Clinicians › Shoulder

Comprehensive Arthroscopic Management (CAM)

The Comprehensive Arthroscopic Management (CAM) procedure — a joint-preserving arthroscopic alternative to arthroplasty for glenohumeral osteoarthritis, combining debridement, capsular release, osteophyte excision, microfracture, loose-body removal and axillary nerve neurolysis.

73 citationsUpdated Nov 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

The Comprehensive Arthroscopic Management (CAM) procedure is a systematic, inclusive approach to the array of pathologies encountered in the setting of early glenohumeral arthritis [2]. It serves as a joint-preserving alternative to arthroplasty for young, active patients with advanced shoulder osteoarthritis [3]. The procedure provides a predictable short-term joint-preserving option for younger, high-demand patients by reducing pain and improving function [4]. CAM reliably improves pain and function in active patients with advanced glenohumeral osteoarthritis (GHOA) [1]. Arthroscopic management in patients younger than 50 years of age can achieve predictably good to excellent results regardless of tear size [5].

The CAM procedure demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction [8]. It has a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced osteoarthritis of the glenohumeral joint [6]. However, isolated arthroscopic debridement and capsular release may not provide substantial benefit to justify its use in most patients with glenohumeral arthritis [34]. Treatment of glenohumeral arthritis with arthroscopic glenoid resurfacing provided superior results to previously performed arthroscopic debridement in a series of patients with failed previous arthroscopic debridement [28].

CAM is a reasonable option for patients with localized cartilage defects and specific radiographic findings [10]. Arthroscopic debridement is a reasonable next-line treatment if antiinflammatory medications and therapy fail in patients with small, contained, unipolar lesions [12]. This approach provides good short-term results and minimal complications in such patients [12]. Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands [16]. Long-term consequences of arthroscopic debridement for massive rotator cuff tears require further evaluation [16]. Patients with advanced GHOA who have less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure after CAM [1]. Hemiarthroplasty or total shoulder arthroplasty are feasible options for patients with humeral head incongruity or large anterior osteophytes [10].

Anatomy & Pathophysiology

Glenohumeral Joint Anatomy

The glenohumeral joint is a ball-and-socket articulation where the large humeral head articulates against, but not within, the small glenoid cavity [75]. The glenoid cavity is a shallow socket approximately one-third the size of the humeral head [64]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [66]. The glenoid articular surface and labrum combine to create a socket approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [76]. The fibrocartilaginous glenoid labrum increases the depth of the socket by 50% around the humeral head [76]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [76]. The glenoid averages 5° of retroversion in relation to the axis of the scapular body [66].

The articular surface of the humeral head is essentially spherical with an arc of approximately 160 degrees covered by articular cartilage [75]. The radius of curvature of the humeral head is approximately 25 mm and is slightly larger in men than in women [75]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [75]. The articular head of the humerus is spherical with a diameter of 37 to 57 mm [62]. The superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [75]. The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [62].

The average neck-shaft angle of the humerus is 45 degrees (±5 degrees), with a range of 30 to 50 degrees [75]. Arthritic shoulders have a flatter neck-shaft angle close to 50 degrees [75]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [62]. The neck-shaft angle measures an average of 135 degrees [64]. The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [66]. The humeral head is retroverted an average of 30 degrees [64]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [75]. The humeral version averages 29.8 degrees (range, 10 to 55 degrees) [62].

The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is defined as the lateral humeral offset [75]. A significant decrease in lateral humeral offset reduces the lever arms for the deltoid and supraspinatus muscles, weakening abduction and impairing function [75]. A significant increase in lateral humeral offset causes excessive tension on soft tissues, resulting in loss of motion and likely accelerating polyethylene wear [75]. Humeral articular malposition of more than 4 mm leads to increased subacromial contact [75]. An offset of 8 mm in any direction significantly decreases passive range of motion [75].

The bicipital groove lies between the greater and lesser tuberosities and serves as a pathway for the long head of the biceps [62]. The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [62]. The anatomic neck of the proximal humerus is located at the junction of the articular surface and the tuberosities [62]. The surgical neck represents an indistinct region (metadiaphyseal junction) below the tuberosities but above the humeral shaft [62]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [62]. The lesser tuberosity serves as the attachment site for the subscapularis tendon [62].

Scapular Anatomy

The scapula is attached to the axial skeleton by the clavicle via the acromioclavicular and sternoclavicular joints [65]. The scapula is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion over the chest wall [65]. The basic part of the scapula is the body, which is triangular when viewed anteroposteriorly with its base situated superiorly and its apex inferiorly [65]. The glenoid is connected with the flat body of the scapula by the scapular neck [65]. The hook-shaped coracoid process curves forwards from the superior surface of the scapular neck [65]. The scapular spine arises from the posterior surface of the scapular body and ends in a flattened bony process, the acromion, which curves forwards [65].

The distribution of bony mass in the scapula is highly uneven, with the highest concentration in the glenoid, scapular neck, and lateral border of the scapular body [65]. Two bony pillars extend between the glenoid and the scapular body to transmit compressive forces from the glenoid fossa [65]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [65]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [65]. The two pillars, connected by a markedly thinner medial border, form the basic load-bearing structure known as the biomechanical body of the scapula [65]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically the infraspinous fossa [65]. The weakest area of the circumference of the biomechanical body is the connection of the scapular spine and the medial border, known as the spinomedial angle [65].

The scapula has only one true diarthrodial articulation, the acromioclavicular joint [66]. Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [66]. The acromion has three ossification centers: the metacromion (base), the mesoacromion (middle), and the preacromion (tip) [66]. Failure of fusion of acromial ossification centers results in os acromiale [66]. Os acromiale is incomplete fusion of secondary ossification centers, most commonly between the mesoacromion and meta-acromion [77]. The coracobrachialis muscle and the short head of the biceps tendon originate from the coracoid process [66]. The pectoralis minor muscle inserts onto the medial coracoid process [66].

The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [77]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [77]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [77]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [77]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [77]. The coracoacromial ligament is the arthroscopic landmark for a complete release of the rotator interval for adhesive capsulitis [77].

