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Degenerative Conditions

Glenohumeral osteoarthritis and cuff tear arthropathy: radiographic classification, management of primary vs secondary disease, and surgical indications.

159 citationsUpdated Sep 2026

Overview

Degenerative conditions span multiple joints, requiring management strategies that address the underlying degenerative cascade [1]. For the thoracolumbar spine, total disk replacement has demonstrated short-term success, though long-term effects require further investigation [1]. Arthrodesis remains the best surgical treatment for the persistently painful degenerative back, despite increased morbidity, mortality, and non-union risks [14]. In the knee, degenerative joint disease is common and necessitates an understanding of pathology and diagnosis to provide evidenced-based care [2]. Current non-surgical managements do not alter the clinical course or arrest disease progression [12]. Joint replacement is indicated for end-stage osteoarthritis, relieving pain and improving function more than other current operative treatments [12, 51]. However, these procedures are limited by the inability of synthetic materials to duplicate articular cartilage properties [51]. For young patients or those with less advanced disease, procedures that restore rather than replace the joint may offer advantages [51]. Total hip arthroplasty remains a very good option in young patients who are not ideal candidates for joint preservation surgery [148].

Shoulder degenerative conditions present distinct therapeutic pathways. Clinical outcomes after reverse total shoulder replacement are best observed in patients with degenerative diseases and lowest in those undergoing secondary interventions [3]. There are no significant differences in clinical or radiographic outcomes at a minimum of 5 years follow-up for patients undergoing reverse total shoulder arthroplasty for acute fracture versus degenerative conditions [24]. Patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications [142]. Reverse arthroplasty can achieve highly favorable outcomes for glenohumeral osteoarthritis with an intact rotator cuff [53]. For young patients with glenohumeral osteoarthritis, experts recommend a stepwise approach starting with nonoperative treatment, followed by joint-preserving arthroscopic procedures for selected patients, and reserving joint replacement or resurfacing for cases where less invasive options fail [58]. Careful consideration should be made of the relative benefits of humeral head replacement compared to total shoulder arthroplasty for osteoarthritis [59]. The AAOS developed Appropriate Use Criteria to determine the appropriateness of various treatments for shoulder osteoarthritis with intact rotator cuff and severe glenoid retroversion, utilizing a multidisciplinary panel to rate 240 patient scenarios across five treatment options [138].

Rotator cuff disease is widespread with prevalence increasing with age [22]. Both surgical and nonsurgical treatments can be effective [22]. Surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease [9]. Patients with degenerative rotator cuff disease demonstrate clinically relevant differences in pain and functional outcomes between surgical and nonoperative treatment [9]. At 1 year, no significant difference in functional outcome was observed between surgical and conservative treatment for degenerative rotator cuff tears, although significant differences in pain and disability favored surgical treatment [46]. A follow-up of at least 2 years is necessary to determine short-term outcomes for arthroscopic rotator cuff repair, especially in patients with severe preoperative fatty degeneration [16]. Untreated chronic rotator cuff tears can lead to arthrosis, for which salvage options exist [22]. In the hip, few asymptomatic hips with normal findings on initial radiographs in patients with non-traumatic osteonecrosis are at risk for pain or radiographic abnormalities [8]. When disease develops in these asymptomatic hips, deterioration is slow and operative intervention is rarely indicated [8]. Core decompression is regarded as the first surgical option for humeral head avascular necrosis in the precollapse stage, though it has not been confirmed to prevent or delay natural progression [25]. Shoulder arthroplasty is reserved for late stages of humeral head avascular necrosis with fairly good outcomes, although long-term implant survival and complications are undocumented [25]. For glenohumeral cartilage defects, evidence for microfracture is limited to Level IV studies, with concerns remaining regarding long-term durability and progression of osteoarthritis [5]. An expert panel of cartilage surgeons reached a consensus that osteochondral allograft transplantation was clearly suitable for a variety of specific indications [52]. In the wrist, proximal-row carpectomy should be considered after conservative measures fail for diseases of the proximal row [38]. Mild degenerative arthritis is not a contraindication for this procedure, and progressive degenerative arthritis of the radial capitate articulation did not occur following proximal-row carpectomy [38]. The prevalence of chronic non-orthopedic conditions did not differ between satisfied and dissatisfied patients when evaluated independent of the degree of degeneration [11].

Anatomy & Pathophysiology

General Degenerative Mechanisms

Lifelong moderate use of normal joints does not increase the risk of articular cartilage degeneration [19], whereas high-impact and torsional loads may increase this risk [19]. Individuals with abnormal joint anatomy, joint instability, disturbances of joint or muscle innervation, or inadequate muscle strength or endurance face a greater risk of degenerative joint disease [19]. The degeneration of normal articular cartilage is not simply the result of aging and mechanical wear [19]; rather, age-related changes in chondrocyte function contribute to the development and progression of osteoarthritis [19].

The joint must be considered an organ where synovium, tendon, and subchondral bone contribute to the disease process of posttraumatic osteoarthritis [202]. Native articular cartilage exists in a state of relative cellular quiescence and homeostasis, which is tipped out of equilibrium by traumatic insults [202]. Momentary mechanical trauma on the articular surface during shoulder dislocation results in focal injury to the cartilage matrix and chondrocyte apoptosis [202]. In the context of rotator cuff pathology, altered mechanical loading after rotator cuff tears is the primary factor in cartilage degeneration [220], while shoulder activity level is not related to tear progression risks [163].

Spine Pathophysiology

Charcot spine arthropathy is explained by two primary theories. The neurovascular theory proposes that autonomic dysfunction leads to increased bone resorption in hypervascular regions of subchondral bone, causing microfractures and joint destruction [4]. The neurotraumatic theory proposes that loss of proprioception and protective joint mechanisms in spinal cord injury patients leads to increased biomechanical loads and instability [4]. In Charcot spine arthropathy, increased stresses result in hyperplasia and hypertrophy of the synovial joint capsule, leading to instability and progressive subdislocation [4]. After an initial phase of destruction and bone resorption, the Charcot joint becomes surrounded by dense fibrous tissue and sclerotic bone [4]. Osseous debris in Charcot joints solidifies around the affected region due to decreased vascularity over time [4].

The risk of early occurrence of Charcot spine arthropathy is greater in very active patients with spinal cord injury [4]. Increased repetitive movements for transfer and sitting in surgically treated paraplegic patients contribute to the development of Charcot spine arthropathy [4]. Degenerative cervical myelopathy involves a cascade of events after spinal cord compression, including ischemia, destruction of the blood–spinal cord barrier, demyelination, and neuronal apoptosis [6].

Shoulder Bony Anatomy

The humeral head is spherical with a diameter of 37 to 57 mm [71] and an articular surface arc of approximately 160 degrees covered by articular cartilage [88]. The radius of curvature of the humeral head is approximately 25 mm and is slightly larger in men than in women [88]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [71], and the superior margin is normally superior to the top of the greater tuberosity by 8 to 10 mm [88]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [71], and the humeral head is retroverted an average of 30 degrees [73]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the method used for measurement [88]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [71], and the neck-shaft angle measures an average of 135 degrees [73].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [71]. The glenoid cavity is a shallow socket, approximately one third the size of the humeral head [73]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [88]. The glenoid averages 5° of retroversion in relation to the axis of the scapular body [76]. The average neck-shaft angle is 45 degrees (±5 degrees), with a range of 30 to 50 degrees [88], and arthritic shoulders have a flatter neck-shaft angle close to 50 degrees [88].

The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [88]. A significant decrease in lateral humeral offset reduces the lever arms for the deltoid and supraspinatus muscles, weakening abduction [88]. Conversely, a significant increase in lateral humeral offset causes excessive tension on soft tissues, resulting in loss of motion and likely accelerating polyethylene wear [88]. Humeral articular malposition of more than 4 mm leads to increased subacromial contact [88], and an offset of 8 mm in any direction significantly decreases passive range of motion [88].

The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [92]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [92], and the humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [92]. Head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [92]. The scapula spans second through seventh ribs and serves as an attachment for 17 muscles [92]. The clavicle is the first bone in the body to ossify at 5 weeks gestation and the last to fuse with the medial epiphysis at 25 years of age [92].

The scapula has only one true diarthrodial articulation, the acromioclavicular joint [76]. Normal shoulder motion is approximately two-thirds glenohumeral and one third scapulothoracic [76]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [76]. Failure of fusion of acromial ossification centers results in os acromiale [76]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [76].

