Skeletal Anatomy

Osseous geometry of the shoulder girdle, focusing on the glenohumeral, AC, and SC joints and the concavity-compression mechanism of the glenoid.

Overview

Scapular anatomy requires standardized landmark definitions to ensure consistency in CT-based 3-dimensional orientation measurements [1]. Scapular bone density varies by region, age, and sex, with significant individual variability despite overall trends of bone loss [82]. This variability suggests that subject-specific tools may be beneficial for planning surgical procedures requiring scapular fixation [82]. In injured baseball players, osseous adaptations at the glenohumeral joint must be considered during evaluation and treatment [77].

Comprehensive clinical approaches emphasizing the extent of anatomic injury and its mechanical consequences on shoulder and arm function are key to developing operative or non-operative treatment protocols and establishing outcomes [6]. The success of total shoulder arthroplasty depends on proper patient selection and the surgeon's ability to restore native anatomy [79]. Conventional surgical options for osteoarthritis include arthroscopy, preservation, arthrodesis, and replacement [81]. Operative repair of rotator cuff rupture should be reserved for cases with unassailable indications, as anatomical reconstruction is not necessary for satisfactory function and early and delayed repair results are substantially the same [13].

For specific pathologies, computed tomography is routinely recommended to assess coronal shear fractures of the capitellum and trochlea and to perform surgical planning [16]. Consensus on proximal humerus reconstruction after tumor resection is not established; the choice depends on patient age, clinical picture, functional demands, and potential sacrifice of muscles or nerves [76]. Longer-term radiographic and clinical analysis is needed to confirm findings and theoretical benefits for future revision surgeries regarding stemless humeral components for anatomic total shoulder arthroplasty [7]. Literature on snapping scapula syndrome treatment is limited by low-level evidence and high heterogeneity, necessitating future prospective, standardized studies to optimize patient selection and treatment protocols [69].

Anatomy & Pathophysiology

Osseous and Joint Geometry

The shoulder complex relies on a careful balance between stability and mobility [25]. Glenohumeral geometry is specific to gender and population, suggesting that future joint replacements may need to address these anatomical differences [72]. The critical shoulder angle (CSA) significantly modifies glenohumeral joint biomechanics: increasing the CSA produces higher shear forces that may contribute to rotator cuff overuse, whereas reducing the CSA results in higher compressive forces that contribute to joint wear [62]. Scapulothoracic motion is a vital component of active shoulder function in both healthy shoulders and those compromised by common pathologies [46]. Normative kinematic values for scapulothoracic movements have been established through whole cadaver studies [29].

Ligamentous and Soft Tissue Stabilizers

Shoulder stability depends on multiple anatomical and functional factors, with bony structures like the glenoid cavity and humeral head playing a critical role alongside soft tissues [71]. In the Latarjet procedure, a more inferior coracoid graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics [70]. For three-part humeral head fractures, a blocked threaded wires construct is biomechanically valid, allowing only micromovements that do not cause humeral head rotation or translation [67].

Kinematics and Biomechanical Modeling

The biomechanics of the shoulder rely on balancing stability and mobility [25]. Small but significant asymmetries exist between dominant and nondominant shoulders in terms of kinematics [22]. Abduction of the arm involves complex movements with divergent opinions on the functional interrelationships of participating muscles and joints; however, a linear relationship holds for the whole movement, with the final phase showing a relative increase in glenohumeral motion [73]. Anatomic total shoulder arthroplasty aims to reproduce premorbid kinematics [25], while reverse shoulder arthroplasty achieves stability through a semi-constrained design [25]. Reverse total shoulder arthroplasty (rTSA) restores forward elevation primarily via compensatory scapulothoracic motion and deltoid-driven neuromuscular strategies rather than normalization of glenohumeral mechanics [63].

Advanced measurement techniques that account for glenoid concavity are more accurate in determining the biomechanical relevance of glenoid bone loss, whereas the reliability of manually performed, more complex measurements for quantifying glenoid bone loss is moderate [64]. A validated finite-element shoulder numerical model is suitable for evaluating shoulder articular contact [61]. Despite these tools, a precise, easy-to-use, and low-cost non-invasive method to draw and analyze the kinematics of the shoulder complex has not yet been developed [23].

Regional Anatomy and Surgical Considerations

Acromioclavicular joint injuries require evaluation of the extent of anatomic injury and understanding of mechanical consequences regarding shoulder and arm function to guide operative or non-operative treatment protocols [6]. Recent changes in elbow arthroplasty device design and implantation methods are driven by biomechanical and clinical outcome-based research to better reproduce elbow kinematics [65]. A comprehensive review of the anatomy of the shoulder, arm, and elbow includes ossification patterns, joint mechanics, ligamentous stabilizers, musculature, neurovascular structures, and surgical approaches [68].