The scapula in humans is suspended by muscles alone and has shifted caudally from the cervical position in lower animals [73]. Broadening of the infraspinatus fossa has resulted in a change in the vector of muscle pull from the axillary border of the scapula to the glenoid fossa [73]. This adaptation allows the infraspinatus and teres minor muscles to be more effective in their roles as depressors and external rotators of the humeral head [73]. The acromion has enlarged in humans compared to pronograde animals, reflecting the increasing role of the deltoid muscle in shoulder function [73]. The broader attachment of the deltoid on the acromion and its more distal insertion on the humerus have increased its mechanical advantage in shoulder motion [73]. The coracoid process has undergone an increase in size over time [73]. With the shoulder in 90 degrees of abduction, the coracoid extension over the glenohumeral joint can mechanically limit anterior translation of the humerus relative to the glenoid [73].

Ligaments and Soft Tissue Stabilizers

The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [66]. The superior shoulder suspensory complex is composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion [66]. The superior strut of the superior shoulder suspensory complex comprises the middle clavicle [66]. The inferior strut of the superior shoulder suspensory complex comprises the lateral scapular border and spine of the scapula [66]. The superior shoulder suspensory complex is a bone–soft-tissue ring that provides a stable connection of the glenoid and scapula to the clavicle [72]. The superior shoulder suspensory complex is composed of four bony landmarks—distal clavicle, acromion, coracoid process, and glenoid neck—and the supporting ligamentous complexes of the acromioclavicular joint and coracoclavicular ligaments [72]. The coracoclavicular ligaments are the primary stabilizers to superior (vertical) translation of the distal clavicle [66]. The conoid ligament is medial and the trapezoid ligament is lateral within the coracoclavicular complex [66].

The rotator cuff stabilizes the glenohumeral joint via joint compression [66]. Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [66]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [66]. The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [66]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [66]. Laxity of the rotator interval results in inferior laxity (the sulcus sign) [66]. Contracture of the rotator interval is seen with adhesive capsulitis [66].

The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [66]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [66]. With the coracohumeral ligament, the superior glenohumeral ligament forms a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [66]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [66]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90° of abduction and external rotation [66]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [66].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [66]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to the ligament [66]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [66]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [66]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [66].

The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress in the same position [76]. Tightening of the rotator interval decreases posterior and inferior translation [76]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction [76]. The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch, creating a hammock-type sling [76]. With external rotation, the hammock slides anteriorly and superiorly, the anterior band tightens, and the posterior band fans out [76]. With internal rotation, the opposite occurs to the inferior glenohumeral ligament bands [76]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [76].

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 [76]. 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 [76]. The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [76]. The infraspinatus and teres minor fuse near their musculotendinous junctions [76]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [76]. The roof of the biceps sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor [76]. The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule and inserting mainly into the greater tuberosity of the humerus, with subscapularis inserted into the lesser tuberosity [76].

Vascular & Neural

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [62]. The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [62]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis and provides vascular inflow to the humeral head via its terminal anterolateral branch, the artery of Laing (arcuate artery) [62]. The ascending branch of the anterior humeral circumflex artery courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [62]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [62]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [62].

The primary blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [64]. Quantitative assessment shows that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [70]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head, traveling proximally in the lateral aspect of the intertubercular groove [66]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [66].

Classification

Arthritis Diagnosis and Grading: Arthritis is diagnosed using multiple methods, including preoperative radiographs, magnetic resonance imaging, or direct visualization at arthroscopy [149]. One study applied the Samilson-Prieto classification to grade preoperative arthritis [149], while two other studies utilized 4-stage classification systems that were neither validated nor previously described [149]. During arthroscopic evaluation, four studies employed the Outerbridge classification to grade articular cartilage degeneration [149]. Three of these studies provided specific data on Outerbridge grades, reporting 8 grade I, 14 grade II, 21 grade III, and 79 grade IV lesions [149].

Weinstein Classification: The Weinstein radiographic classification for shoulder osteoarthritis defines four stages based on joint space and bony morphology [20]. Stage I presents with normal radiographs [20]. Stage II is characterized by minimal joint space narrowing with a concentric humeral head and glenoid [20]. Stage III involves moderate space narrowing accompanied by early inferior osteophyte formation [20]. Stage IV demonstrates severe loss of joint space, osteophyte formation, and loss of concentricity between the humeral head and the glenoid [20].

Walch Classification: Walch et al. introduced a classification system for glenoid wear in osteoarthritic shoulders [30]. In one cohort, patients were classified using the modified Walch classification through blinded radiographic assessments and consensus, yielding 42 A1 glenoids, 29 B2 glenoids, and 21 B3 glenoids [156]. A separate review of shoulders with glenoid bone loss identified 4 type A2 glenoids and 2 type C glenoids on preoperative imaging [163]. Type A2 glenoids were classified as severe examples of those defined by the Walch classification [163].

Other Considerations: A classification of subscapularis tendon tears has been proposed based on observations of the pathoanatomy of the tears [177].

Clinical Presentation

Indications and Patient Selection

The CAM procedure is recommended for young patients (age younger than 60) with glenohumeral osteoarthritis who have failed nonoperative treatment [20]. Younger patients participating in high-demand shoulder activities with Weinstein stage III glenohumeral osteoarthritis are ideal candidates [20]. Many patients with Weinstein stage IV glenohumeral osteoarthritis may also be good candidates [20]. The indication includes patients with capsular contractures [20] and those with or without large inferior humeral spurs [20]. For patients with localized cartilage defects and specific radiographic findings, the CAM procedure is a reasonable option [10]. Arthroscopic debridement serves as a reasonable next-line treatment if anti-inflammatory medications and therapy fail in patients with small, contained, unipolar lesions [12]. In younger patients with mild or moderate osteoarthritic changes, arthroscopic debridement with capsular release may provide a window of improved symptoms and function before deterioration of the joint leads to a more significant operation [43].

Preoperative Factors and Prognostic Indicators

Preoperative assessment identifies specific risk factors for early failure. Patients with less joint space are significantly more likely to progress to early failure after the CAM procedure [1]. Similarly, patients with abnormal posterior glenoid shape are significantly more likely to progress to early failure [1]. During counseling, total shoulder arthroplasty is suggested over the CAM procedure for patients with a type B2 or C glenoid according to the Walch classification [19]. Total shoulder arthroplasty is also suggested for patients with less than 2 mm of glenohumeral joint space [19]. Magnetic resonance imaging can be useful to confirm axillary nerve compression by showing neurogenic edema or fatty infiltration of the deltoid or teres minor [20].