The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [76]. The humeral head ossification center is usually present at birth, the greater tuberosity appears by 1 to 3 years of age, and the lesser tuberosity appears by 5 years of age [80]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [80]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to adult values by 11 years of age [80]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis, accounting for approximately 40% of the growth of the entire upper extremity [80].

The distribution of bony mass in the scapula is highly uneven, with the highest concentration in the glenoid, scapular neck, and lateral border [74]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically the infraspinous fossa [74]. The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [74]. The lateral pillar connects the inferior border of the glenoid with the inferior angle of the scapula [74]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [74]. The two bony pillars connected by a markedly thinner medial border form the basic load-bearing structure of the scapular body [74]. The superior angle and adjacent supraspinous fossa form an appendage that does not transmit compressive forces from the glenoid [74].

Shoulder Soft Tissue Anatomy

The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [73]. The teres major is not a rotator cuff muscle [73]. The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [73]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [73]. The greater tuberosity provides attachment for the supraspinatus, infraspinatus, and teres minor muscles [73], while the lesser tuberosity contains the attachment of the subscapularis muscle [73].

The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch [71]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath the coracoacromial arch [71]. The subscapular bursa lies between the subscapularis tendon and the neck of the scapula and communicates with the joint cavity between the superior and middle glenohumeral ligaments [77]. The subscapular bursa often houses loose bodies in the shoulder and is a region where synovitis may be most intense [77].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [76]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [76]. Laxity of the rotator interval results in inferior laxity (the sulcus sign), and contracture of the interval is seen with adhesive capsulitis [76].

The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [76]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [76]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [76]. 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 [76]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [76].

The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction [89]. 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 [89]. The inferior glenohumeral ligament is composed of an anterior band, a posterior band, and a thinner intervening axillary pouch, creating a hammock-type sling [89]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [89].

The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [89]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [89]. 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 [89].

The glenoid labrum increases the depth of the socket by 50% around the humeral head [89]. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [89]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [89]. The fibrocartilaginous glenoid labrum deepens the socket 50% and provides a bumper to translation [92]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [92].

The superior shoulder suspensory complex is composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion [76]. The superior strut of the superior shoulder suspensory complex comprises the middle clavicle, and the inferior strut comprises the lateral scapular border/spine of the scapula [76]. The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [76]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability [92].

The acromioclavicular joint is a plane/gliding joint with a fibrocartilaginous disc [92]. The posterior and superior acromioclavicular ligaments are considered the strongest stabilizers against anteroposterior displacement [92]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint, and the conoid ligament is located approximately 45 mm from the acromioclavicular joint [92]. The conoid ligament is posteromedial and stronger than the trapezoid ligament [92].

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 [73]. 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 by way of its terminal anterolateral branch known as the artery of Laing [71]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [71]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [71]. Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [80]. The primary blood supply to the clavicle is periosteal, and there is no nutrient blood supply [83].

The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [79]. The axillary nerve passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction [79]. The axillary nerve splits into anterior and posterior branches within the quadrangular space [79]. The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [79]. The posterior deltoid muscle innervation varies, with supply only from the anterior branch in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [79]. The posterior branch of the axillary nerve branches to supply the teres minor muscle and then terminates as the superior lateral brachial cutaneous nerve [79].

The humeroscapular motion interface lies between the inner structures of the proximal humerus, rotator cuff, coracohumeral ligament, and biceps tendon sheath and the superficial layer of the acromion, deltoid, coracoacromial ligament, coracoid process, and conjoined tendon [79]. Smooth, unrestricted motion at the humeroscapular motion interface is vital to shoulder mobility [79]. The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch, allowing them to glide [81]. 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 [81]. The subscapularis is inserted into the lesser tuberosity [81].

Shoulder Pathophysiology and Degeneration

Hooked, curved, and laterally sloping acromions are strongly associated with

Classification

Minami Classification: This system classifies osteochondritis dissecans (OCD) of the elbow into three grades based on lesion stability and morphology. Grade 1 is defined as a stable lesion with a translucent cystic shadow in the capitellum [45]. Grade 2 presents a clear zone between the OCD and adjacent subchondral bone [45]. Grade 3 is characterized by the presence of loose bodies [45]. A recent study identified the Minami Classification as the most reliable for classifying different stages of OCD of the capitellum [45].

Itsubo et al. MRI Classification: This MRI-based system distinguishes five stages of OCD of the elbow. Stage 1 presents a normally shaped capitellum with several spotted areas of high signal intensity [45]. Stage 2 presents a normally shaped capitellum with several spotted areas of higher intensity than that of cartilage [45]. Stage 3 presents discontinuity and noncircularity of the chondral surface signal of the capitellum with no high signal interface apparent between the lesion and the bottom of the lesion [45]. Stage 4 presents a lesion separated by a high-intensity line in comparison with the cartilage [45]. Stage 5 presents a capitellar lesion displaced from the floor or a defect of the capitellar lesion [45].

Goutallier Classification: This system defines fatty degeneration in five stages. Stage 0 is normal muscle with no fatty deposits [47]. Stage I indicates some fatty streaks present [47]. Stage II is defined as more muscle than fat [47]. Stage III represents equal muscle and fat [47]. Stage IV indicates more fat than muscle [47]. The Goutallier classification system and the Quartile system performed equally well in assessing fatty degeneration of the gluteus muscles, demonstrating excellent levels of interrater and intrarater agreement [120]. The Goutallier/Fuchs classification system can be reliably and reproducibly applied to the evaluation of abductor tendon tears of the hip and appears to correlate with patient-rated outcomes after repair [188].

Fuchs MRI Classification: This system includes stages II and III, which correspond to Goutallier stages II and III for fatty degeneration [47].

Hemophilic Arthropathy Classification: A new four-category, 7-point classification system demonstrated interobserver reproducibility and correlation with joint function equivalent to the Pettersson et al. system [114]. This new system is easier to apply and more sensitive in discriminating advanced arthropathy than the Arnold and Hilgartner system [114].

Royal Berkshire Hospital Classification: This system categorizes coracoacromial ligament (CAL) degeneration into four grades. Grade 0 is defined as normal appearance [241]. Grade 1 is defined as minor fraying [241]. Grade 2 is defined as major fraying [241]. Grade 3 is defined as visualization of the bare bone under the CAL [241].

Samilson and Prieto Grading System: This system for glenohumeral arthropathy is based on the size of the inferior glenohumeral osteophyte [235]. Inter- and intraobserver reliability of this grading system varied between fair and poor using radiographs in neutral rotation [235].

Rosenberg Classification System: This system for glenohumeral osteoarthritis is based on all radiological signs of osteoarthritis, including joint space narrowing, sclerosis, and cysts [235].

ICRS Hyaline Cartilage Lesion Classification System: This system is a modification of the Outerbridge classification and is currently used as the international standard [70].

Walch Classification: This classification for glenoid morphology allowed a fair to substantial agreement in the evaluation of glenoid morphology [242]. It has been used to stratify patients for shoulder arthroplasty [151]. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses than the Walch classification [151].

Other Considerations: A new concise MRI classification of haemodialysis-related amyloidosis of the shoulder was proposed [56]. Factors associated with calcium reabsorption in the shoulder include the Gartner classification, disease duration, and blood flow around calcium deposits [154].

Clinical Presentation

General Degenerative Joint Disease

Degenerative joint disease of the knee is a common condition [2]. The degeneration of articular cartilage as part of the clinical syndrome of osteoarthritis is one of the most common causes of pain and disability in middle-aged and older people [19]. Patients present with a broad range of symptoms, with 33% being asymptomatic [35]. Radiographic evidence of osteoarthritis does not necessarily correlate with poor function [41]. Nontraumatic pathologic conditions of the upper extremity, such as neuropathy, vascular disease, and degenerative arthritis can have a profound effect on function and quality of life [42].

The diagnosis of osteonecrosis might be challenging because of overlapping clinical presentation with other disorders particularly in the early stage of the disease with normal radiographs [32]. The presence of bone and cartilage debris ground into the synovial membrane is a significant pathological finding indicative of early neuropathic joints, often appearing before clinical or roentgenographic evidence is demonstrable [33]. Rapidly destructive arthrosis presents with unique radiographic features, MRI findings, and a specific clinical course characterized by rapid humeral head collapse [43]. The clinical presentation of Charcot spine arthropathy can vary dependent on the presence of biological processes in the different stages of Charcot joint arthropathy [4].

Cervical Spine

Degenerative cervical conditions are common and present with axial neck pain, radiculopathy, or myelopathy [7].