Classification

Scapular Landmarks: A clear and standardized definition of scapular anatomical landmarks is needed to ensure consistency across measurements [1]. Scapular morphological variations include sex-related and generational differences in global scapular shape, which may be considered when analyzing scapular morphology [59]. A proposal of 16 new terms defining grossly visible structures on the scapula that have not yet been described by officially recognized terms was communicated, including a call to unify 13 previously contributed terms that have not been codified and are often used interchangeably within different surgical and scientific fields [55].

Walch Classification: The Walch classification has undergone evolution, with modifications made to its rationale and potential future developments discussed [9].

Proximal Humeral Fractures: A new classification for the three-dimensional anatomy of proximal humeral fractures presents the frequency of each injury type and suggests a technique for viewing 3D images to maximize usefulness [27]. The Neer classification system is an anatomically valid and excellent means of communication between orthopaedists [34]. Poor interobserver reliability in cited studies of the Neer classification reflects the difficulty of classifying certain fracture patterns on routine preoperative radiographs rather than a fault of the classification system itself [34].

Suprascapular Nerve Topography: A new classification of suprascapular triad topography and quantitative analysis of the space available for the path of the suprascapular nerve is important for understanding morphological conditions that may promote suprascapular nerve entrapment, especially those with a type III arrangement [37].

Degenerative Glenohumeral Arthritis: A 3D classification system using combined humeroscapular alignment and glenoid erosion can be applied to describe degenerative glenohumeral arthritis comprehensively [44]. A post-treatment glenoid classification system for total shoulder arthroplasty addresses the surgical management of the glenoid during prosthetic replacement and allows direct follow-up comparison of similarly treated glenoid replacements [53]. A radiological classification system for glenoid deformity in rheumatoid arthritis identifies three types of glenoid fossa shape changes and six total deformity types when including upward humeral head migration [54].

Medial Meniscus Ramp Tears: A surgically relevant classification system for medial meniscus ramp tears, based on tear morphology, allows for the evaluation of differing repair patterns and their effects on postoperative clinical outcomes [45]. Only minor variations in the overall anatomical pattern of the supporting structures and layers on the medial side of the knee were found [48].

Distal Humeral Epiphysis: A separation of the distal humeral epiphysis with medial displacement is classified as Type II by the Salter-Harris classification [56].

Other Considerations: The evidence highlights a need for standardized terminology and classification refinement across multiple anatomical regions to improve communication, surgical planning, and outcome comparison.

Clinical Presentation

History and Risk Factors

Evaluation of coxa vara requires a search for family history, trauma, infection, and associated skeletal abnormalities [4]. Atypical mycobacterium infections of the musculoskeletal system follow a chronic course, requiring biopsy with microbiological analysis for definitive diagnosis [35]. Rhabdomyosarcoma of the hand is a distinct clinical entity that is often painless [43].

Inspection and Scapular Dynamics

Scapular winging arises from neurogenic causes or traumatic muscular detachment, with lesions of the long thoracic nerve being the most common aetiological factor [20]. Scapular dyskinesis is a major contributor to shoulder pain, particularly in cases of recalcitrant shoulder pain and dysfunction [40]. Double acromion and coracoid processes are scapular anomalies that may be associated with other skeletal and renal anomalies but do not have significant clinical implications for treatment [39].

Palpation and Localized Pain

Coracoid pain is a rare symptom with diverse soft tissue and bony causes [2]. An aberrant origin of the long head of the biceps does not appear to contribute to shoulder pathology [21]. Radiographic greater tuberosity spurs and narrow acromiohumeral intervals are associated with advanced retraction of the supraspinatus tendon in patients with symptomatic rotator cuff tears [42].

Diagnostic Assessment and Special Tests

A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis [3]. A thorough understanding of shoulder physical examination and specific diagnostic tests is essential for diagnostic accuracy [24]. Improved understanding of the fascial anatomy and innervation pattern of the teres minor muscle may help clinicians treat patients with symptomatic isolated teres minor muscle atrophy [28]. Common benign and malignant shoulder bone and soft-tissue tumors and tumor-like conditions have key features that help determine diagnosis and treatment plans [26].