Clinical Outcomes and Survivorship

The CAM procedure reliably improves pain and function in active patients with advanced glenohumeral osteoarthritis [1]. It demonstrated significant improvements in midterm clinical outcomes and high patient satisfaction for glenohumeral osteoarthritis [8]. The survivorship rate after the CAM procedure was 76.9% at a minimum of 5 years postoperatively [8]. Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement, and patient satisfaction in glenohumeral osteoarthritis in the intermediate-term [40]. Treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture can result in long-term improved function and reduced pain for some patients [31].

Limitations and Evidence Quality

Debate remains regarding the durability of managing primary glenohumeral arthritis arthroscopically [7]. Most studies on arthroscopic management of glenohumeral osteoarthritis are level IV with low patient numbers and relatively short follow-up [7]. Some 2- and 5-year follow-up data for arthroscopic management of primary glenohumeral arthritis remain limited to level IV series [7]. Previously published literature places survivorship at 85% at 2 years postoperatively after arthroscopic management of primary glenohumeral arthritis [7]. Previously published literature places survivorship at 76.9% at 5 years after arthroscopic management of primary glenohumeral arthritis [7]. It is unclear whether the reported survivorship rates represent the natural history of primary glenohumeral arthritis or whether arthroscopic management delays arthritis progression because no control group exists for the previously published case series [7]. There may be a placebo effect for shoulder arthroscopy that may improve patient outcomes in the short- and mid-term after surgery [7].

The duration of symptom relief and subsequent conversion to arthroplasty after arthroscopic treatment of glenohumeral osteoarthritis varied among studies, ranging from approximately 8 weeks to 8 years [17]. Significant heterogeneity was observed in the rates of conversion to arthroplasty across all studies of arthroscopic treatment of glenohumeral osteoarthritis, with an I-squared value greater than 75% [17]. Studies with a longer duration of minimum follow-up (>2 years) showed greater agreement in conversion rates to arthroplasty [17]. Studies that excluded patients with absent preoperative radiographic evidence of arthritis showed greater agreement in conversion rates to arthroplasty [17]. The most common sources of possible bias in noncomparative studies of arthroscopic treatment of glenohumeral osteoarthritis were lack of blinding or an unbiased assessment of endpoints, greater than 5% loss of patients at final follow-up, and absence of any prospective calculation of study sample size [17].

Investigations

General Imaging Principles: The purpose of shoulder imaging is to establish the diagnosis, determine the severity of pathoanatomy, assist in surgical planning, and illustrate the condition to the patient [36]. Because the shoulder is a three-dimensional structure that cannot be represented by a single planar view, critical relationships such as humeral head centering change with arm position [83]. Overlying structures and metallic implants may complicate imaging, necessitating a judicious approach that yields necessary information while avoiding the tendency to "over-image" [83]. Unless a specific research protocol is in place, only the scans or reconstructions necessary for patient care should be obtained [36]. Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome [36].

Plain Radiography: Standardized plain films are almost always sufficient for shoulder evaluation [36]. The standard shoulder series includes orthogonal views: a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [89]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [89]. The AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [89]. The axillary view is necessary for evaluating glenohumeral joint instability and determining humeral head position in the glenoid fossa [89]. It may detect occult, locked posterior shoulder dislocation in patients lacking passive external rotation [89]. The axillary view is also helpful for evaluating glenoid morphology in osteoarthritis and provides good visualization of the coracoid process, acromion, and distal clavicle [89]. The scapular Y view visualizes the coracoacromial arch, revealing coracoacromial spurs associated with rotator cuff pathology [89]. It is a reliable alternative for evaluating glenohumeral subluxation and dislocation, and can show scapular body abnormalities and acromial shape [89].

The first key radiographic view is the anteroposterior (AP) view in the plane of the scapula, taken so the x-ray beam passes through the glenohumeral joint [36]. This view shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, joint space narrowing, degree of medial displacement of the humerus, bone quality, loose bodies, and humeral head collapse or deformity [36]. The second key view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula [36]. Oriented so both the spinoglenoid notch and scapular neck are visible, this view demonstrates a different perspective of humeral anatomy, amount of glenoid bone, glenoid shape, its version relative to the scapular plane, and the relationship of the humeral head to the glenoid fossa [36]. Referred to as the “truth view” because it demonstrates glenohumeral relationships in the functional position of elevation, it is superior to CT scans which are taken with the arm adducted [36]. Joint space narrowing is most evident on the axillary truth view compared to images made with the arm at the side [36]. This view can show posterior subluxation or “functional decentering” not evident in images taken with the arm at the side [36].

The degree of posterior subluxation can be measured by the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [36]. The point of contact reflects the degree of centering of the net humeral joint reaction force on the glenoid [36]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and “rocking horse” loosening of prosthetic glenoid components [36]. At least two X-ray views should be obtained: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction to show the relationship of the humeral head to the glenoid [80].

The Neer trauma series consists of an AP view, a lateral view in the scapular plane, and a Velpeau modified axillary view [82]. The lateral radiograph in the scapular plane is the tangential Y-view of the scapula [82]. The combination of these three views allows evaluation of the shoulder joint in three separate perpendicular planes [82]. The axillary view is important for evaluating the glenoid articular surface and the relationship of the humeral head anteriorly and posteriorly [82]. On occasion, other studies including CT scanning for detailing bony anatomy may be necessary for proximal humerus fractures [82].

Normal values include an acromiohumeral distance of 7 to 14 mm [89]. The width of the glenohumeral joint space should be symmetric superiorly and inferiorly [89]. The coracoclavicular distance is normally 1.1 to 1.3 cm [89]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked) [89]. 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 [89].

Computed Tomography: CT scans may offer a few degrees of increased precision in the measurement of glenoid version, but this precision does not necessarily improve the quality of the surgery or the clinical outcome [36]. CT is helpful for planning fracture surgery and shoulder joint replacement [80]. 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 [88]. 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 [89]. Three-dimensional reconstructions can reveal fine details of the shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty [36]. Recognizing significant glenoid deficiency preoperatively is critical for the surgeon contemplating methods to deal with the bone loss in total shoulder arthroplasty [30]. In patients with osteoarthritis, it is important to assess the degree and location of glenoid bone loss and any associated humeral head subluxation [30].

Magnetic Resonance Imaging: MRI is useful to identify osteonecrosis of the humeral head, or a bone tumour [80]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [80]. MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [88]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance arthrograms to provide a more detailed picture of the joint surfaces [88]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [88]. Traditional magnetic resonance imaging is utilized for evaluation of soft tissues with high contrast and spatial resolution in the management of patients with anterior shoulder instability [85]. MR accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [85]. The acquired multi-planar imaging allows for the detailed evaluation of the glenoid, labrum, joint capsule, and rotator cuff in different planes [85].

Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [85]. Limited range of motion or pain may prohibit patients from performing the ABER provocative maneuver [85]. Full routine MRI or MRA examination had similar accuracy as the ABER sequence in evaluating the anteroinferior labral–ligamentous complex [85]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of the MRA in neutral position [85]. MRA with the ABER position is more effective in identifying Perthes lesions than MRA in neutral position [85]. MRAs can demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability [85]. MRAs can be helpful in evaluating lesions of the rotator interval and other associated findings that may affect the eventual surgical plan [85]. The presence of glenoid dysplasia, increased capsular cross-sectional area, and increased glenoid retroversion have all been found to be associated with increased posterior labral tears and symptomatic instability [85]. Glenoid retroversion was significantly increased in patients with symptomatic posterior labral tears, but there was no significant association between instability and increased humeral head subluxation [85]. The diagnosis of multidirectional instability is a clinical one, and the need for expensive and/or invasive imaging should be weighed against the information that will be gained from these studies [85].

Magnetic Resonance Arthrography: MR arthrography refers to MRI of a joint that has been injected with an intra-articular contrast agent such as diluted gadolinium or saline solution [85]. The contrast material is injected prior to MRI by fluoroscopic or ultrasound guidance under strict aseptic technique [85]. By distending the joint capsule, the cartilage, ligaments, and labrum are outlined with contrast, increasing the sensitivity for detecting tears and other lesions [85]. In the acute dislocation setting, a joint effusion with distension of the joint may outline these structures similarly, making the arthrogram unnecessary [85]. MR arthrography has proven utility by increasing both sensitivity and specificity in detecting injuries to the capsulolabral–ligamentous complex as compared to traditional MRI [85]. A meta-analysis found greater diagnostic test accuracy for MRA over MRI in the detection of glenoid labral lesions, with MRA sensitivity of 88% and specificity of 93% versus MRI sensitivity of 76% and specificity of 87% [85]. Arthrography involves injection of contrast agent in conjunction with either an MRI or CT scan, enhancing imaging of the joint to enable better identification of normal structures and pathology involving the joint surfaces [88]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [88]. When MRI or MR arthrography is contraindicated, such as in patients with a pacemaker or vascular clips, CT arthrography is indicated [88].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [80]. It can be useful in guiding injections or barbotage, such as aspirating calcific deposits in the rotator cuff [80]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [88]. It can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [88]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [88]. As a result of providing images in real-time, ultrasonography can evaluate impingement in various positions and motions [88]. It is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [88]. The most commonly performed joint examination using ultrasonography is the shoulder examination [79]. Accuracy of ultrasonography depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [79]. There are 10 common pitfalls of rotator cuff ultrasonography that can reduce overdiagnosis or underdiagnosis of rotator cuff pathology [79].

The sensitivity of ultrasonography for the detection of full-thickness rotator cuff tears is 98% [89]. The specificity of ultrasonography for the detection of full-thickness rotator cuff tears is 80% [89]. The positive predictive value of ultrasonography for the detection of full-thickness rotator cuff tears is 90% [89]. The negative predictive value of ultrasonography for the detection of full-thickness rotator cuff tears is 95% [89]. The accuracy of ultrasonography for the detection of full-thickness rotator cuff tears is 94% [89]. The sensitivity of MRI for the detection of full-thickness rotator cuff tears is 100% [89]. The specificity of MRI for the detection of full-thickness rotator cuff tears is 68% [89]. The positive predictive value of MRI for the detection of full-thickness rotator cuff tears is 85% [89]. The negative predictive value of MRI for the detection of full-thickness rotator cuff tears is 100% [89]. The accuracy of MRI for the detection of full-thickness rotator cuff tears is 89% [89].

Treatment

Non-Operative

Any surgical intervention must be preceded by an adequate trial of conservative management, which includes activity modification, physical therapy, antiinflammatory medication, and corticosteroid injections [38]. Injectable viscosupplementation represents an additional nonoperative option; however, evidence supporting its use in the shoulder is limited, and it is not currently approved by the U.S. Food and Drug Administration for injection in joints other than the knee [38].

Operative

Indications: The Comprehensive Arthroscopic Management (CAM) procedure is recommended as a systematic, inclusive approach for the array of pathologies encountered in early glenohumeral arthritis [2]. Typical candidates are young patients (age younger than 60) with glenohumeral osteoarthritis who have failed nonoperative treatment, including those with capsular contractures and with or without large inferior humeral spurs [20]. Younger patients participating in high-demand shoulder activities in Weinstein stage III are ideal candidates, although many patients in stage IV may also be good candidates [20]. Arthroscopic debridement is a reasonable next-line treatment if antiinflammatory medications and therapy fail, offering good short-term results and minimal complications in patients with small, contained, unipolar lesions [12]. Arthroscopic glenoidplasty and osteocapsular arthroplasty should be considered a viable alternative to shoulder replacement in patients who place high demands on the shoulder or refuse prosthetic replacement, even in the presence of abnormal glenoid morphology [144]. Preoperative radiographs and clinical examination were unreliable in predicting osteoarthritis that was intraoperatively documented [38].

Surgical Approach / Technique: The CAM procedure includes synovectomy, loose body removal, chondroplasty, subacromial decompression, extensive capsular release, biceps tenodesis, humeral inferior osteophyte removal (osteoplasty), and axillary nerve neurolysis [136]. Neurolysis and decompression of the axillary nerve was not performed in all patients unless symptoms suggested nerve compression or when direct nerve encroachment with a change in its course was found on magnetic resonance imaging [136]. Releasing an axillary nerve arthroscopically is technically demanding and potentially dangerous for less experienced arthroscopists, who risk nerve injury or transection [7]. A certain skill level and proficiency with shoulder arthroscopy are required to undertake some of the components of CAM for primary glenohumeral osteoarthritis [7]. Arthroscopic management in patients younger than 50 can achieve predictably good to excellent results regardless of tear size [5]. The authors have increasingly used all-arthroscopic techniques with satisfactory results for rotator cuff tears in active duty military personnel [13]. Successful management of glenohumeral instability requires a full understanding of all responsible pathologic components, typically involving reattachment of the fibrocartilaginous labrum and re-creating proper tension of the capsuloligamentous structures [14]. Arthroscopic reconstruction provides results equal to those of the open procedure for patients age 22 and older, would provide a success rate of 90% in patients age 18 to 23, but would only work approximately 80% of the time in patients 18 and younger and is not indicated in patients in this age range [22]. Arthroscopic release resulted in normal motion in all cases of postoperative stiffness following arthroscopic rotator cuff repair [25]. Treatment of glenohumeral arthritis with arthroscopic glenoid resurfacing provided superior results to previously performed arthroscopic debridement in a series of patients with failed previous debridement [28]. Arthroscopic debridement with microfracture has yielded good-to-excellent results with significant improvements in motion, pain reduction, and high levels of patient satisfaction for unstable, contained osteochondritis dissecans lesions of the capitellum [108].