Shoulder

Osteoarthritis of the acromioclavicular (AC) joint is a common condition causing anterior or superior shoulder pain, especially with overhead and cross-body activities [100]. Diagnosis of AC joint osteoarthritis can be challenging given the lack of specificity with positive physical examination findings and the variable nature of AC joint pain [100]. 32% of patients with painful AC joints had a normal X-ray [35].

Rotator cuff tears represent a spectrum of disease progressing from tendinitis to cuff arthropathy, with prevalence increasing significantly with age [20]. Rotator cuff tears—even ones of substantial size—can be asymptomatic [126]. The amount of shoulder discomfort experienced by the patient is not related to the size of the tear [126]. Pain may not be the primary symptom of rotator cuff failure, which may also produce weakness, stiffness, crepitus, or instability [126]. Degenerative tearing typically occurs in older patients [126]. The profile of age-related degenerative rotator cuff disorders fails to correlate systematically with self-reported nontraumatic shoulder pain, particularly in older age [111]. Gender, age, duration of symptoms, accompanying medical disease, cuff tear size, and degenerative indicator of cuff tear have no effect on stiffness [99].

Clinical features are not very reliable for diagnosis of acetabular labrum tears in sports patients with groin pain [39]. The diagnostic criteria for confirming a labral tear included patient history, physical examination findings, radiographic analysis, and magnetic resonance imaging (MRI) [82]. Physical examination findings consistent with a labral tear, such as a positive anterior impingement sign, were positive in all patients [82]. The indications for surgery for labral tears were pain interfering with the activities of daily living and failure to improve with nonoperative treatment, including physical therapy and anti-inflammatory medications, for 3 months [82].

Females had more profound symptomatology and milder morphologic abnormalities in femoroacetabular impingement [118]. Males had a higher activity level, larger morphologic abnormalities, more common combined-type FAI morphologies, and more extensive intra-articular disease in femoroacetabular impingement [118]. Diagnosis and management of snapping scapula syndrome remains challenging despite recent advances [108]. Careful clinical assessment can differentiate between causes of shoulder pain and guide best management after a cerebrovascular accident or traumatic brain injury [98].

Hip

Few asymptomatic hips with normal findings on initial radiographs are at risk for pain or radiographic abnormalities [8]. When disease does develop in asymptomatic hips with non-traumatic osteonecrosis, deterioration is slow and operative intervention is rarely indicated [8].

Investigations

General Principles and Biomarkers

No currently available osteoarthritis-related biomarker serves as a surrogate for clinical or imaging features in the diagnosis or prognosis of the disease [36]. In early neuropathic joints, the presence of bone and cartilage debris ground into the synovial membrane is a significant pathological finding that often appears before clinical or roentgenographic evidence is demonstrable, though it is not absolutely specific as it can occur in advanced degenerative arthritis [33]. Pseudogout can mimic synovial chondromatosis clinically and roentgenographically due to extensive calcification of synovial tissue, but the two diseases have different treatments [218]. Hips with synovial chondromatosis may present with clinical and radiographic features resembling those of cam-type femoroacetabular impingement [217]. While CT and MRI can assist in diagnosis, definitive diagnosis relies on histopathological confirmation, requiring incisional biopsy in most cases [159, 194].

Shoulder Imaging

The purpose of shoulder imaging is to establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and illustrate the condition to the patient [31]. Because the shoulder is a three-dimensional structure where critical relationships such as humeral head centering change with arm position, a judicious approach is required to avoid over-imaging while obtaining necessary information [115].

Plain radiography: Standardized plain films are almost always sufficient for shoulder evaluation [31]. The standard series should include orthogonal views: a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [122]. At least two views are required: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction to show the humeral head-glenoid relationship [107]. The axillary view taken with the arm in the functional position of elevation is referred to as the "truth view" because it demonstrates glenohumeral relationships in that position and enables measurement of posterior subluxation or "functional decentering" not evident with the arm at the side [31]. Radiographs provide better reproducibility and accuracy for critical shoulder angle measurement compared to MRI [180]. Normal acromiohumeral distance is 7 to 14 mm, the glenohumeral joint space width should be symmetric superiorly and inferiorly, and the coracoclavicular distance is normally 1.1 to 1.3 cm [122]. Type III acromial morphology correlates with rotator cuff disease, though no direct causal relationship has been demonstrated [122]. Increased age is the main determinant of radiological changes in shoulder OA, as well as pain [200]. Osteoarthritis patients had a broad range of symptoms with 33% being asymptomatic, and 32% of patients with painful AC joints had a normal X-ray [35]. Asymptomatic AC-OA remained asymptomatic in 90% over 7 years [198]. In a systematic review of posterior shoulder dislocations, a missed initial diagnosis occurred in 73% of patients due to the lack of an axillary view, Y view, or computed tomography imaging [125]. Of the patients with missed initial diagnosis of posterior dislocation, almost all (147/150 or 98%) had only AP or lateral views of the shoulder [125]. When the axillary or Y-view radiographs were made subsequently, the diagnosis of posterior dislocation was confirmed in 100% of patients [125]. In a comparison of axillary and scapular "Y" view in 75 consecutive patients with suspected shoulder dislocations, both views resulted in the same diagnosis in 69 patients (92%) [125]. 81% of patients preferred the scapular "Y" view because of less pain [125]. The radiology technician preferred the "Y" view due to the ease of obtaining the image compared to the axillary view [125].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [121]. 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 [121]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [121]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [121]. When MRI or MR arthrography is contraindicated, CT arthrography is indicated [121]. MRI is useful to identify osteonecrosis of the humeral head, or a bone tumour [107]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [107]. Traditional magnetic resonance imaging (MRI) is utilized for evaluation of soft tissues with high contrast and spatial resolution in patients with anterior shoulder instability [117]. MR accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [117]. MR arthrography (MRA) increases the sensitivity for detecting tears and other lesions by distending the joint capsule with contrast [117]. In a meta-analysis of 6 studies including 4,667 shoulders, MRA had greater diagnostic test accuracy for glenoid labral lesions than MRI, with MRA sensitivity of 88% and specificity of 93% versus MRI sensitivity of 76% and specificity of 87% [117]. Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [117]. A retrospective study found that full routine MRI or MRA examination had similar accuracy as the ABER sequence in evaluating the anteroinferior labral–ligamentous complex [117]. A study found that the sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of the MRA in neutral position and more effective in identifying Perthes lesions [117]. MRAs can demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability [117]. 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 [117]. The sensitivity of MRI for the detection of full-thickness rotator cuff tears is 100% [122]. The specificity of MRI for the detection of full-thickness rotator cuff tears is 68% [122]. The positive predictive value of MRI for the detection of full-thickness rotator cuff tears is 85% [122]. The negative predictive value of MRI for the detection of full-thickness rotator cuff tears is 100% [122]. The accuracy of MRI for the detection of full-thickness rotator cuff tears is 89% [122].

CT: CT scans may offer a few degrees of increased precision in the measurement of glenoid version, but this precision does not improve the quality of the surgery or the clinical outcome [31]. CT is helpful for planning fracture surgery and shoulder joint replacement [107]. 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 [122]. A fatty infiltration graded 2, a common threshold for management decision, was commonly found in aging patients with an intact cuff on CT arthrography [214].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [107]. Ultrasonography can be useful in guiding injections or barbotage [107]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [121]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [121]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [121]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [121]. The sensitivity of ultrasonography for the detection of full-thickness rotator cuff tears is 98% [122]. The specificity of ultrasonography for the detection of full-thickness rotator cuff tears is 80% [122]. The positive predictive value of ultrasonography for the detection of full-thickness rotator cuff tears is 90% [122]. The negative predictive value of ultrasonography for the detection of full-thickness rotator cuff tears is 95% [122]. The accuracy of ultrasonography for the detection of full-thickness rotator cuff tears is 94% [122]. The most commonly performed joint examination using ultrasonography is the shoulder examination [101]. Accuracy of rotator cuff ultrasound depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [101]. In 70% of shoulders treated with ultrasonography-guided lavage for rotator cuff calcific tendinitis, the treatment resulted in significant reduction of symptoms [101]. Calcifications that were softer and middle-sized (12 to 17 mm) had more significant improvement after ultrasonography-guided lavage [101]. Better results occurred in patients aged 30 to 40 years after ultrasonography-guided lavage for rotator cuff calcific tendinitis [101]. With direct visualization, ultrasonography can pick up on partial tears that may need treatment but have normal physical examination findings [101].

Arthroscopy: Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, detachment of the glenoid labrum and rotator cuff tears [107]. This minimally invasive approach using the NanoScope Arthroscopy System is an effective alternative to traditional diagnostic techniques of diagnostic surgical arthroscopy and magnetic resonance imaging (MRI) [193].

