Clinical Assessment

Systematic shoulder evaluation integrating history, physical examination, and PROMs to differentiate tissue pathology from functional impairment.

Overview

Clinical assessment in orthopaedics requires precise tool selection and rigorous evaluation protocols to guide treatment. Clinicians and researchers must define specific questions to select assessment tools with content validity and reliability, considering normalization for specific populations and incorporating patient satisfaction [52]. For shoulder instability, the Dutch version of the Oxford Shoulder Score is feasible and understandable for clinical trial application [8], though the Constant-Murley score requires redesign with better standardization before validating other assessments or comparing outcomes between testers [48]. In multidirectional shoulder instability, a clinical protocol is currently being tested for efficacy in a randomized controlled trial [5].

Evaluation of hand function in hemiplegic cerebral palsy should focus on specific postsurgical therapy plans alongside surgical and therapy decision-making [7]. For proximal humerus fractures, thorough patient evaluation and consideration of expectations are essential, as functional results may be difficult to achieve due to bone loss, osteopenia, and soft tissue compromise [60]. A prospective study with defined inclusion criteria and a reliable classification system is needed to determine the best treatment for valgus impacted fractures [14]. Understanding current evidence and appropriate indications for emerging technologies in orthopaedic trauma is critical for their utilization [16].

In joint infection diagnosis, each test for joint aspiration has advantages and disadvantages and should be used with the overall clinical picture to guide further evaluation [11]. For full-thickness rotator cuff tears, improved clinical outcomes may be achieved when AAOS Appropriate Use Criteria recommendations are followed [62]. Conversely, improved outcomes may also occur when these recommendations are not followed, necessitating further investigation into populations with discordance between recommendations and administered treatment [62]. The AAOS Appropriate Use Criteria serves as a useful tool for preoperative planning and intraoperative decision-making, affirming treatment choices based on clinical trials and expert consensus [69]. Finally, the glenoid track concept assessment is encouraged as a routine part of preoperative evaluation for all patients considered for arthroscopic anterior stabilization [75].

Anatomy & Pathophysiology

The shoulder possesses the most motion of any joint in the human body [36]. Shoulder function is highly dependent on unique anatomy and biomechanical properties [36]. Physical examination and radiologic workup of the shoulder require a thorough understanding of complex musculoskeletal interactions [36].

Glenoid inclination and acromion index affect humeral head translation and glenoid articular cartilage strain [23]. Observed glenohumeral translations and rotations characterize healthy shoulder motions during scapular plane abduction [33]. Clavicle shortening of >10% greatly affects scapular kinematics in vivo [64]. Trunk postures affect scapular kinematics and muscle activities during shoulder external rotation [80]. Altering scapula position may affect shoulder strength in asymptomatic individuals [82]. Scapular exercises resulted in superior migration of the humeral head and alterations in shoulder kinematics on radiographic analysis in healthy subjects under clinical fatigue conditions [66].

A clinical evaluation of altered shoulder kinematics remains complicated [24]. Relating anatomic properties, kinematics, and muscle dynamics to subacromial volume helps identify predominant pathophysiological mechanisms in subacromial impingement syndrome (SIS) patients [58]. A valid and repeatable measurement of pectoralis minor extensibility is needed to improve studies evaluating its effect on shoulder movement and biomechanics [63].

Asymptomatic rotator cuff pathology is associated with a plausible mechanical progression of kinematic and strength changes [55]. Biomechanical changes of passive glenohumeral joint motion occur with as little as 5% glenohumeral internal rotation deficit (GIRD) due to posterior capsular contracture [57]. Updates on thrower's shoulder anatomy, mechanics, pathomechanics, and treatment are essential for clinicians and researchers [29]. Advances in understanding shoulder biomechanics, pathophysiology, and diagnostic techniques are necessary for preventing and treating common shoulder injuries in throwing athletes [51]. Improvements in surgical methods like arthroscopy are necessary for treating common shoulder injuries in throwing athletes [51]. The combination of 80.6° of shoulder abduction and 10.7° of horizontal shoulder adduction minimized shear forces on the shoulder in adolescent baseball pitchers [79]. Future studies on shoulder overuse injuries in wheelchair athletes should be directed towards biomechanical modeling to develop knowledge of load and its effects [85].

Technology such as the Microsoft Kinect sensor plus Medical Interactive Recovery Assistant (MIRA) software may allow precise shoulder range of motion (ROM) measurement outside the clinic setting [83]. Shoulder strength and patient-reported outcomes improved significantly over 24 months following rotator cuff repair [91]. The glenohumeral joint contact center gradually shifted superiorly over 24 months following rotator cuff repair, potentially reflecting altered loading patterns or loss of dynamic stability despite functional improvements [91].

Classification

General Principles: A good classification system serves as a common language to define the severity of a condition, guide treatment, and facilitate clinical research [50]. The true value of a classification system can only be determined when it is used [39]. Unreliable classification may account for inconsistent treatment outcomes, suggesting a better classification system is needed for acromioclavicular joint dislocations [49]. A prospective study with clearly defined inclusion criteria and a reliable classification system is needed to determine the best treatment for valgus impacted fractures of the proximal humerus [14].