Pain Management: Multimodal shoulder injection is a safe and effective modality for management of pain after arthroscopic rotator cuff repair [98]. Following arthroscopic rotator cuff repair, patients can achieve satisfactory pain control using a multimodal approach with a median of 18 opioid pills over 6.9 days when used in combination with non-opioid pain medications [150].

Other Considerations: The CAM procedure reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder osteoarthritis, serving as a joint-preserving alternative to arthroplasty [3]. The CAM procedure demonstrated significant improvements in midterm clinical outcomes and high patient satisfaction, with a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. Most studies reported that arthroscopic treatment of glenohumeral osteoarthritis and related pathology provided overall symptomatic improvement in pain and function [17]. Most patients showed postoperative improvements in forward elevation and external rotation, although 1 study suggested that these improvements may regress over time [17]. Most patients showed improvements in both pain (e.g., VAS score) and function (e.g., ASES score), which likely represent clinically significant functional improvements [17]. The duration of symptom relief and subsequent conversion to arthroplasty varied among studies, ranging from approximately 8 weeks to 8 years [17]. Significant heterogeneity was observed in the rates of conversion to arthroplasty across all studies (I² > 75%) [17]. Studies with a longer duration of minimum follow-up (>2 years), as well as those that excluded patients with absent preoperative radiographic evidence of arthritis, showed greater agreement (reduced heterogeneity) in conversion rates [17]. Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands, though long-term consequences require further evaluation [16]. Arthroscopic repair was safe and effective in both elderly and younger groups, even for those with massive tears [106]. Patients achieved excellent functional outcomes and pain improvement after total shoulder arthroplasty with an augmented glenoid component [15]. Debate remains regarding the durability of managing primary glenohumeral arthritis arthroscopically, with some 2- and 5-year follow-up data limited to level IV series [7]. Previously published literature places survivorship at 85% at 2 years postoperatively and at 76.9% at 5 years after arthroscopic management of primary glenohumeral arthritis [7]. It is unclear whether the reported survivorship represents the natural history of primary glenohumeral arthritis or whether arthroscopic management delays arthritis progression because no control group exists for the previously published case series [7]. Most studies evaluating arthroscopic management of glenohumeral osteoarthritis are level IV with low patient numbers and relatively short follow-up [7]. The American Academy of Orthopaedic Surgeons clinical practice guidelines classify the use of arthroscopy for the treatment of glenohumeral arthritis as grade I, implying that they are unable to recommend for or against this option [38]. A systematic review of the literature showed that arthroscopic debridement for glenohumeral arthritis lacks high-quality evidence to support its routine use [38]. Although there are limited nonarthroplasty surgical options available for glenohumeral arthritis, isolated arthroscopic debridement and capsular release may not provide substantial benefit to justify its use in most patients [34]. Risk-of-bias assessment using MINORS criteria for noncomparative studies showed scores ranging from 5 to 13 out of a possible score of 16 [17]. The most common sources of possible bias in the systematic review were lack of blinding or an unbiased assessment of endpoints, greater than 5% loss of patients at final follow-up, and absence of any prospective calculation of study sample size [17]. Glenohumeral osteoarthritis in young patients is a difficult condition with higher failure rates after surgical management compared to older patients [121]. Patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure after CAM [1].

Postoperative Rehabilitation: Early active mobilization and early passive mobilization were both safe and beneficial to improve range of motion after arthroscopic surgery for patients with small to large sized tears [117]. Functional recovery after arthroscopic rotator cuff repair follows a predictable but non-uniform sequence, characterized by early improvements in range of motion and patient-reported outcomes, followed by delayed strength restoration [169]. Phase-to-phase progression through rehabilitation guidelines is based on achievement of milestones, and if impairment and criteria-based milestones are not reached, progressing to the next phase is likely not appropriate [137]. Signs and symptoms suggesting the patient is not ready to advance to the next phase include excessive complaints of pain (≥3 of 10 for phase 1 and ≥2 of 10 for phases 2-4), lack of achievement of the lower range of the staged range of motion goals, noncompliance with the home exercise program, and failure to adhere to healing precautions [137]. Complications related to postoperative pain and stiffness are not unexpected after arthroscopic rotator cuff repair, especially in the first 3 months [137]. The primary clinical decision in managing range of motion deficits is to determine whether they are due to excessive pain or true loss of motion [137].

Complications

Nerve palsy: Axillary nerve neurolysis during CAM is technically demanding and potentially dangerous in less experienced arthroscopists, who risk nerve injury or transection [7].

Wound complications: Complications of the fingers and hand, including carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome, occur more easily in patients with a past history of carpal tunnel syndrome or tenosynovitis [182]. These upper extremity complications also occur more easily in patients with edema as per a subjective assessment [182].

Instrumentation failure: Suture passing needle breakage is a reported complication associated with the use of specific suturing devices during arthroscopic rotator cuff repair [56].

Other Considerations: The CAM procedure has a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. Other data report an 84% survivorship at 3 years and 72% survivorship at 5 years [46]. Patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure after the CAM procedure [1]. The duration of symptom relief after arthroscopic treatment of GHOA and subsequent conversion to arthroplasty varies among studies, ranging from approximately 8 weeks to 8 years [17]. Significant heterogeneity was observed in the rates of conversion to arthroplasty across studies of arthroscopic treatment of GHOA, with an I² of 75% [17]. Some patients undergoing CAM for GHOA progressed to arthroplasty at long-term follow-up [45].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for manual work, sport, or full range of motion and strength return.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for when pain, strength, and final functional outcomes stabilise.

Rehabilitation protocol: Patients assigned to early or delayed postoperative physical therapy groups demonstrated very similar clinical outcomes and range of motion at 1 year after arthroscopic rotator cuff repair [175]. No clinically discernible differences in active range of motion at 1-year follow-up were found between patients assigned to early or delayed motion protocols after arthroscopic rotator cuff repair with biceps rerouting [187].