Other Considerations: The MOON Shoulder Group developed and standardized imaging protocols for rotator cuff disease [105]. The MOON Shoulder Group conducted validation studies on the classification of rotator cuff tears based on MRI and arthroscopy videotapes as well as radiographic findings associated with rotator cuff disease [105].

Hip Imaging

Clinical features are not very reliable for diagnosis of acetabular labrum tears, and magnetic resonance arthrography and hip arthroscopy should be utilized more [39]. The exact definition of 'impingement' eludes the current literature, and while dynamic MRI has potential to better define hip impingement, it is not yet optimized for widespread clinical use [179]. Clinicians must 'treat the patient, not the MRI' regarding hip impingement [179]. Approximately, 1 in 11 patients with FAI and normal radiographic joint space width can present unequivocal signs of OA [212].

Spine Imaging

The North American Spine Society (NASS) Evidence-Based Clinical Guideline on the Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders reviews the diagnosis and treatment of cervical radiculopathy from degenerative disorders [6]. This review summarizes current knowledge of the pathophysiology of cervical disk degeneration and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood–spinal cord barrier, demyelination, and neuronal apoptosis [6]. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies [6].

Knee Imaging

Degenerative joint disease of the knee is a common condition with various disease processes requiring understanding of pathology, diagnosis, and treatment options to provide evidenced-based care [2]. This article reviews the imaging of hyaline cartilage, including consideration of technique, accuracy of diagnosis, and concepts for future imaging techniques, with the knee as the prototype joint [205].

General Cartilage and Joint Imaging

MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement, serving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities [30]. MRI results were not statistically different between the 2 treatments in an ovine model comparing novel osteochondral biotemplate and microfracture [164].

Treatment

Non-Operative

An initial trial of nonsurgical management is usually warranted for articular cartilage and subchondral bone pathology in the knee, consisting of rest, activity modification, anti-inflammatory medications, physical therapy, bracing treatment, or injections [91]. Nonoperative treatment is helpful for most patients with painful conditions of the acromioclavicular joint, although those with osteolysis may have to modify their activities [165]. In early-stage atraumatic osteonecrosis of the humeral head, nonoperative treatment is the preferred option and may prevent disease progression [155]. For primary and posttraumatic arthritis of the elbow, nonoperative treatment is almost always initiated, although surgical treatment may be indicated in cases refractory to conservative management [137]. Nonsurgical measures for distal radioulnar joint arthritis should include an initial trial of activity modification, gentle physical therapy, nonsteroidal antiinflammatory drugs, and immobilization [226].

Nonoperative modalities for shoulder osteoarthritis in athletes or active individuals have been poorly studied, and recommendations for or against certain treatments are not well established [170]. Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care [144]. A supervised stretching programme renders significant short and long-term decrease in symptom for patients with retro-trochanteric pain [227]. Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear [186]. Conservative treatment was effective in 77% of patients with a degenerative supraspinatus tear [97]. In secondary care for subacromial pain, physiotherapy or non-surgical treatment should be first line of management [201]. Patients with neuropathic arthropathy of the shoulder should be treated nonoperatively with an emphasis on the maintenance of function rather than immobilization [149]. For compression neuropathies with intermittent symptoms, treatment is generally initiated with physical therapy and splinting prior to proceeding to surgical decompression [94]. Treatment for pain in degenerative osteoarthritis of the digits is tailored to the individual’s age and occupation to optimize outcome [94]. Nonoperative and operative treatments show similar proportions of osteoarthritis at any point of follow-up for post-dislocation shoulder osteoarthritis [143].