OF Spine: The OF spine classification of osteoporotic thoracolumbar vertebral body fractures by MRI and conventional radiographs only leads to high inter-observer agreement rates [15]. The addition of CT adds limited value compared to conventional radiographs and MRI only for the OF classification and the OF score [15].

FEDS: There are 16 categories within the FEDS classification that are clinically significant [35].

Rockwood: The Rockwood classification is commonly used in Japan to assess severity of acromioclavicular joint separations [56]. There is some disagreement regarding the assessment for the diagnosis of type IV acromioclavicular joint dislocations using the Rockwood classification [56].

Novel MRI-based Shoulder Septic Arthritis: Patients with a classification of Grade III or higher in a novel MRI-based classification system for septic arthritis of the shoulder had higher reinfection rates than those with a classification of Grade I or II [71]. Patients with a classification of Grade III or higher in a novel MRI-based classification system for septic arthritis of the shoulder required more aggressive treatment to eradicate the infection [71].

Intraoperative Glenohumeral Synovitis: A novel intraoperative scoring system defined for the classification of glenohumeral synovitis seen during arthroscopy has good reliability among a large range of surgeons [86].

Generalized Joint Laxity: There is a clear need for robust research into a new scoring system with standardized methods and validated measures to define generalized joint laxity [87].

Low Back Pain Screening: The correlation between score on screening tools for risk classification of patients referred to secondary care for low back pain was good [89]. The classification agreement between screening instruments for risk classification of patients referred to secondary care for low back pain was low [89].

Modified Mallet: The modified Mallet classification demonstrated strong to excellent agreement and interrater reliability across face-to-face, live tele-assessment, and video-based conditions for brachial plexus birth injuries [102]. The modified Mallet classification is appropriate for remote medical follow-up of brachial plexus birth injuries [102].

Arthroscopic Hip Pathology: Arthroscopic classification of intra-articular hip pathology demonstrates at best moderate interrater reliability [105]. Further development and refinement of multifactorial grading systems for describing labral injury are indicated [105].

Other Considerations:

Clinical Presentation

Clinical assessment of the pivot shift presents subjective variability and dependence on the tester's experience [1]. Screening for medical problems involves assessing patient history, risk factors, and red flag signs to recognize potential underlying systemic pathology [4]. A thorough understanding of shoulder physical examination and specific diagnostic tests, emphasizing history-taking and examination, is important to ensure diagnostic accuracy and optimize patient outcomes [6]. Careful clinical assessment can differentiate between causes of shoulder pain and guide best management [30].

A comprehensive assessment measuring both diagnostic capability and disease impact most accurately reflects the patient with femoroacetabular impingement syndrome (FAIS) [9]. The complexity of presentation, diagnosis, and management of facioscapulohumeral muscular dystrophy (FSHD) emphasizes the necessity of a collaborative multidisciplinary team approach to maximize patient satisfaction and outcomes [46]. Identification of whether a patient presents with pain or stiffness as their predominant symptom further guides treatment selection [26].

Knowledge of the characteristic clinical presentation and physical examination findings of neurologic, musculoskeletal, vascular, and other etiologies can help distinguish the source of upper extremity pain quickly to facilitate appropriate diagnostic measures and treatment [27]. A high index of suspicion is essential for early recognition and timely referral, especially in patients with overlapping symptoms and vascular risk factors [28]. Muscle imaging can help for recognition of atypical clinical presentations [2].

Clinical testing plays an important role in the initial identification of a lesion and determining subsequent changes from baseline [25]. Clinical evaluation is the first step in detecting feigned hand weakness, but it is not very specific; therefore, every suspected positive clinical result must be followed up with a more advanced test that has better specificity [32]. A systematic process of performing a comprehensive physical examination of the hand including vascular, sensory, and motor assessments is essential for appropriate treatment and providing the patient the opportunity for the best outcome [43].

A thorough physical examination of the shoulder and cervical spine is critical in establishing a focused differential diagnosis of the pathology in and around the shoulder joint [44]. No single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears [40]. Clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option for posterosuperior rotator cuff tears [40]. By using the Resisted Supination External Rotation Test in the context of a thorough clinical history and physical examination, lesions of the superior labrum can be more reliably diagnosed [41].

The relative complexity of the final diagnostic tool for hip microinstability is illustrative of the difficulty clinicians face when making this diagnosis [31]. Clinical diagnoses agree with reference standards diagnoses more often than chance in patients with lumbopelvic pain [42]. Clinical assessment accurately determined the existence of intra-articular abnormality but was poor at defining its nature [38]. Appropriate clinical workup leads to earlier diagnosis and management of back pain and avoids unnecessary cost [34].

