and 2D MRI demonstrated inconsistent results; therefore, the additional information provided by 2D CT may be of significant value for clinical decision-making. [232] (10.1016/j.jseint.2025.02.014)
[L4] These findings may support the potential role of SPECT/CT in early detection of stress-related changes in symptomatic patients. [233] (10.1016/j.jse.2025.09.011)

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