Operative

Indications: Arthrodesis is at present the best surgical treatment for the persistently painful degenerative back, though it increases morbidity and mortality rates and carries a risk of non-union [14]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion for spondylolisthesis [17]. Surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease, with patients demonstrating clinically relevant differences in pain and functional outcomes compared to nonoperative treatment [9]. In patients with degenerative rotator cuff tears, no significant difference in functional outcome was observed between surgical and conservative treatment at 1 year; however, significant differences in pain and disability favored surgical treatment [46]. Arthrodesis is successful in patients with degenerative changes in the glenohumeral joint causing severe pain unrelieved by conservative treatment [129]. Arthrodesis of the shoulder is a contraindication in patients with neuropathic arthropathy of the shoulder [149]. Open sternoclavicular debridement has proved to be a simple, safe and highly effective new surgical treatment for patients with symptomatic sternoclavicular osteoarthritis unresponsive to non-operative management [176]. All-arthroscopic repair is an effective treatment modality for degenerative subscapularis tendon tears with an anterosuperior tear pattern with good clinical results and high patient satisfaction [131]. Arthroscopic rotator cuff repair appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time [132]. Clinical outcomes after reverse total shoulder replacement varied according to the underlying indication, with the best results observed in patients with degenerative diseases and the lowest in patients undergoing secondary interventions [3]. Arthroscopic treatment of synovial chondromatosis of the shoulder can result in immediate and durable improvement of shoulder function, though surgical treatment should be performed before irreversible degenerative changes occur [23]. Proximal-row carpectomy should be considered after conservative measures fail for diseases of the proximal row, as mild degenerative arthritis is not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur [38]. Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage [51]. Arthrodesis is indicated for degenerative arthropathies of the foot and ankle via fusion or replacement when treatment is based on symptom relief through nonsurgical methods fails [50]. Surgical management of articular cartilage and subchondral bone pathology in the knee should focus on removing inflammatory mediators and restoring the osteochondral unit [91]. Surgical options for articular cartilage and subchondral bone pathology in the knee include arthroscopic débridement, bone marrow stimulation, osteochondral autograft transfer, osteochondral allograft transplantation, autologous chondrocyte implantation, and various newer, emerging techniques [91]. Current clinical treatments for articular cartilage defects have limited ability to repair tissue and often result in mechanically inferior cartilage [124]. The evidence for microfracture for glenohumeral cartilage defects is limited to Level IV studies, and concerns remain regarding long-term durability and progression of osteoarthritis [5]. Arthroscopic osteochondroplasty and lavage was compared with arthroscopic lavage alone in a multi-centre randomized controlled trial for young adult femoroacetabular impingement [195]. Surgical treatment is not recommended as the first-choice treatment for primary shoulder stiffness, and the majority of published studies indicate a period of 3–6 months for initial evidence-based conservative treatment before considering surgical intervention [173]. When indicated, surgical treatment for primary shoulder stiffness shows excellent results in terms of range of motion and functional recovery and pain relief [173]. Anterior–inferior capsular release yields satisfactory results in terms of symptom resolution, pain reduction, functional recovery and range of motion improvement for primary shoulder stiffness [173]. The optimal treatment of glenohumeral arthritis in patients ≤ 50 years of age remains controversial, and there are many treatment options to consider when responding to the variety of clinical presentations and anatomic pathologies [130]. Arthroscopic debridement is an efficacious and particularly safe alternative in the short term for young patients with concerns about arthroplasty [49]. Experts recommend a stepwise approach for glenohumeral osteoarthritis in the young patient starting with nonoperative treatment, followed by joint-preserving arthroscopic procedures for selected patients, and reserving joint replacement or resurfacing for cases where less invasive options fail [58]. Nonoperative modalities should be utilized before surgical options for shoulder osteoarthritis, particularly for patients with moderate-to-mild disease, while surgical treatments like arthroplasty are considered effective for severe cases [128]. The best treatment for rotator cuff disease continues to be controversial and is currently based on the individual surgeon's clinical experience rather than firm scientific data [127]. There is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease [133]. In secondary care for subacromial pain, if symptoms fail to resolve with non-surgical treatment by six months, there is moderate evidence that surgical treatment could be considered and subacromial decompression may offer satisfactory long-term outcomes [201]. Patients should be made aware that there are studies which show no evidence of the benefit of surgery compared to sham surgery for subacromial pain [201]. The indications for use of steroids must be clearly delineated, probably more narrowly than has been done in the past, given the risk of multiple joint osteonecrosis following short-term steroid therapy [139]. Until further studies determine the aetiology, authors recommend considering carefully before performing arthroscopic procedures in the elderly, given cases of osteonecrosis following arthroscopic meniscectomy [135]. Proper indication for autologous osteochondral grafting relies on identifying and simultaneously correcting malalignment and/or traumatic changes in affected joints [134]. Management strategies for thoracolumbar degenerative conditions must address the degenerative cascade, with surgical options like total disk replacement showing short-term success but requiring further investigation into long-term effects [1]. Rotator cuff disease is widespread with prevalence increasing with age; both surgical and nonsurgical treatments can be effective, and while untreated chronic tears can lead to arthrosis, salvage options exist [22]. Modern medicine does not have a cure for degenerative arthropathies of the foot and ankle, and treatment is based on symptom relief through nonsurgical methods or surgical removal of arthritis via fusion or replacement [50]. Orthopaedic treatments available for neuromuscular disorders treat symptoms of the disease, but it is important to be aware of the overall prognosis and natural history to devise an appropriate treatment plan [90]. There is currently no cure for any of the included neuromuscular conditions, but advances in medical management, genetic treatment, and surgical care have increased life expectancy [96]. The orthopaedic approach to patients with neuromuscular diseases can be challenging as both surgical and supportive methods of interventions are available, and the timing of each should be chosen carefully and be placed in context of the patients’ overall function and the point in time of recovery [90]. In general, an interdisciplinary approach with regular longitudinal follow-ups will hopefully provide patients and their family an improved day-to-day satisfaction alongside with optimal clinical outcomes for neuromuscular disorders [90]. Nontraumatic pathologic conditions of the upper extremity, such as neuropathy, vascular disease, and degenerative arthritis, can be sometimes difficult to diagnose, and it is crucial to recognize common clinical presentations of each condition with appropriate history and physical examination, followed by well-chosen diagnostic studies as needed to confirm the suspected diagnosis [94]. Constant symptoms or motor involvement in compression neuropathies are cues to proceed with surgical intervention to preserve remaining nerve function [94]. There is no good evidence for steroid administration or surgical intervention for idiopathic brachial plexopathy, and most patients will have recovery with a variable functional end point over the course of multiple months to more than one year [94]. A thorough workup is imperative for vascular conditions of the upper extremity to determine the cause and formulate an appropriate treatment plan, ranging from lifestyle modification to pharmaceutical to surgical intervention [94]. The treatment algorithm for degenerative arthritis in the finger joints is largely based on relief of pain symptoms which improves function, with the choice of nonsurgical management or surgical intervention (arthrodesis versus arthroplasty) based on patient lifestyle and usual level of physical activities [94]. Clinical decision-making for the management of rotator cuff tears can be complex and lacks consensus among orthopedic surgeons [75]. Neither the clinical practice guidelines set out by the American Academy of Orthopaedic Surgeons nor the Cochrane systematic reviews provide guidance on the management of rotator cuff tears [75]. Patients with rotator cuff tears can generally be divided into three main categories based on the potential risk of nonoperative treatments and the proposed benefits of surgical intervention: those needing urgent or early operative repair, those that can benefit from a trial of conservative treatment, and those that may be best suited for nonoperative treatment [75]. The utility of arthroscopy for treating glenohumeral arthritis has been recently questioned [86]. The current American Academy of Orthopaedic Surgeons clinical practice guidelines classifies 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 [86]. Injectable viscosupplementation is an additional nonoperative treatment option for glenohumeral arthritis, although there is a paucity of evidence that supports its use in the shoulder, and it is not currently approved by the U.S. Food and Drug Administration for injection in joints other than the knee [86]. Preoperative radiographs and clinical examination were unreliable in predicting osteoarthritis that was intraoperatively documented in patients with shoulder pain [86]. In patients with unexpected intraoperative osteoarthritis, it is crucial to know what can be arthroscopically performed to address the condition [86]. The benefits of a lower complication rate and quicker return to normal activities after arthroscopy compared with total shoulder arthroplasty make arthroscopic treatment appealing for patients with coexistent soft tissue pathology [86]. Postoperative rehabilitation for rotator cuff arthropathy varies greatly and hinges on both the surgical procedure performed and the individual patient’s status and motivation to improve [221]. A systematic review on rehabilitation after reverse total shoulder arthroplasty demonstrated time frames ranging from 12 weeks to 6 months [221]. All included studies on rehabilitation after reverse total shoulder arthroplasty suggested initiation of passive range of motion and resistance exercise by week 6 along with full passive and active range of motion by week 12 [221]. A randomized control trial on immediate rehabilitation versus delayed with immobilization after reverse total shoulder arthroplasty demonstrated that both time courses produced statistically and clinically significant improvements in American Shoulder and Elbow Surgeons scores and patient recorded outcome measurements within 6 weeks [221]. The study on immediate versus delayed rehabilitation after reverse total shoulder arthroplasty demonstrated no significant difference in dislocation rates or opioid use [221]. While a statistically significant difference in pain existed favoring delayed therapy in the rehabilitation study, this did not translate to a clinically significant difference [221]. The study on immediate versus delayed rehabilitation after reverse total shoulder arthroplasty supports the safety of early initiation of therapy to avoid complications associated with prolonged immobilizations [221]. The study on immediate versus delayed rehabilitation after reverse total shoulder arthroplasty does not provide data to support one methodology over the other [221]. Further studies on the timing and method of postoperative rehabilitation are critical to optimize patient recovery for rotator cuff arthropathy [221]. An abduction sling was applied immediately after surgery for grade III acromioclavicular joint injuries and was discontinued between 4 and 6 weeks postoperatively [219]. Passive range-of-motion exercises were performed during the sling period for grade III acromioclavicular joint injuries [219]. Active and active-assisted range of motion was begun at approximately 6 weeks postoperatively for grade III acromioclavicular joint injuries [219]. Strengthening was delayed until at least 8 weeks postoperatively according to patient progress and tolerance for grade III acromioclavicular joint injuries [219]. Patients were typically cleared for full activities at approximately 4 months postoperatively for grade III acromioclavicular joint injuries [219]. Modifications to the rehabilitation protocol for grade III acromioclavicular joint injuries were necessary depending on concomitant pathologies [219].

Complications

Spine

Arthrodesis Morbidity: Arthrodesis for the persistently painful degenerative back increases morbidity and mortality rates [14]. The procedure also carries a specific risk of non-union [14].

Charcot Spine Arthropathy: In Charcot spine arthropathy, autonomic dysfunction leads to increased bone resorption in hypervascular regions of subchondral bone, resulting in microfractures and joint destruction [4]. Concurrently, loss of proprioception and protective joint mechanisms leads to increased biomechanical loads on anatomical stability factors [4]. Repetitive movements for transfer and sitting in surgically treated paraplegic patients contribute to the development of this condition [4].

Shoulder

Rotator Cuff Repair: Surgical intervention for degenerative rotator cuff tears has the potential to alter the early natural history of the disease, with clinically relevant differences in pain and functional outcomes compared to nonoperative treatment [9]. The re-tear rate of Sugaya III tendons between 1 and 2 years postoperatively after arthroscopic rotator cuff repair is over 30% [16]. Re-tears are associated with higher tear size and fatty degeneration [16]. A follow-up of at least 2 years is necessary to determine short-term outcomes in patients with severe preoperative fatty degeneration [16]. Histological degeneration of remnant tendon deteriorates with chronicity [13].

Bankart Repair: After arthroscopic Bankart repair for anterior instability, significantly degenerative changes were found at the latest follow-up compared to preoperative examinations [26]. Patients with a higher number of dislocation episodes before surgery are more likely to develop evidence of arthropathy after arthroscopic Bankart repair [26]. However, arthrosis after arthroscopic Bankart repair rarely causes more than minor subjective symptoms or a minor objectively perceived disadvantage during 13 years' follow-up [236].

Avascular Necrosis: In the precollapse stage of humeral head avascular necrosis, core decompression has not been confirmed to prevent or delay natural progression of the disease [25]. Shoulder arthroplasty for late-stage humeral head avascular necrosis has undocumented long-term implant survival and complications [25].

Glenohumeral Arthrosis: Arthroscopic debridement for glenohumeral arthrosis is a palliative measure, and it is unknown whether arthroscopy can alter the natural history of degeneration or decrease the probability of disease progression [18]. The clinical significance of early chondral lesions and their likelihood of progression is unknown [18].

Adhesive Capsulitis: In adhesive capsulitis, persistent limitation occurs in 50% to 60% of patients [65]. A high percentage of patients present with impaired range of movement even at long-term follow-up [68]. In the long term, 41% of patients with frozen shoulder reported some ongoing symptoms [57].

Calcific Tendinitis: Patients with calcific tendinitis and associated endocrine disease have a significantly more protracted natural history and more frequently undergo surgical treatment than patients with no associated endocrine disease [67].

Rugby Participation: Rugby participation tends to involve degenerative changes in the shoulder, such as osteoarthritis or labral tears, regardless of any history of instability [234].

Hip

Sickle-Cell Disease: In symptomatic osteonecrosis of the hip in sickle-cell disease, 65 of 75 hips without collapse at initial evaluation demonstrated collapse within five years after diagnosis [187]. Furthermore, 88 of 92 hips had surgery because of intractable pain at the most recent follow-up [187].