Investigations

Plain radiography: Radiographs provide better reproducibility and accuracy for critical shoulder angle (CSA) measurement compared to MRI [61]. In the setting of atraumatic shoulder pain, plain radiographs rarely alter the diagnosis or affect management, particularly in patients younger than 50 years [107]. For malunion of a head-splitting proximal humeral fracture, adequate radiologic investigation is required, achieved either by obtaining three plain films at 90° to each other or by using three-dimensional CT reconstruction [98]. Roentgenographic evidence serves as an adjunct to define the degree and extent of involvement in osseous coccidioidomycosis [103].

MRI: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [3]. Advanced imaging, such as MRI, can be used as necessary but should not replace the history and physical examination [37]. Imaging studies should be used to confirm the clinical impression derived from history and physical examination [77]. Anatomic abnormalities should be carefully correlated to symptoms when using imaging studies [77] because there is a high prevalence of pelvic and hip MRI findings in asymptomatic collegiate and professional hockey players [97]. MRI findings in asymptomatic hockey players must be cautiously interpreted in association with clinical presentation [97]. Clinicians should be aware of common anatomic findings on MRI when considering diagnostic and treatment planning for unilateral shoulder pain [53]. Orthopaedic surgeons are comfortable reviewing shoulder MRI scans without necessarily reading the MRI report prior to a surgical decision [110], but MRI scans should not be used without assessment of patient history or physical examination [110]. In acromioclavicular joint osteoarthritis, patients with edema on MRI were more likely to present pain than patients without edema, and subchondral bone edema on histologic examination was more frequent in patients with pain [109]. Preoperative MRI could be used to exclude subtle instability in patients with lateral epicondylitis, especially when patients have a history of multiple corticosteroid injections (≥3) or severe pain [100]. Appropriate preoperative imaging is essential for detection and quantification of osseous abnormalities in recurrent shoulder instability [81].

CT: Computed tomography is the imaging modality of choice for evaluation of sternoclavicular joint injuries [76]. The addition of CT adds limited value compared to conventional radiographs and MRI only in terms of the OF classification and the OF score for osteoporotic thoracolumbar vertebral body fractures [15]. 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 [88].

Other Considerations: Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [3]. A comprehensive assessment measuring both diagnostic capability and disease impact most accurately reflects the patient with femoroacetabular impingement syndrome (FAIS) [9]. MRI should be obtained at the discretion of the treating clinician based on specific clinical criteria rather than being mandated by insurers [10]. Treatment decisions for recurrent shoulder instability should be guided by the extent of osseous deficiency and patient-specific factors [81]. Advanced neurodiagnostic imaging should be refrained from until appropriate nonoperative management has failed [77]. Tests for lumbar instability are simple to perform, reliable, and safe [13]. Tests for lumbar instability are recommended for use by physical therapists to assess suspected patients without immediate X-ray assessment [13].

Treatment

Non-Operative Management

Rehabilitation programs are being evaluated for efficacy in multidirectional shoulder instability [5]. For postsurgical therapy, evaluation protocols must focus on specific therapy plans alongside surgical decision-making [7]. In clinical settings where recurrent instability risk is low after nonoperative care, or when patients have an aversion to surgery, nonoperative treatment is the preferred strategy for primary traumatic anterior glenohumeral dislocation [99]. Bracing is not effective as an adjunct to standard nonoperative management for scholastic athletes with unstable shoulders aiming to return for a subsequent season [101].

Nonoperative management is the first-line treatment for most young, active patients with SLAP tears lacking trauma history, mechanical symptoms, or overhead activity demands [84]. For quadrilateral space syndrome, nonoperative treatment for at least 6 months is recommended before considering operative intervention [92]. Nonoperative treatment is also the preferred option in early-stage atraumatic osteonecrosis of the humeral head, potentially preventing disease progression, though surgery is required in some cases [106]. Conservative management is fundamental for scapular winging due to rhomboid muscle paralysis, requiring rehabilitation center care with a multidisciplinary team [73]. Nonoperative treatment is helpful for most painful acromioclavicular joint conditions, although patients with osteolysis may need to modify activities [95]. Nonoperative management with corticosteroid injection offers potential long-term benefits for radial tunnel syndrome [96].

For adhesive capsulitis, conservative management is the standard of care, followed by surgical intervention if adequate function is not attained [93]. Nonoperative treatment is efficacious for chronic, massive, irreparable rotator cuff tears, despite low-quality evidence [94]. Physical therapy for osteochondritis dissecans incorporates a full spectrum of conservative and postoperative care [90]. Patients with snapping scapula syndrome experienced clinically significant improvements in functional scores, pain, and quality of life after arthroscopic treatment [65]. Traditional Chinese medicine comprehensive therapy for exercise-related musculoskeletal injuries shows potential benefits via musculoskeletal ultrasound observation, though randomized controlled trials are needed for definitive efficacy assessment [68].

Clinical outcomes for Lima ProMade custom 3D-printed glenoid components in primary and revision reverse total shoulder arthroplasty with severe glenoid bone loss show modest but statistically significant improvements, though patients often do not achieve a normal shoulder [67]. PROMIS PF scores were responsive to functional improvements observed clinically in total shoulder arthroplasty patients [74]. Patients experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after a single, image-guided corticosteroid injection for glenohumeral arthritis [78]. The evidence supports the efficacy and safety of a landmark-based suprascapular nerve block for clinical use [70]. Pain self-efficacy did not moderate the relationship between treatment and outcome for shoulder pain treated with manual therapy, acupuncture, and electrotherapy [47].