Functional milestones: The CAM procedure reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder OA [3]. Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced OA of glenohumeral joint [6]. The CAM procedure demonstrated significant improvements in midterm clinical outcomes and high patient satisfaction for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. After the CAM procedure, survivorship was 84% at 3 years and 72% at 5 years [46]. The majority of patients demonstrated sustained improvement in patient-reported outcomes and satisfaction without conversion to total shoulder arthroplasty at long-term follow-up, although some patients progressed to arthroplasty [45]. At minimum 2-year follow-up, arthroscopic repair of rotator cuff tears produced significant improvements in both patient-derived and objectively measured variables [143].

Other Considerations: Radiographs at 6 month follow-up demonstrate a space between the humeral head and the glenoid in all cases [55]. A follow-up of at least 2 years is necessary to determine short-term outcomes, especially in patients with severe preoperative fatty degeneration [145]. Radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair [60]. The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between platelet-rich plasma and control groups, with clinical differences observed at 2 years disappearing at long term [186].

Key Evidence

• [L3] The CAM procedure reliably improves pain and function in active patients with advanced GHOA, but patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure. [1] (10.1177/0363546516668823)
• [L4] The authors recommend a systematic, inclusive approach to the array of pathologies encountered in the setting of early glenohumeral arthritis: the Comprehensive Arthroscopic Management (CAM) procedure. [2] (10.1016/j.arthro.2022.01.033)
• [L4] The CAM procedure reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder OA, serving as a joint-preserving alternative to arthroplasty. [3] (10.1016/j.arthro.2012.10.028)
• [Paper] The comprehensive arthroscopic management procedure provides a predictable short-term joint-preserving option for younger, high-demand patients with advanced glenohumeral osteoarthritis by reducing pain and improving function. [4] (10.1016/j.eats.2015.04.003)
• [L4] Arthroscopic management in patients younger than 50 can achieve predictably good to excellent results regardless of tear size. [5] (10.1016/j.jse.2007.05.006)
• [L3] Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced OA of glenohumeral joint. [6] (10.1186/s12891-015-0741-9)
• [L5] [7] (10.5435/jaaos-d-17-00214)
• [L4] This study demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively. [8] (10.1177/0363546516656372)
• [L4] CAM is a reasonable option for patients with localized cartilage defects and specific radiographic findings, while HA or TSA are feasible options for those with humeral head incongruity or large anterior osteophytes. [10] (10.1530/eor-2023-0156)
• [Paper] Arthroscopic debridement is a reasonable next-line treatment if antiinflammatory medications and therapy fail, with good short-term results and minimal complications in patients with small, contained, unipolar lesions. [12] (10.1016/j.csm.2018.05.003)
• [L4] The authors state they have increasingly used all-arthroscopic techniques with satisfactory results. [13] (10.1053/j.otsm.2005.10.003)
• [L4] Successful management requires a full understanding of all responsible pathologic components, typically involving reattachment of the fibrocartilaginous labrum and re-creating proper tension of the capsuloligamentous structures. [14] (10.1177/03635465000280042801)
• [L4] Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. [15] (10.1016/j.jse.2022.12.004)
• [L3] Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands, though long-term consequences require further evaluation. [16] (10.1007/s00402-004-0738-6)
• [L1] [17] (10.1016/j.arthro.2020.02.036)
• [L3] [19] (10.1177/0363546520962756)
• [L5] [20] (10.1097/bte.0b013e31825ce947)
• [L5] In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. [21] (10.1016/j.arthro.2020.05.018)
• [L2] By the criteria of this study, arthroscopic reconstruction provides results equal to those of the open procedure for patients age 22 and older, would provide a success rate of 90% in patients age 18 to 23 but would only work approximately 80% of the time in patients 18 and younger and is not indicated in patients in this age range. [22] (10.1016/s1058-2746(96)80205-9)
• [L3] The combined approach appears to be a viable joint-preserving option for select patients with concomitant rotator cuff tears and focal humeral head cartilage lesions. [24] (10.1177/23259671261436439)
• [L4] Arthroscopic release resulted in normal motion in all cases. [25] (10.1016/j.arthro.2009.01.018)
• [L4] Treatment of glenohumeral arthritis with arthroscopic glenoid resurfacing provided superior results in this series to their previously performed arthroscopic procedure. [28] (10.1016/j.arthro.2009.04.015)
• [L5] [30] (10.1097/bte.0b013e31818d1e52)
• [L4] Treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture can result in long-term improved function and reduced pain for some patients. [31] (10.1177/0363546517750627)
• [L4] Although there are limited nonarthroplasty surgical options available for glenohumeral arthritis, isolated arthroscopic debridement and capsular release may not provide substantial benefit to justify its use in most patients. [34] (10.1016/j.arthro.2014.08.025)
• [L4] Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement and patient satisfaction, in glenohumeral osteoarthritis, in the intermediate-term. [40] (10.1007/s00167-010-1155-8)
• [L4] At long-term follow-up (≥15 years), the patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline preoperative function and remain durable over a period of 15 years. [42] (10.1016/j.jse.2022.01.116)
• [L4] Arthroscopic debridement with capsular release may provide a window of improved symptoms and function before deterioration of the joint leads to a more significant operation, especially in younger patients with mild or moderate osteoarthritic changes. [43] (10.1016/j.arthro.2006.11.016)
• [L4] The majority of patients demonstrated sustained improvement in patient-reported outcomes and satisfaction without conversion to total shoulder arthroplasty at long-term follow-up, although some patients progressed to arthroplasty. [45] (10.1177/2325967121s00213)
• [L4] After the CAM procedure we found an 84% survivorship at 3 years and 72% survivorship at 5 years. [46] (10.1177/2325967116s00104)
• [Paper] The benefits of this physeal-sparing arthroscopic technique far exceed those of previously described open procedures without radiographic guidance. [51] (10.1016/j.eats.2019.02.012)
• [L4] Radiographs at 6 month follow-up demonstrate a space between the humeral head and the glenoid in all cases. [55] (10.1097/01.bte.0000135965.23606.f0)
• [L4] This is the first reported complication associated with the use of this type of suturing device, highlighting the need for careful examination of all devices during and after arthroscopic surgery. [56] (10.1016/j.arthro.2007.10.010)
• [L3] Radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair. [60] (10.1177/23259671221126095)
• [L1] Multimodal shoulder injection is a safe and effective modality for management of pain after arthroscopic rotator cuff repair. [98] (10.1007/s00167-012-2202-4)
• [L3] Arthroscopic repair was safe and effective in both groups, even for those with massive tears. [106] (10.1016/j.jse.2018.10.010)
• [Paper] Arthroscopic debridement with microfracture has yielded good-to-excellent results with significant improvements in motion, pain reduction, and high levels of patient satisfaction. [108] (10.1016/j.eats.2020.01.001)
• [L1] EAM and EPM were both safe and beneficial to improve ROM after arthroscopic surgery for patients with small to large sized tears. [117] (10.1186/s12891-023-07075-5)
• [L5] Glenohumeral osteoarthritis in young patients is a difficult condition with higher failure rates after surgical management compared to older patients; nonsurgical modalities are the mainstay of management, while surgical options include arthroscopic débridement, humeral head replacement, and total or reverse total shoulder arthroplasty. [121] (10.5435/jaaos-d-16-00657)
• [L4] [136] (10.1007/s00167-023-07377-0)
• [L5] [137] (10.1016/j.jse.2015.12.018)
• [L2] At minimum 2-year follow-up, arthroscopic repair of rotator cuff tears produced significant improvements in both patient-derived and objectively measured variables. [143] (10.1016/j.jse.2006.12.011)
• [L4] These arthroscopic procedures should be considered a viable alternative to shoulder replacement in patients who place high demands on the shoulder or refuse prosthetic replacement, even in the presence of abnormal glenoid morphology. [144] (10.1016/j.jse.2021.03.100)
• [L4] A follow-up of at least 2 years is necessary to determine short-term outcomes, especially in patients with severe preoperative fatty degeneration. [145] (10.1016/j.arthro.2024.12.029)
• [L1] [149] (10.1016/j.arthro.2013.02.022)
• [L2] Following arthroscopic rotator cuff repair, patients can achieve satisfactory pain control using a multimodal approach with a median of 18 opioid pills over 6.9 days when used in combination with non-opioid pain medications. [150] (10.1016/j.asmr.2021.10.005)
• [L2] [156] (10.2106/jbjs.20.01420)
• [L4] [163] (10.1016/j.jse.2015.12.010)
• [L3] Functional recovery after arthroscopic RCR follows a predictable but non-uniform sequence, characterized by early improvements in ROM and patient-reported outcomes, followed by delayed strength restoration. [169] (10.1016/j.otsr.2026.104787)
• [L1] Patients in the early and delayed groups demonstrated very similar clinical outcomes and range of motion at 1 year. [175] (10.1016/j.jse.2012.01.025)
• [L4] The study proposes a classification of subscapularis tendon tears based on observations of the pathoanatomy of the tears. [177] (10.4103/0973-6042.91000)
• [L2] Complications of the fingers and hand after arthroscopic rotator cuff repair easily occurred in patients with a past history of carpal tunnel syndrome or tenosynovitis and in patients with edema as per a subjective assessment. [182] (10.1016/j.jseint.2021.07.001)
• [L1] The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between the two groups, with clinical differences observed at 2 years disappearing at long term. [186] (10.1177/2325967121s00245)
• [L1] This study's findings reveal no clinically discernible differences in active range of motion at 1-year follow-up between patients assigned to either early or delayed motion protocols. [187] (10.1016/j.jse.2024.01.029)