Knee

Rheumatoid Synovectomy: In rheumatoid patients undergoing synovectomy, radiographic changes of degenerative joint disease may progress [10]. Inflammatory disease changes are arrested in about 67 per cent of the knees [10].

Foot and Ankle

Degenerative Arthropathies: Modern medicine does not have a cure for degenerative arthropathies of the foot and ankle [50].

Wrist

Scaphoid Non-Union: In patients with established scaphoid non-union, osteoarthritis will most likely develop [166]. The incidence of osteoarthritis increased with time after injury [166].

Elbow

Radial Head Arthroplasty: Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for radial head arthroplasty [204].

Recovery

Rotator Cuff

Natural History and Progression: Asymptomatic degenerative rotator cuff tears progress in patients 65 years and younger [44]. The progressive nature of degenerative rotator cuff disease is demonstrated by the survivorship of asymptomatic tears [66]. In early to moderate degenerative cuff disease, glenohumeral arthritic changes progress significantly but remain minimal within an 8-year period [245]. Histological degeneration of remnant tendon deteriorates with chronicity [13]. Following acromioplasty without repair for partial-thickness tears, there was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years [69].

Other Considerations: A follow-up of at least 2 years is necessary to determine short-term outcomes, especially in patients with severe preoperative fatty degeneration [16].

Shoulder Arthroplasty and Osteoarthritis

Clinical Outcomes and Survivorship: Clinical outcomes after reverse total shoulder replacement (RTSA) vary according to the underlying indication, with the best results observed in patients with degenerative diseases and the lowest in patients undergoing secondary interventions [3]. There are no significant differences in the clinical or radiographic outcomes at a minimum of 5 years follow-up for patients undergoing reverse total shoulder arthroplasty (rTSA) for acute fracture versus degenerative conditions [24]. Shoulder function and outcome scores showed no significant deterioration between 5 and 20 years of follow-up for reverse total shoulder arthroplasty for rotator cuff dysfunction [64]. Humeral head replacement (HHR) remains a successful operation for osteoarthritis at long-term follow-up [54]. For stemless ceramic head anatomic shoulder arthroplasty in severe primary osteoarthritis, the severity of osteoarthritis did not show any association with glenoid component survivorship or with patient-reported outcome measures at 5 years review [55]. Total glenohumeral arthroplasty improved both the function of the shoulder and the general health status of patients with primary glenohumeral degenerative joint disease within a relatively short time [61].

Progression and Risk Factors: The time course from initial presentation to total shoulder arthroplasty (TSA) is similar between primary osteoarthritis and rotator cuff arthropathy patients managed conservatively with corticosteroid injections, but there are distinct prognostic factors for progression to TSA in both groups [237]. Predictors of glenohumeral osteoarthritis in unstable shoulders included time from injury to surgery and age [243]. Patients with a higher number of dislocation episodes before surgery were more likely to develop evidence of arthropathy following arthroscopic Bankart repair [26]. At the latest follow-up, all patients with preoperative degenerative changes showed signs of progression, and 12 patients with no preoperative degeneration had developed degenerative changes [26].

Functional Limitations: Arthropathic shoulders were more likely to have limitation of external rotation in abduction [26]. The average external rotation in abduction was 72.5° for stage 4 osteoarthritis, compared to 95.8° for stage 0 [26]. Patients with arthropathy averaged 9° of loss in external rotation compared to uninjured shoulders, while patients with no evidence of postoperative changes had an average loss that was not specified in the provided excerpt [26].

Adhesive Capsulitis

Natural History and Resolution: Adhesive capsulitis is primarily a clinical diagnosis with a natural history of gradual resolution over 1 to 3 years, though persistent limitation occurs in 50% to 60% of patients [65]. It is a self-limiting condition with a natural history of 18–30 months, although a high percentage of patients present with impaired range of movement even at long-term follow-up [68]. In the long term, 59% of patients with frozen shoulder had normal or near normal shoulders and 41% reported some ongoing symptoms [57].

Other Degenerative Conditions

Hip and Knee Pathology: Few asymptomatic hips with normal findings on initial radiographs are at risk for pain or radiographic abnormalities; when disease does develop, deterioration is slow and operative intervention is rarely indicated [8]. While radiographic changes of degenerative joint disease may progress, inflammatory disease changes are arrested in about 67 per cent of the knees following synovectomy in rheumatoid patients [10]. A long-term followup study with a large cohort is required to determine if an intraoperative load sensor improves early postoperative results of posterior-stabilized TKA for osteoarthritis with varus deformities [62].

Specific Disease Progression: The final diagnosis of palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time [15]. Immediate and durable improvement of shoulder function can be expected from arthroscopic treatment of synovial chondromatosis, though surgical treatment should be performed before irreversible degenerative changes occur [23]. In the precollapse stage of humeral head avascular necrosis in patients with sickle cell disease, core decompression is regarded as the first surgical option, but it has not been confirmed to prevent or delay natural progression of the disease [25]. Shoulder arthroplasty for humeral head avascular necrosis in patients with sickle cell disease is reserved for late stages with fairly good outcomes but undocumented long-term implant survival and complications [25]. The delay between the beginning of corticosteroid treatment and the different stages of osteonecrosis (ON) of the shoulder appeared to be longer than the delay observed in ON of the hip related to corticosteroid treatment [60]. Patients with calcific tendinitis and associated endocrine disease have symptoms develop at a younger age, have a significantly more protracted natural history, and more frequently undergo surgical treatment than patients with no associated endocrine disease [67].

Systemic and Structural Factors: Patients with persistent renal osteodystrophy live longer and are more physically active, leading to trauma in a setting of weakened pathologic bone, while musculoskeletal problems significantly limit their quality of life [191]. Cartilage defects rarely heal spontaneously and generally require surgical intervention because of the poor vascularization of articular cartilage and the presence of few undifferentiated cell populations able to respond to degenerative or traumatic injury [70]. Osteoarthritis affects not only the articular cartilage but also the bone and the capsule of the joint, resulting in osteophyte formation, subchondral sclerosis, and capsular thickening [70].