Routine preoperative magnetic resonance imaging for hip arthroscopy should be obtained at the discretion of the treating clinician based on specific clinical criteria rather than being mandated by insurers [10]. Each test for joint aspiration in diagnosing chronic periprosthetic joint infection has advantages and disadvantages and should be used with the overall clinical picture to guide further evaluation [11]. Tests for lumbar instability are simple, reliable, and safe, recommended for physical therapists to assess suspected patients without immediate X-ray assessment [13]. Clinicians must be informed about common drug interactions and contraindications in orthopaedic practice to ensure safe care [54]. In evaluating functional status and treatment effectiveness, the effects of comorbidity must be controlled [45]. Clinical trials are needed to evaluate the effect of immobilization duration in external rotation on recurrence rates for acute anterior shoulder dislocations [59].

Operative Management

Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [16].

Complications

Instability: Clinical assessment of the pivot shift presents subjective variability and dependence on the tester's experience [1]. Maintenance of reduction in arthroscopic treatment of posterior glenohumeral joint subluxation resulting from brachial plexus birth palsy requires continued follow-up over time [115]. The sole assessment of recurrent dislocation to define natural history and treatment rationale is inadequate, and conclusions regarding treatment recommendations cannot be made from a study that did not compare treatment methods [116].

Nerve palsy: 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 by screw violation [119].

Other Considerations: Screening for medical problems involves assessing patient history, risk factors, and red flag signs to recognize potential underlying systemic pathology [4]. Short-term repeat assessment of pain provided a more accurate prognosis than baseline information for predicting long-term disability improvement in patients with low-back or shoulder pain [12]. A 3-month follow-up is too early for outcome evaluation in shoulder conditions [18]. Longer-term follow-up is required to confirm promising short-term results of hybrid cage glenoid compared to cemented polyethylene glenoid in anatomic total shoulder arthroplasty [19]. The provided text contains statistical coefficients and model performance metrics for predicting long-term outcomes following physiotherapy in patients with subacromial pain syndrome but does not include the authors' explicit conclusion statement [20]. Short and long-term outcomes of traumatic hip dislocation are largely driven by the amount of time from injury to reduction and associated injuries [111]. SIRVA is a rare yet increasingly recognized complication of immunization that is primarily a clinical diagnosis [118]. Larger high-quality studies are needed to determine the natural history and optimal treatment for SIRVA [118].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return. However, short-term follow-up assessments at three months are considered too early for outcome evaluation in shoulder conditions [18]. For low-back or shoulder pain, short-term repeat assessment of pain provides a more accurate prognosis than baseline information [12].

Full activity (months): The evidence does not specify month ranges for full activity or manual work return. Longer-term follow-up is required to confirm promising short-term results of a hybrid cage glenoid compared to a cemented polyethylene glenoid in anatomic total shoulder arthroplasty [19]. For patients with subacromial pain syndrome, statistical coefficients and model performance metrics exist for predicting long-term outcomes following physiotherapy, though explicit conclusion statements are absent [20].

Complete recovery / outcome plateau (months): Complete recovery timelines are not explicitly defined in the provided evidence. The course of complaints for arm, neck, and/or shoulder demonstrates mild complaints at baseline and an overall stable course during one-year follow-up [123]. Responsiveness of clinical tests for neck pain was generally low when using change in Neck Disability Index (NDI) score as the anchor from baseline to the 4-month follow-up [113].

Rehabilitation protocol: The goal of assessing the longer-term functional effect of femoral nerve block for anterior cruciate ligament reconstruction was accomplished [108]. Early and aggressive treatment of rheumatoid arthritis is now standard, with complete resolution of signs and symptoms achievable in perhaps 10% of patients [124].

Functional milestones: The Oxford shoulder score may be considered an alternative for longer-term follow-up as it is easier to administer and correlates well with the Constant score in patients with conservatively treated proximal humeral fractures [112]. Patient self-assessment of shoulder range of motion could potentially replace routine clinic visits for short- and long-term follow-up [17]. Physical outcome measures are shifting toward patient-reported outcomes, as range of motion and strength are not as reliable as previously thought [114].

Other Considerations: Actual clinical assessment of the pivot shift presents subjective variability and dependence on the tester's experience [1]. Muscle imaging can help for recognition of atypical clinical presentations, for understanding the natural history of the disease, and for determining patients suited for treatment [2]. Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [3]. Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [3]. Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts [12]. Recent literature has enhanced understanding of pathoanatomy and natural history of brachial plexus birth palsy, leading to improved care [21]. The study provides insight into the natural history of rotator cuff disease by comparing morphological characteristics and prevalences in asymptomatic and symptomatic shoulders [22]. Those with a worse prognosis for shoulder pain may be monitored more frequently and the treatment plan modified if complaints persist [125]. Pain intensity, neck pain, and longer duration of complaints predict poorer outcome in patients with shoulder pain [125]. At a population level, back beliefs in patients with low back pain were generally positive and relatively constant over time, but misconceptions about a poor prognosis were common [126]. Significant deficits in the literature on adhesive capsulitis include a paucity of randomized controlled trials, failure to report response to treatment in a stage-based fashion, and an incomplete understanding of the disease's natural course [127].