Surgical Anatomy Considerations

Standardized definitions of scapular anatomical landmarks are needed to ensure consistency in measurements of scapular orientation [1]. Scapular winging requires review of relevant anatomy, etiology, clinical evaluation, and diagnostic testing to differentiate between neurogenic and traumatic causes [38]. Thorough musculoskeletal assessment is important for operative fixation of intra-articular scapula fractures with significant articular displacement [30]. Recognition of ulnar nerve anatomical details and variations is essential for accurate diagnosis and surgical decompression to avoid iatrogenic injury [31]. Recognizing anatomical variations at the suprascapular notch is crucial for understanding the etiology of suprascapular nerve entrapment and ensuring adequate surgical decompression [33]. Coracoacromial morphology is a pathologic anatomy that may contribute to recurrent traumatic anterior glenohumeral instability and is not addressed by current soft-tissue stabilization procedures [36].

Investigations

Plain radiography: Standardized clinical criteria are necessary to guide the differential diagnosis of joint chondrolysis [3]. In bony-mediated shoulder instability, accurate imaging and assessment of the size and relations of bone defects are crucial for treatment planning [52]. Measurement of the critical shoulder angle using X-ray demonstrates excellent interrater reliability [92]; however, these measurements were highly congruent with digitally reconstructed radiographs from 3-dimensional computed tomography images [110], yet a large measurement deviation occurred between radiographs and true anteroposterior views for critical shoulder angle measurements [110]. Clinical studies using radiographs in the true anteroposterior view with degrees of arm rotation are necessary to reach consensus on humeral head rotation and head-shaft angle evaluation [103]. Medial end clavicle fractures can be difficult to diagnose by less experienced health practitioners on plain radiographs [91]; a low threshold for more senior review or additional imaging should be considered for medial end clavicle fractures due to diagnostic difficulty on plain radiographs [91].

MRI: Coracoid pain is a rare symptom with diverse soft tissue and bony causes [2]. Physeal-specific MRI reveals minimal growth plate disturbance following all-inside anterior cruciate ligament reconstruction relative to a through-the-physis technique in skeletally immature athletes [17]. MRI is essential for accurate diagnosis and surgical planning in cases of complete transections of the coracobrachialis and short head of biceps brachii [96]. Three-dimensional magnetic resonance imaging quantification of glenoid bone loss is equivalent to three-dimensional computed tomography quantification [98]; however, the error in bone loss measurement tends to increase with increased defect size regardless of imaging modality [98]. Clinicians can assess glenoid version on MRI in the absence of CT imaging, as MRI is comparable to CT even when the entire scapula is not visible [99]; measuring glenoid version on MRI does not appear to be significantly affected when the entirety of the medial border of the scapula is not included in the imaging field [109]. MRI determination of posterior interosseus nerve position is reliable and consistent with prior cadaveric studies [102]. If an avulsion fracture is clinically suspected, MRI will determine the pathology and allow early appropriate management [107]. Findings on magnetic resonance images alone should not be used to determine a handicap or disability rating if clinical findings do not correlate [100]; MRI should remain an adjunctive diagnostic aid rather than a basis for operative intervention [108].

CT: CT scan or MRI is likely sufficient to analyse osteoarthritis in the acromioclavicular joint, suggesting conventional radiography may not be relevant [85]. The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography should be considered when using CT scans to assess symptomatic sternoclavicular joint pathology [88].

Other Considerations: Both all-inside and through-the-physis anterior cruciate ligament reconstruction techniques reveal no evidence of significant complications in skeletally immature athletes [17]. The MRI-based formula produced estimates of glenoid width for instability-related bone loss nearly as accurate as CT-specific formulas when applied to CT scans [111]; however, CT-specific formulas are more accurate than MRI-based formulas for estimating glenoid width for instability-related bone loss [111].

Treatment

Non-Operative

Evaluation of coxa vara requires a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [4]. A comprehensive clinical approach emphasizing the extent of anatomic injury and its mechanical consequences is key in developing guidelines for operative or non-operative treatment protocols for acromioclavicular joint injuries [6]. Nonoperative treatment of complete tear of the short head of the biceps brachii and coracobrachialis yielded successful results, noting that the natural history and role of nonoperative management for this condition were previously undefined [15]. Nonoperative treatment for Panner disease resulted in favorable outcomes with favorable sports return and remodeling [57]. Conservative treatment is sufficient for non-displaced type A periprosthetic humeral fractures associated with reverse total shoulder arthroplasty [74]. Nonoperative treatment is the best approach for patients with symptomatic scapulothoracic crepitus and bursitis [93]. Non-operative treatment is a viable alternative to surgical treatment of isolated greater tuberosity fractures and is associated with good patient reported outcome measures and a low incidence of complications [105]. Excellent functional outcomes can be achieved with a conservative approach for open antero-lateral dislocation of the elbow even after extensive soft tissue damage from minor injury [106]. Both non-operative and operative treatments for adhesive capsulitis are described with evidence-based support to ensure acceptable functional outcomes [87]. Further studies are needed to assess the safety and efficacy of selective denervation of painful shoulders while limiting the loss of proprioceptive function [60].