Key Evidence

• [L4] Clinical outcomes after RTSA varied according to the underlying indication, with the best results observed in patients with degenerative diseases and the lowest in patients undergoing secondary interventions. [3] (10.1186/s12891-025-09329-w)
• [L5] [4] (10.5435/jaaos-d-22-00212)
• [L4] However, the evidence is limited to Level IV studies, and concerns remain regarding long-term durability and progression of osteoarthritis. [5] (10.1177/17585732261469823)
• [L3] Few asymptomatic hips with normal findings on initial radiographs are at risk for pain or radiographic abnormalities; when disease does develop, deterioration is slow and operative intervention is rarely indicated. [8] (10.2106/00004623-199703000-00006)
• [L2] Surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease, with patients demonstrating clinically relevant differences in pain and functional outcomes compared to nonoperative treatment. [9] (10.1016/j.jse.2024.05.056)
• [L3] While radiographic changes of degenerative joint disease may progress, inflammatory disease changes are arrested in about 67 per cent of the knees. [10] (10.2106/00004623-198668020-00004)
• [L3] However, the prevalence of these conditions did not differ between satisfied and dissatisfied patients when evaluated independent of the degree of degeneration. [11] (10.1016/j.arth.2015.01.051)
• [L5] Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression, while joint replacement is indicated for end-stage disease. [12] (10.1530/eor-2025-0050)
• [L4] Histological degeneration of remnant tendon deteriorated with chronicity. [13] (10.1016/j.arthro.2021.09.027)
• [L5] Arthrodesis is at present the best surgical treatment for the persistently painful degenerative back, though it increases morbidity and mortality rates and carries a risk of non-union. [14] (10.2106/00004623-196345070-00016)
• [L4] A follow-up of at least 2 years is necessary to determine short-term outcomes, especially in patients with severe preoperative fatty degeneration. [16] (10.1016/j.arthro.2024.12.029)
• [L3] Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion. [17] (10.1186/s13018-015-0186-8)
• [L4] [18] (10.1177/0363546510369250)
• [L5] [19] (10.2106/00004623-199704000-00022)
• [L4] Immediate and durable improvement of shoulder function can be expected, though surgical treatment should be performed before irreversible degenerative changes occur. [23] (10.1016/j.jse.2008.12.003)
• [L3] This study demonstrates no significant differences in the clinical or radiographic outcomes at a minimum of 5 years follow-up for patients undergoing rTSA for acute fracture versus degenerative conditions. [24] (10.1016/j.jseint.2024.08.105)
• [L4] In the precollapse stage, core decompression is regarded as the first surgical option, but it has not been confirmed to prevent or delay natural progression of the disease, while shoulder arthroplasty is reserved for late stages with fairly good outcomes but undocumented long-term implant survival and complications. [25] (10.1016/j.jseint.2021.01.011)
• [L4] [26] (10.1177/0363546511404207)
• [L5] MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement, serving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities. [30] (10.2106/jbjs.rvw.15.00093)
• [L5] The diagnosis of osteonecrosis might be challenging because of overlapping clinical presentation with other disorders particularly in the early stage of the disease with normal radiographs. [32] (10.5435/jaaosglobal-d-20-00095)
• [L4] The presence of bone and cartilage debris ground into the synovial membrane is a significant pathological finding indicative of early neuropathic joints, often appearing before clinical or roentgenographic evidence is demonstrable, though it is not absolutely specific as it can occur in advanced degenerative arthritis. [33] (10.2106/00004623-194830030-00006)
• [L3] Osteoarthritis patients had a broad range of symptoms with 33% being asymptomatic, and 32% of patients with painful AC joints had a normal X-ray. [35] (10.1016/j.jse.2021.03.086)
• [L5] Although many OA-related biomarkers are currently available, none can be considered as a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease at this time. [36] (10.1186/1471-2474-16-s1-s2)
• [L4] It should be considered after conservative measures fail, as mild degenerative arthritis is not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur. [38] (10.2106/00004623-197759040-00004)
• [L4] Clinical features are not very reliable for diagnosis, and magnetic resonance arthrography and hip arthroscopy should be utilized more. [39] (10.1007/s00167-003-0390-7)
• [L4] Rapidly destructive arthrosis presents with unique radiographic features, MRI findings, and a specific clinical course characterized by rapid humeral head collapse. [43] (10.1016/j.jse.2014.10.020)
• [L2] Asymptomatic degenerative rotator cuff tears progress in patients 65 years and younger. [44] (10.1016/j.jse.2023.03.008)
• [L5] [45] (10.1136/jisakos-2015-000008)
• [L2] In this population of patients with degenerative rotator cuff tears, no significant difference in functional outcome was observed between surgical and conservative treatment at 1 year; however, significant differences in pain and disability favored surgical treatment. [46] (10.1016/j.jse.2015.05.040)
• [L5] [47] (10.1016/j.jse.2011.11.017)
• [L1] AD is an efficacious and particularly safe alternative in the short term for young patients with concerns about arthroplasty. [49] (10.1016/j.arthro.2014.11.012)
• [L5] Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage; procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease. [51] (10.2106/00004623-199409000-00019)
• [L5] In contrast, an expert panel of cartilage surgeons reached a consensus that OCA transplantation was clearly suitable for a variety of specific indications. [52] (10.2106/jbjs.21.01191)
• [L4] The findings suggest that reverse arthroplasty can achieve highly favorable outcomes for this indication. [53] (10.1016/j.jse.2021.06.010)
• [L4] HHR remains a successful operation for osteoarthritis at long-term follow-up. [54] (10.1016/j.jse.2017.10.017)
• [L4] The severity of osteoarthritis did not show any association with glenoid component survivorship or with patient-reported outcome measures at 5 years review. [55] (10.1177/17585732211048120)
• [L3] A new concise MRI classification of HDS was proposed. [56] (10.1007/s00167-016-4033-1)
• [L3] In the long term, 59% of patients had normal or near normal shoulders and 41% reported some ongoing symptoms. [57] (10.1016/j.jse.2007.05.009)
• [L5] Experts recommend a stepwise approach starting with nonoperative treatment, followed by joint-preserving arthroscopic procedures for selected patients, and reserving joint replacement or resurfacing for cases where less invasive options fail. [58] (10.1016/j.jse.2011.11.011)
• [L3] Careful consideration should be made of the relative benefits of this procedure compared to total shoulder arthroplasty for osteoarthritis. [59] (10.1016/j.jse.2007.02.094)
• [L2] [60] (10.1007/s11999-009-1094-1)
• [L4] The study demonstrates that total glenohumeral arthroplasty improved both the function of the shoulder and the general health status of patients with primary glenohumeral degenerative joint disease within a relatively short time. [61] (10.2106/00004623-199602000-00013)
• [L2] A long-term followup study with a large cohort is required. [62] (10.1007/s00167-018-5314-7)
• [L1] Shoulder function and outcome scores also showed no significant deterioration between 5 and 20 years of follow-up. [64] (10.1016/j.jse.2018.10.005)
• [L2] This study demonstrates the progressive nature of degenerative rotator cuff disease. [66] (10.2106/jbjs.n.00099)
• [L3] Patients with associated endocrine disease have symptoms develop at a younger age, have a significantly more protracted natural history, and more frequently undergo surgical treatment than patients with no associated endocrine disease. [67] (10.1016/j.jse.2006.06.007)
• [L4] Adhesive capsulitis is a self-limiting condition with a natural history of 18–30 months, although a high percentage of patients present with impaired range of movement even at long-term follow-up. [68] (10.1007/s00167-007-0291-2)
• [L4] There was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years. [69] (10.1177/03635465020300021801)
• [L4] [70] (10.1155/2012/160923)
• [L4] [82] (10.1016/j.arthro.2015.03.032)
• [L2] Conservative treatment was effective in 77% of patients with a degenerative supraspinatus tear. [97] (10.1302/0301-620x.107b12.bjj-2025-0742.r2)
• [L5] This review article describes how careful clinical assessment can differentiate between causes of shoulder pain and guide best management. [98] (10.1016/j.jse.2014.12.003)
• [L4] Gender, age, duration of symptoms, accompanying medical disease, cuff tear size, and degenerative indicator of cuff tear have no effect on stiffness. [99] (10.1016/j.jse.2011.04.011)
• [L5] [100] (10.1177/0363546513485359)
• [L5] Diagnosis and management of snapping scapula syndrome remains challenging despite recent advances. [108] (10.5435/jaaos-21-04-214)
• [L3] The profile of age-related degenerative rotator cuff disorders fails to correlate systematically with self-reported nontraumatic shoulder pain, particularly in older age; thus, it appears that degeneration should not be considered the primary source of the pain. [111] (10.1016/j.jse.2016.09.060)
• [L4] The new four-category, 7-point classification system demonstrated interobserver reproducibility and correlation with joint function equivalent to the Pettersson et al. system, while being easier to apply and more sensitive in discriminating advanced arthropathy than the Arnold and Hilgartner system. [114] (10.2106/00004623-198971020-00010)
• [L1] Females had more profound symptomatology and milder morphologic abnormalities, while males had a higher activity level, larger morphologic abnormalities, more common combined-type FAI morphologies, and more extensive intra-articular disease. [118] (10.2106/jbjs.m.01320)
• [L4] Both the Goutallier classification system and the new Quartile system performed equally well in assessing fatty degeneration of the gluteus muscles, showing excellent levels of interrater and intrarater agreement. [120] (10.1016/j.arth.2013.04.045)
• [L4] Current clinical treatments for articular cartilage defects have limited ability to repair tissue and often result in mechanically inferior cartilage; emerging regenerative approaches and strategies informing future treatment options are discussed to address these limitations. [124] (10.3389/fbioe.2021.770655)