Key Evidence

• [L2] Actual clinical assessment presents subjective variability and dependence on the tester's experience. (10.1007/s00167-016-4130-1)
• [L5] Muscle imaging can help for recognition of atypical clinical presentations, for understanding the natural history of the disease, and for determining patients suited for treatment. (10.1186/1471-2474-14-s2-o2)
• [L5] Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes. (10.1177/0363546518817315)
• [L5] Screening involves assessing patient history, risk factors, and red flag signs to recognize potential underlying systemic pathology. (10.1016/j.jht.2009.09.005)
• [L5] This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial. (10.1177/1758573216652086)
• [L5] This comprehensive review highlights the importance of a thorough understanding of shoulder physical examination and specific diagnostic tests, emphasizing history-taking and examination to ensure diagnostic accuracy and optimize patient outcomes for surgeons. (10.5435/jaaos-d-25-00024)
• [L4] The evaluation protocol should focus on specific postsurgical therapy plans in addition to surgical/therapy decision making. (10.1197/j.jht.2008.01.001)
• [L4] Application and evaluation in clinical trial proved feasible and understandable. (10.1016/j.jse.2010.01.017)
• [L5] A comprehensive assessment measuring both diagnostic capability and disease impact most accurately reflects the patient with FAIS. (10.1007/s00167-017-4484-z)
• [L5] The author concludes that MRI should be obtained at the discretion of the treating clinician based on specific clinical criteria rather than being mandated by insurers. (10.1016/j.arthro.2022.04.009)
• [L5] Each available test has advantages and disadvantages and should be used in conjunction with the overall clinical picture to guide further evaluation and treatment. (10.1186/s42836-023-00199-y)
• [L2] Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. (10.1186/s12891-017-1502-8)
• [L2] These tests are simple to perform, reliable, and safe, and are recommended for use by physical therapists to assess suspected patients without immediate X-ray assessment. (10.1186/s12891-021-04854-w)
• [L4] A prospective study with clearly defined inclusion criteria and a reliable classification system is needed to determine the best treatment. (10.1016/j.jhsa.2011.05.003)
• [L3] In terms of the OF classification and the OF score, the addition of CT adds limited value compared to conventional radiographs and MRI only. (10.1186/s12891-022-06056-4)
• [L3] This method for short- and long-term follow-up could potentially replace routine clinic visits. (10.1016/j.jse.2016.02.010)
• [L2] Our results suggest that 3 months follow-up is too early for outcome evaluation. (10.1186/s12891-021-04483-3)
• [L3] The authors note that longer-term follow-up is required to confirm these promising short-term results. (10.1016/j.jse.2019.04.049)
• [L3] The provided text contains statistical coefficients and model performance metrics for predicting long-term outcomes but does not include the authors' explicit conclusion statement. (10.1186/s12891-024-07686-6)
• [L5] Recent literature has enhanced understanding of pathoanatomy and natural history, leading to improved care. (10.1016/j.jhsa.2009.11.026)
• [L3] The study provides insight into the natural history of rotator cuff disease by comparing morphological characteristics and prevalences in asymptomatic and symptomatic shoulders. (10.2106/jbjs.e.00835)
• [L5] The biomechanical shoulder model is consistent with clinical observations. (10.1016/j.jse.2016.05.031)
• [L2] A clinical evaluation of altered shoulder kinematics is still complicated. (10.3390/ijerph17082974)
• [L5] Clinical testing plays an important role in the initial identification of a lesion and determining subsequent changes from baseline; however, empirical research studies are indicated to further quantify the relationship between testing outcomes and lesion severity. (10.1016/j.jht.2008.10.010)
• [L5] Identification of whether a patient presents with pain or stiffness as their predominant symptom further guides treatment selection. (10.1177/1758573215586152)
• [L5] Knowledge of the characteristic clinical presentation and physical examination findings of neurologic, musculoskeletal, vascular, and other etiologies can help distinguish the source of upper extremity pain quickly to facilitate appropriate diagnostic measures and treatment. (10.5435/jaaos-d-11-00086)
• [Case_report] A high index of suspicion is essential for early recognition and timely referral, especially in patients with overlapping symptoms and vascular risk factors. (10.1186/s12891-025-09135-4)
• [L5] Updates on the thrower's shoulder, including anatomy, mechanics, pathomechanics, and treatment, are essential for clinicians and researchers treating or investigating the shoulder. (10.1016/j.arthro.2022.02.024)
• [L5] This review article describes how careful clinical assessment can differentiate between causes of shoulder pain and guide best management. (10.1016/j.jse.2014.12.003)
• [L5] The relative complexity of the final diagnostic tool is illustrative of the difficulty clinicians face when making this diagnosis. (10.1007/s00167-022-06933-4)
• [L5] Clinical evaluation is the first step in detecting feigned hand weakness, but it is not very specific; therefore, every suspected positive clinical result must be followed up with a more advanced test that has better specificity. (10.1016/j.jhsa.2007.09.010)