See Also

• Capsular Release for Frozen Shoulder
• Rotator Cuff
• Total Shoulder Arthroplasty
• Os Acromiale
• Shoulder Arthroscopy
• Fractures
• Shoulder Arthritis
• Shoulder Instability
• Calcific Tendinitis
• Subacromial Decompression
• Biceps Tenodesis
• Rotator Cuff Repair

References

[1] Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Preoperative Factors Predictive of Treatment Failure. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516668823

[2] Comprehensive Arthroscopic Management of Shoulder Arthritis. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.01.033

[3] Comprehensive Arthroscopic Management (CAM) Procedure: Clinical Results of a Joint‐Preserving Arthroscopic Treatment for Young, Active Patients With Advanced Shoulder Osteoarthritis. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2012.10.028

[4] The Comprehensive Arthroscopic Management Procedure for Treatment of Glenohumeral Osteoarthritis. Arthroscopy Techniques. 2015. DOI: 10.1016/j.eats.2015.04.003

[5] Arthroscopic rotator cuff repair in patients younger than fifty years of age. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.05.006

[6] Relationship between probability of future shoulder arthroplasty and outcomes of arthroscopic debridement in patients with advanced osteoarthritis of glenohumeral joint. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0741-9

[7] Arthroscopic Management of Glenohumeral Arthritis: A Joint Preservation Approach. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00214

[8] Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516656372

[10] Comprehensive arthroscopic management versus total shoulder arthroplasty and hemiarthroplasty in patients with primary glenohumeral arthritis younger than 50 years old. EFORT Open Reviews. 2026. DOI: 10.1530/eor-2023-0156

[12] Nonarthroplasty Options for the Athlete or Active Individual with Shoulder Osteoarthritis. Clinics in Sports Medicine. 2018. DOI: 10.1016/j.csm.2018.05.003

[13] Arthroscopic Rotator Cuff Repair in Active Duty Military Personnel: A Young Cohort of Patients with Rotator Cuff Tears. Operative Techniques in Sports Medicine. 2005. DOI: 10.1053/j.otsm.2005.10.003

[14] Arthroscopic Management of Glenohumeral Instability. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280042801

[15] Factors associated with functional improvement after posteriorly augmented total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.12.004

[16] Arthroscopic debridement of massive rotator cuff tears: negative prognostic factors. Archives of Orthopaedic and Trauma Surgery. 2004. DOI: 10.1007/s00402-004-0738-6

[17] Outcomes and Survivorship After Arthroscopic Treatment of Glenohumeral Arthritis: A Systematic Review. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.02.036

[19] Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520962756

[20] Comprehensive Arthroscopic Management (CAM) Procedure for Shoulder Osteoarthritis. Techniques in Shoulder & Elbow Surgery. 2012. DOI: 10.1097/bte.0b013e31825ce947

[21] Posterior Glenohumeral Instability: Diagnosis and Management. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2020.05.018

[22] Arthroscopic reconstruction of recurrent traumatic anterior instability. Journal of Shoulder and Elbow Surgery. 1996. DOI: 10.1016/s1058-2746(96)80205-9

[24] Midterm Outcomes of Concomitant Arthroscopic Rotator Cuff Repair and Microfracture of Humeral Head, Focal, Full-thickness Cartilage Lesions. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261436439

[25] Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff Repair. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.01.018

[28] Arthroscopic Glenoid Resurfacing: Results in Patients With Failed Previous Arthroscopic Debridement (SS‐14). Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.04.015

[30] Management of Glenoid Bone Deficiency in Total Shoulder Arthroplasty for Osteoarthritis. Techniques in Shoulder & Elbow Surgery. 2008. DOI: 10.1097/bte.0b013e31818d1e52

[31] Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546517750627

[34] Arthroscopic Debridement and Capsular Release for the Treatment of Shoulder Osteoarthritis. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.08.025

[36] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Radiographic Evaluation.