• [L4] The best treatment for rotator cuff disease continues to be controversial and is currently based on the individual surgeon's clinical experience rather than firm scientific data. [127] (10.5435/00124635-199807000-00007)
• [L5] The article provides an overview of available treatments for shoulder osteoarthritis, noting that nonoperative modalities should be utilized before surgical options, particularly for patients with moderate-to-mild disease, while surgical treatments like arthroplasty are considered effective for severe cases. [128] (10.1155/2013/370231)
• [L4] Arthrodesis is successful in patients with degenerative changes in the glenohumeral joint causing severe pain unrelieved by conservative treatment. [129] (10.2106/00004623-197254080-00017)
• [L5] The optimal treatment of glenohumeral arthritis in patients ≤ 50 years of age remains controversial, and there are many treatment options to consider when responding to the variety of clinical presentations and anatomic pathologies. [130] (10.1016/j.jse.2023.01.009)
• [L4] All-arthroscopic repair is an effective treatment modality for degenerative subscapularis tendon tears with an anterosuperior tear pattern with good clinical results and high patient satisfaction. [131] (10.1007/s00167-012-2147-7)
• [L4] ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. [132] (10.1007/s00167-014-3234-8)
• [L1] This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease. [133] (10.5435/00124635-200701000-00002)
• [Paper] Proper indication relies on identifying and simultaneously correcting malalignment and/or traumatic changes in affected joints. [134] (10.1016/j.injury.2008.01.041)
• [L4] Until further studies determine the aetiology, the authors recommend considering carefully before performing arthroscopic procedures in the elderly. [135] (10.1007/s001670050090)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. [137] (10.1155/2013/473259)
• [L5] The AAOS developed Appropriate Use Criteria to determine the appropriateness of various treatments for shoulder osteoarthritis with intact rotator cuff and severe glenoid retroversion, utilizing a multidisciplinary panel to rate 240 patient scenarios across five treatment options. [138] (10.5435/jaaos-d-23-00669)
• [Case_report] The indications for use of steroids must be clearly delineated, probably more narrowly than has been done in the past. [139] (10.2106/00004623-198264010-00020)
• [L3] Although initially exhibiting slower recovery, patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications. [142] (10.1177/17585732221097415)
• [L1] Non-operative and operative treatments show similar OA proportions at any point of follow-up. [143] (10.1007/s00167-020-06263-3)
• [Paper] Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care. [144] (10.1016/j.csm.2014.01.001)
• [L5] Total hip arthroplasty remains a very good option in young patients who are not ideal candidates for joint preservation surgery, and future developments will help to better identify ideal surgical candidates and improve understanding of the disease processes. [148] (10.1016/j.arth.2015.02.046)
• [L4] Neuropathic arthropathy of the shoulder is a contraindication to arthrodesis and synovectomy is not helpful; the condition should be treated nonoperatively with an emphasis on the maintenance of function rather than immobilization. [149] (10.2106/00004623-199809000-00010)
• [L3] Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses. [151] (10.1016/j.jse.2023.08.029)
• [L3] Factors associated with calcium reabsorption include the Gartner classification, disease duration, and blood flow around calcium deposits. [154] (10.1016/j.jse.2024.07.056)
• [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. [155] (10.1016/j.xrrt.2022.02.005)
• [L4] MRI provides valuable clues, but definitive diagnosis relies on histopathological confirmation. [159] (10.1186/s12891-026-09563-w)
• [L2] Shoulder activity level is not related to tear progression risks. [163] (10.1016/j.jse.2017.05.023)
• [Paper] MRI results were not statistically different between the 2 treatments. [164] (10.1177/03635465231189808)
• [L5] Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. [165] (10.5435/00124635-199905000-00004)
• [L4] [166] (10.2106/00004623-198567030-00013)
• [Paper] Nonoperative modalities have been poorly studied, and recommendations for or against certain treatments are not well established. [170] (10.1016/j.csm.2018.05.003)
• [L1] [173] (10.1002/ksa.12017)
• [L4] Open sternoclavicular debridement has proved to be a simple, safe and highly effective new surgical treatment for patients with symptomatic sternoclavicular osteoarthritis unresponsive to non-operative management. [176] (10.1177/1758573220972093)
• [L5] The exact definition of 'impingement' eludes the current literature, and while dynamic MRI has potential to better define hip impingement, it is not yet optimized for widespread clinical use; clinicians must 'treat the patient, not the MRI.' [179] (10.1016/j.arthro.2019.05.009)
• [L3] Radiographs provide better reproducibility and accuracy for CSA measurement compared to MRI. [180] (10.1007/s00167-015-3587-7)
• [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. [186] (10.1016/j.jse.2017.10.009)
• [L2] [187] (10.2106/00004623-200303000-00016)
• [L4] The Goutallier/Fuchs classification system can be reliably and reproducibly applied to the evaluation of abductor tendon tears of the hip and appears to correlate with patient-rated outcomes after repair. [188] (10.1016/j.arthro.2015.04.101)
• [L5] Patients with persistent disease live longer and are more physically active, leading to trauma in a setting of weakened pathologic bone, while musculoskeletal problems significantly limit their quality of life. [191] (10.5435/00124635-200605000-00006)
• [L5] This minimally invasive approach is an effective alternative to traditional diagnostic techniques of diagnostic surgical arthroscopy and magnetic resonance imaging (MRI). [193] (10.1016/j.eats.2022.07.006)
• [L4] While CT and MRI can assist in diagnosis, incisional biopsy is required in most cases for definitive histopathological confirmation. [194] (10.1186/s12891-020-03601-x)
• [L2] [195] (10.1186/s12891-015-0500-y)
• [L2] Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. [198] (10.1016/j.jse.2019.04.004)
• [L3] This study shows that increased age is the main determinant of radiological changes in shoulder OA, as well as pain. [200] (10.1186/s13018-022-03137-x)
• [L1] [201] (10.1177/17585732251374282)
• [L5] [202] (10.2106/jbjs.23.00492)
• [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. [204] (10.1016/j.jse.2010.05.022)
• [Paper] This article reviews the imaging of hyaline cartilage, including consideration of technique, accuracy of diagnosis, and concepts for future imaging techniques, with the knee as the prototype joint. [205] (10.1016/j.csm.2004.08.008)
• [L4] Approximately, 1 in 11 patients with FAI and normal radiographic joint space width can present unequivocal signs of OA. [212] (10.1016/j.arthro.2013.09.014)
• [L4] A fatty infiltration graded 2, a common threshold for management decision, was commonly found in aging patients with an intact cuff on CT arthrography. [214] (10.1016/j.jse.2018.09.020)
• [L4] Hips with synovial chondromatosis may present with clinical and radiographic features resembling those of cam-type femoroacetabular impingement. [217] (10.2106/jbjs.l.01550)
• [L4] Pseudogout can mimic synovial chondromatosis clinically and roentgenographically due to extensive calcification of synovial tissue, but the two diseases have different treatments. [218] (10.2106/00004623-197557060-00030)
• [L3] [219] (10.1016/j.arthro.2015.11.024)
• [L5] Our results suggest that altered mechanical loading after rotator cuff tears is the primary factor in cartilage degeneration after rotator cuff tears. [220] (10.1016/j.jse.2013.03.014)
• [L4] [221] (10.1016/j.jhsg.2023.12.014)
• [L5] [226] (10.5435/00124635-201210000-00002)
• [L4] [227] (10.1007/s00167-009-0750-z)
• [L4] Rugby affects the shoulder joint, regardless of any history of instability, suggesting that 'rugby shoulder' tends to involve degenerative changes, such as osteoarthritis or labral tears. [234] (10.1016/j.jse.2012.07.015)
• [L4] [235] (10.1007/s001670100205)
• [L4] Arthrosis rarely causes more than minor subjective symptoms or a minor objectively perceived disadvantage during 13 years' follow-up. [236] (10.1016/j.jse.2011.04.023)
• [L3] The time course from initial presentation to TSA is similar between primary OA and RTC arthropathy patients managed conservatively with corticosteroid injections, but there are distinct prognostic factors for progression to TSA in both groups. [237] (10.1016/j.jisako.2023.03.336)
• [L4] [241] (10.1016/j.jse.2016.02.026)
• [L4] [242] (10.1016/j.jse.2024.11.039)
• [L4] Predictors of osteoarthritis included time from injury to surgery and age. [243] (10.1177/03635465030310012001)
• [L2] Glenohumeral arthritic changes progress significantly but remain minimal within an 8-year period in early to moderate degenerative cuff disease. [245] (10.1016/j.jse.2016.07.022)

See Also

• Total shoulder arthroplasty
• Fractures
• Reverse Shoulder Arthroplasty
• Rotator Cuff
• Rotator cuff repair
• Shoulder Arthroplasty
• Os Acromiale
• AC Joint Osteoarthritis
• Cuff Arthropathy
• Rotator Cuff Disorders
• Shoulder Instability
• Calcific Tendinitis
• Capsular Release for Frozen Shoulder
• Subacromial Decompression
• Frozen Shoulder

References

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[52] Inconsistent Reporting of Preauthorization Medical Criteria for Osteochondral Allograft Transplantation Surgery. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.21.01191

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[55] Encouraging outcomes of stemless ceramic head anatomic shoulder arthroplasty in severe primary osteoarthritis (Walch type B glenoids). Shoulder & Elbow. 2021. DOI: 10.1177/17585732211048120

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[64] Long-term results of reverse total shoulder arthroplasty for rotator cuff dysfunction: a systematic review of longitudinal outcomes. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.10.005

[65] Chapter 74 Adhesive Capsulitis. 2019.

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[70] Glenohumeral Joint Preservation: A Review of Management Options for Young, Active Patients with Osteoarthritis. Advances in Orthopedics. 2012. DOI: 10.1155/2012/160923

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