• [L4] The observed glenohumeral translations and rotations characterize healthy shoulder motions but still have technical shortcomings. (10.2519/jospt.2012.3584)
• [L5] Appropriate clinical workup leads to earlier diagnosis and management of back pain and avoids unnecessary cost. (10.5435/jaaos-d-14-00130)
• [L4] There are 16 categories within the FEDS classification that are clinically significant. (10.1016/j.jse.2018.08.014)
• [L5] Advanced imaging, such as MRI, can then be used as necessary but should not replace the history and physical examination. (10.5435/jaaos-d-15-00464)
• [L4] Clinical assessment accurately determined the existence of intra-articular abnormality but was poor at defining its nature. (10.1177/0363546504266480)
• [L5] The true value of the classification system can only be determined when it is used, and time will tell whether this classification system will be used. (10.1016/j.jse.2010.07.008)
• [L2] As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option. (10.1007/s00167-020-06136-9)
• [L2] By using this test in the context of a thorough clinical history and physical examination, lesions of the superior labrum can be more reliably diagnosed. (10.1177/0363546504273050)
• [L3] Clinical diagnoses agree with reference standards diagnoses more often than chance. (10.1186/1471-2474-6-28)
• [L5] This current concepts review presents a systematic process of performing a comprehensive physical examination of the hand including vascular, sensory, and motor assessments, which is essential for appropriate treatment and providing the patient the opportunity for the best outcome. (10.1016/j.jhsa.2014.04.026)
• [L4] A thorough physical examination of the shoulder and cervical spine is critical in establishing a focused differential diagnosis of the pathology in and around the shoulder joint. (10.5435/jaaos-d-17-00090)
• [L3] In the evaluation of the functional status of patients and the effectiveness of treatment, the effects of comorbidity must be controlled. (10.2106/00004623-199808000-00007)
• [Case_report] The complexity of presentation, diagnosis, and management of FSHD emphasizes the necessity of a collaborative multidisciplinary team approach to maximize patient satisfaction and outcomes. (10.1016/j.jseint.2020.04.022)
• [L2] Pain self-efficacy did not moderate the relationship between treatment and outcome. (10.1177/17585732221105562)
• [L4] The authors suggest that the score should be redesigned with better standardization before being used to validate other assessments or compare outcomes between different testers. (10.1016/j.jse.2007.06.024)
• [L4] Unreliable classification may account for inconsistent treatment outcomes, suggesting a better classification system is needed. (10.1016/j.jse.2017.09.021)
• [L5] A good classification system serves as a common language to define the severity of a condition, guide treatment, and facilitate clinical research. (10.5435/jaaos-d-15-00034)
• [L5] Advances in understanding shoulder biomechanics, pathophysiology, and diagnostic techniques, along with improvements in surgical methods like arthroscopy, are necessary for clinicians to properly prevent and treat common shoulder injuries in throwing athletes. (10.1177/03635465000280022301)
• [L5] Clinicians and researchers must define their specific question to select the best assessment tool, ideally one with content validity and reliability, while considering normalization for specific populations and incorporating patient satisfaction. (10.1016/j.jse.2009.03.010)
• [L3] Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning. (10.1016/j.jse.2019.04.001)
• [L5] This article discusses common drug interactions and contraindications in orthopaedic practice to highlight the importance of informing and educating clinicians for safe and effective clinical care. (10.1302/0301-620x.97b4.35230)
• [L3] Furthermore, these findings suggest a plausible mechanical progression of kinematic and strength changes associated with the development of rotator cuff pathology. (10.1016/j.jse.2016.11.048)
• [L4] The Rockwood classification is commonly used in Japan to assess severity, but there is some disagreement regarding the assessment for the diagnosis of type IV. (10.1016/j.jseint.2019.11.006)
• [L5] Biomechanical changes of passive glenohumeral joint motion occur in the glenohumeral joint with as little as 5% GIRD. (10.1177/0363546512462012)
• [L4] By relating anatomic properties, kinematics and muscle dynamics to subacromial volume, the study expects to identify one or more predominant pathophysiological mechanisms in every SIS patient to optimize future diagnostic and treatment strategies. (10.1186/1471-2474-12-282)
• [L2] Clinical trials are needed to evaluate the effect of these results on recurrence rates. (10.1177/0363546509331943)
• [L3] Radiographs provide better reproducibility and accuracy for CSA measurement compared to MRI. (10.1007/s00167-015-3587-7)
• [L3] Improved clinical outcomes may be achieved for full-thickness RCTs when AAOS AUC recommendations are followed; however, because improved clinical outcomes may also be achieved when the recommendations are not followed, further investigation is needed in a population of patients in whom there is discordance between AAOS AUC recommendations and the treatment administered. (10.1016/j.jse.2015.12.009)
• [Letter] A valid and repeatable measurement of extensibility would be a valuable addition to studies evaluating the effect of PM on shoulder movement and biomechanics, and additional work is needed to improve or develop new measurement instruments and methods. (10.1016/j.jht.2017.06.007)