[38] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > INDICATIONS FOR ARTHROSCOPIC TREATMENT.

[40] Arthroscopic debridement and biological resurfacing of the glenoid in glenohumeral arthritis. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1155-8

[42] Minimum 15-year follow-up for clinical outcomes of arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.116

[43] Arthroscopic Debridement and Capsular Release for Glenohumeral Osteoarthritis. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.11.016

[45] Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00213

[46] Survivorship after Arthroscopic Management of Glenohumeral Osteoarthritis with a Minimum 5 year Follow-up. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00104

[51] Physeal‐Sparing Transosseous‐Equivalent Arthroscopic Rotator Cuff Repair. Arthroscopy Techniques. 2019. DOI: 10.1016/j.eats.2019.02.012

[55] Surgical Treatment for Glenohumeral Arthritis in the Young Patient. Techniques in Shoulder & Elbow Surgery. 2004. DOI: 10.1097/01.bte.0000135965.23606.f0

[56] Suture Passing Needle Breakage During Arthroscopic Rotator Cuff Repair: A Complication Report. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2007.10.010

[60] Evaluation of Radiographic Changes 5 Years After Arthroscopic Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221126095

[62] Rockwood And Matsen S The Shoulder. Shoulder and Elbow Specialty Clinic Workers’ Survey > ANATOMY.

[64] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > SHOULDER AND ARM INJURIES.

[65] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Applied Anatomy Related to Scapular Fractures.

[66] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Shoulder, Arm, and Elbow > I. Shoulder.

[70] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > FRACTURES OF THE PROXIMAL HUMERUS.

[72] Aaos Comprehensive Orthopaedic Review 3. Fractures of the Clavicle, Scapula, and Glenoid > I. Clavicular Fractures.

[73] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > Development of Individual Regions.

[75] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > ANATOMY AND BIOMECHANICS.

[76] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH BONE-PATELLAR TENDON-BONE GRAFT > SHOULDER INJURIES > ANATOMY AND BIOMECHANICS.

[77] Miller S Review Of Orthopaedics. Genetics of musculoskeletal conditions and abnormalities are summarized in Table 1.27 > UPPER EXTREMITY > SHOULDER.

[79] Orthopaedic Knowledge Update Sports Medicine 6. Diagnostic Ultrasonography and Ultrasonography-­Guided Procedures > Annotated References.

[80] Apley And Solomon S Concise System Of Orthopaedics And Trauma. INVESTIGATION.

[82] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > FRACTURES AND DISLOCATIONS AROUND THE SHOULDER.

[83] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > SENIOR EDITOR COMMENTARY.

[85] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Magnetic Resonance Imaging and Arthrography.

[88] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Anatomy and Biomechanics, Clinical Evaluation, Imaging > Clinical Evaluation > Imaging.

[89] Aaos Comprehensive Orthopaedic Review 3. Imaging of the Shoulder and Elbow > I. Shoulder.

[98] Randomized, controlled trial of multimodal shoulder injection or intravenous patient‐controlled analgesia after arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2202-4

[106] Do elderly patients gain as much benefit from arthroscopic rotator cuff repair as their younger peers?. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.10.010

[108] Technique for Arthroscopic Debridement and Microfracture of Unstable, Contained Osteochondritis Dissecans Lesions of the Capitellum. Arthroscopy Techniques. 2020. DOI: 10.1016/j.eats.2020.01.001

[117] Early versus delayed mobilization for arthroscopic rotator cuff repair (small to large sized tear): a meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-07075-5

[121] Glenohumeral Osteoarthritis in the Young Patient. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00657

[136] Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07377-0

[137] The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.018

[143] Arthroscopic rotator cuff repair: Prospective functional outcome and repair integrity at minimum 2-year follow-up. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.12.011

[144] The Role of Arthroscopic Glenoidplasty and Osteocapsular Arthroplasty in the Treatment of Advanced Glenohumeral Arthritis. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.100

[145] Re-tear Rate of Sugaya III Tendons Between 1 and 2 Years Postoperatively After Arthroscopic Rotator Cuff Repair Is Over 30% and Associated With Higher Tear Size and Fatty Degeneration. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2025. DOI: 10.1016/j.arthro.2024.12.029

[149] What Is the Role of Arthroscopic Debridement for Glenohumeral Arthritis? A Critical Examination of the Literature. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.02.022

[150] Satisfactory Pain Management With Minimal Opioid Use After Arthroscopic Rotator Cuff Repair. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2021.10.005

[156] Stepped Augmented Glenoid Component in Anatomic Total Shoulder Arthroplasty for B2 and B3 Glenoid Pathology. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01420

[163] Total shoulder arthroplasty using an inlay mini-glenoid component for glenoid deficiency: a 2-year follow-up of 9 shoulders in 7 patients. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.010

[169] Kinetics of recovery after arthroscopic rotator cuff repair: early motion, delayed strength, and age-related differences. Orthopaedics & Traumatology: Surgery & Research. 2026. DOI: 10.1016/j.otsr.2026.104787

[175] Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2012.01.025

[177] The frequency of subscapularis tears in arthroscopic rotator cuff repairs: A retrospective study comparing magnetic resonance imaging and arthroscopic findings. International Journal of Shoulder Surgery. 2011. DOI: 10.4103/0973-6042.91000

[182] Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair – carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome. JSES International. 2021. DOI: 10.1016/j.jseint.2021.07.001

[186] Platelet Rich Plasma in Arthroscopic Rotator Cuff Repair: Clinical and Radiological Results of A Prospective RCT Study at 10-Year Follow-Up. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00245

[187] Does timing influence rehabilitation outcomes in arthroscopic rotator cuff repair with biceps rerouting? a prospective randomized study. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.01.029