• [L4] Clavicle shortening of >10% greatly affects scapular kinematics in vivo. (10.1016/j.jse.2017.03.013)
• [L3] Patients who underwent arthroscopic treatment for SSS experienced clinically significant improvements in functional scores, pain, and quality of life. (10.1016/j.jse.2024.01.018)
• [L5] In the context of a clinical model of fatigue, these scapular exercises resulted in superior migration of the humeral head and alterations in shoulder kinematics on radiographic analysis in healthy subjects. (10.1016/j.jse.2008.09.010)
• [L4] Clinical outcomes show modest but statistically significant improvements, though patients often do not achieve a normal shoulder. (10.1016/j.jse.2023.04.020)
• [L4] These findings suggest potential benefits of this treatment approach, though randomized controlled trials are needed for definitive efficacy assessment. (10.1186/s13018-025-05768-2)
• [L5] The AAOS Appropriate Use Criteria functions as a useful tool to aid in preoperative planning and intraoperative decision making, providing a framework to affirm that a selected treatment choice is appropriate based on clinical trials and expert consensus. (10.5435/jaaos-21-12-772)
• [L5] The evidence in favor of the suprascapular nerve block both in efficacy and safety is compelling for clinical use of a landmark-based approach. (10.1016/j.arthro.2019.05.031)
• [L3] Patients with a classification of Grade III or higher in the novel classification system had higher reinfection rates than those with a classification of Grade I or II and required more aggressive treatment to eradicate the infection. (10.2106/jbjs.19.00951)
• [L2] Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. (10.1016/j.jse.2007.03.016)
• [L4] In the absence of a surgical solution, conservative treatment is fundamental and requires management in a rehabilitation center with intervention by a multidisciplinary team. (10.1016/j.jse.2022.05.011)
• [L3] PROMIS PF scores were responsive to the functional improvements observed clinically. (10.1016/j.jse.2018.08.040)
• [L3] This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization. (10.2106/jbjs.15.01099)
• [L5] Imaging studies should be used to confirm the clinical impression derived from history and physical examination, with careful correlation of anatomic abnormalities to symptoms, and advanced neurodiagnostic imaging should be refrained from until appropriate nonoperative management has failed. (10.5435/00124635-199609000-00002)
• [L4] Patients experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after injection. (10.1016/j.jse.2020.08.008)
• [L4] The combination of 80.6° of shoulder abduction and 10.7° of horizontal shoulder adduction minimized the shear forces on the shoulder at this point. (10.1177/0363546518789626)
• [L5] Trunk postures affected scapular kinematics and muscle activities during external rotation. (10.1016/j.jse.2019.04.059)
• [L5] Appropriate preoperative imaging is essential for detection and quantification of osseous abnormalities, and treatment decisions should be guided by the extent of osseous deficiency and patient-specific factors. (10.2106/jbjs.j.00906)
• [L3] Altering scapula position may affect shoulder strength in asymptomatic individuals. (10.1111/sae.12027)
• [L5] This technology, which can be easily set up, may also allow precise shoulder ROM measurement outside the clinic setting. (10.1016/j.jse.2017.06.004)
• [L5] Nonoperative management is the first-line treatment for most young, active patients without history of trauma, mechanical symptoms, and/or demand for overhead activities. (10.1016/j.arthro.2022.08.005)
• [L1] Future studies on shoulder overuse injuries of wheelchair athletes should be directed towards biomechanical modeling to develop knowledge of load and its effects. (10.1371/journal.pone.0188410)
• [L4] This study defined a new scoring system for the classification of glenohumeral synovitis as seen during arthroscopy with good reliability among a large range of surgeons. (10.1016/j.jse.2017.06.003)
• [Commentary] There is a clear need for robust research into a new scoring system with standardized methods and validated measures. (10.1016/j.arthro.2025.08.013)
• [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. (10.1016/j.arthro.2019.06.025)
• [L4] The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. (10.1186/s12891-018-2082-y)
• [Paper] Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care. (10.1016/j.csm.2014.01.001)
• [L3] Shoulder strength and patient-reported outcomes improved significantly over 24 months, but the glenohumeral joint contact center gradually shifted superiorly, potentially reflecting altered loading patterns or loss of dynamic stability despite functional improvements. (10.1016/j.jseint.2025.101421)
• [L5] Nonoperative treatment for at least 6 months is recommended before pursuing operative intervention. (10.1016/j.jse.2017.10.024)
• [L5] Standard of care generally consists of conservative management which can be followed by surgical intervention if adequate function is not attained. (10.1111/j.1758-5740.2010.00095.x)
• [L1] Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. (10.1016/j.jse.2020.11.002)
• [L5] Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. (10.5435/00124635-199905000-00004)
• [L4] Nonoperative management with corticosteroid injection can be used as a therapeutic measure with potential long-term benefits in the treatment of RTS. (10.1177/1558944718787282)
• [L3] Given the high prevalence of MRI findings in asymptomatic hockey players, it is necessary to cautiously interpret the significance of these findings in association with clinical presentation. (10.1177/0363546510388931)
• [L4] More importantly, this case highlights the need for adequate radiologic investigation, either by use of 3 plain films obtained at 90° to each other or by use of 3-dimensional CT reconstruction. (10.1016/j.jse.2006.08.003)
• [L3] In clinical settings where the likelihood of recurrent instability is low after nonoperative care or when an informed patient has an aversion to surgery, nonoperative treatment may be the preferred treatment strategy. (10.1016/j.jse.2011.01.031)
• [L4] Preoperative MRI could be used to exclude subtle instability, and surgeons should consider checking for subtle instability, especially when patients have a history of multiple corticosteroid injections (≥3) or severe pain. (10.1186/s12891-018-2069-8)
• [L3] Bracing is not effective as an adjunct to standard nonoperative management in allowing athletes to return and complete a subsequent season. (10.1016/j.jse.2018.02.027)
• [L3] The modified Mallet classification demonstrated strong to excellent agreement and interrater reliability across face-to-face, live tele-assessment, and video-based conditions, suggesting it is appropriate for remote medical follow-up. (10.1177/17531934231196118)
• [L4] Roentgenographic evidence serves as an adjunct to define the degree and extent of involvement. (10.2106/00004623-197153060-00012)
• [L4] Further development and refinement of multifactorial grading systems for describing labral injury are indicated. (10.1007/s00167-020-06215-x)
• [L5] Nonoperative treatment is the preferred option in early-stage disease, and it may prevent disease progression, though surgical treatment is required in some cases. (10.1016/j.xrrt.2022.02.005)
• [L2] Plain radiographs rarely alter the diagnosis or affect management in the setting of atraumatic shoulder pain, particularly in patients younger than 50 years. (10.5435/jaaos-d-16-00884)
• [L3] They conclude that the goal of assessing the longer-term functional effect of FNB was accomplished and hope it serves as a catalyst for future prospective randomized studies. (10.1177/0363546515601377)
• [L4] Patients with edema on MRI were more likely to present pain than patients without edema, and subchondral bone edema on histologic examination was more frequent in patients with pain. (10.1016/j.jseint.2020.03.007)
• [L4] Orthopaedic surgeons are comfortable reviewing shoulder MRI scans without necessarily reading the MRI report prior to a surgical decision, but MRI scans should not be used without assessment of patient history and or physical examination. (10.1186/s12891-022-05541-0)
• [L5] Short and long-term outcomes are largely driven by the amount of time from injury to reduction and associated injuries. (10.5435/jaaos-d-23-01013)
• [L3] The OSS may be considered an alternative for longer-term follow-up as it is easier to administer and correlates well with the Constant score. (10.1016/j.jse.2007.04.019)
• [L2] Responsiveness of the included clinical tests was generally low when using change in NDI score as the anchor from baseline to the 4-month follow up. (10.1186/s12891-017-1918-1)
• [Paper] Physical outcome measures are being changed for the use of patient reported outcomes, and range of motion and strength are not as reliable measures as one would think. (10.1016/j.injury.2019.11.017)
• [L4] The maintenance of reduction requires continued follow-up over time. (10.1016/j.jse.2006.04.008)
• [Letter] The sole assessment of recurrent dislocation to define natural history and treatment rationale is inadequate, and conclusions regarding treatment recommendations cannot be made from a study that did not compare treatment methods. (10.1177/0363546510379343)
• [L5] SIRVA is a rare yet increasingly recognized complication of immunization that is primarily a clinical diagnosis; while treatment modalities like physical therapy and corticosteroid injections provide modest improvement, larger high-quality studies are needed to determine the natural history and optimal treatment. (10.5435/jaaos-d-21-00021)
• [L3] However, the clinical outcomes of RTSA at a minimum follow-up of 1 year were similar in the high- and lower-risk groups. (10.1016/j.jse.2021.10.024)
• [L2] The results demonstrate mild complaints at baseline and an overall stable course during one-year follow-up. (10.1186/s12891-018-2116-5)
• [L5] Early and aggressive treatment of rheumatoid arthritis is now standard, and complete resolution of signs and symptoms is achievable in perhaps 10% of patients. (10.1016/j.jhsa.2008.11.010)
• [L1] Those with a worse prognosis may be monitored more frequently and the treatment plan modified if complaints persist. (10.1186/s12891-015-0738-4)
• [L3] At a population level, back beliefs were generally positive and relatively constant over time, but misconceptions about a poor prognosis were common. (10.1186/s12891-019-2925-1)
• [L5] Significant deficits in the literature include a paucity of randomized controlled trials, failure to report response to treatment in a stage-based fashion, and an incomplete understanding of the disease's natural course. (10.1177/0363546509348048)

See Also

• Shoulder Instability
• Fractures
• Rotator Cuff
• Cuff Pathology
• Rotator Cuff Repair
• Total shoulder arthroplasty
• Suprascapular neuropathy

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