Operative

Indications: Surgical treatment of established clavicular nonunion is efficacious for symptomatic improvement and restoration of function [32]. Patients treated surgically for Sprengel deformity maintain improved shoulder function and appearance in long-term studies [5]. Ender nailing of acute humerus fractures is considered for operative treatment only in fractures recalcitrant to closed reduction and immobilization or in non-compliant patients [104]. Operative repair of rotator cuff rupture should be reserved for cases with unassailable indications, as anatomical reconstruction is not necessary for satisfactory function and results of early and delayed repair are substantially the same [13].

Surgical Approach / Technique: Accurate anatomical knowledge is required to carry out surgical approaches to the shoulder joint with the least possible disturbance of function [95]. Open reduction of interposed tissues in irreducible isolated anteromedial radial head dislocation can result in good functional outcomes in the short term [12]. Successful correction of scapular anatomy via scapular (glenoid and acromion) osteotomies can improve static subluxation and restore subjective and objective shoulder stability at a minimum of 2 years [58]. A CT scan is routinely recommended to assess the extent of coronal shear fractures of the capitellum and trochlea and to perform surgical planning [16].

Implant Selection: Best results in reverse shoulder arthroplasty for proximal humerus fracture sequelae are achieved in patients with previous conservative treatment, structural integrity of the teres minor, and limited amount of metaphyseal bone loss [50]. Integration of bone graft in bony increased offset reverse shoulder arthroplasty occurs effectively with no relevant changes observed on radiographic evaluation [49]. Improved histology at the tendon-to-bone interface using an interposition bioresorbable scaffold with a vented anchor for primary rotator cuff repair is correlated with improved final construct strength at the 12-week time point [47].

Adjuncts: Many periscapular tendon transfer techniques remain in their infancy and require further follow-up before universal adoption, but they provide a novel means of addressing difficult-to-treat and complex shoulder girdle pathologies [8]. Bone-graft operations to lengthen the humerus in short arm amputation stumps are of limited value and recommended only for unusual stumps having a large muscle mass in which to bury the transplant [97]. A clear and standardized definition of scapular anatomical landmarks is needed to ensure consistency across measurements in CT-based 3-dimensional models [1]. Both sling immobilization and no sling groups resulted in excellent early functional outcomes after open Latarjet surgery for anterior shoulder instability [51].

Complications

Coracoid Pain: Coracoid pain is a rare symptom with diverse soft tissue and bony causes [2].

Instability: Posterior bone loss in recurrent posterior glenohumeral instability occurs at a mean of 30° off the long axis of the glenoid in a posteroinferior direction, which is historically different from anterior bone loss [18, 19]. Sole assessment of recurrent dislocation is inadequate for defining natural history and treatment rationale, and treatment recommendations cannot be made from studies that do not compare treatment methods [112].

Osteoarthritis: The most common mid- and long-term complication of open fixation of acute anterior glenoid rim fractures with bioresorbable pins is the occurrence or progression of osteoarthritis [66]. Joint chondrolysis requires standardized clinical criteria to guide differential diagnosis [3].

Nerve Palsy: The natural history of neonatal brachial plexus palsy with absent biceps function at three months provides a benchmark for comparing outcomes with microsurgical repair [14].

Fracture Healing: Significantly displaced scapular fractures can result in adverse healing and long-term functional consequences [90].

Other Considerations: Surgically treated Sprengel deformity patients maintain improved shoulder function and appearance in long-term studies [5]. Longer term radiographic and clinical analysis is needed to confirm findings and theoretical benefits for future revision surgeries regarding stemless humeral components in anatomic total shoulder arthroplasty [7]. The Walch classification for primary glenohumeral arthritis has evolved, with modifications and potential future developments discussed [9]. Anterior deltoid muscle reflection during reversed shoulder arthroplasty is safe and does not influence short-term functional outcomes [10]. Further studies with long-term follow-up are needed to determine if autologous matrix-induced chondrogenesis grafts maintain structural and functional integrity over time [11]. Wakeboarder’s arm, defined as a complete tear of the short head of the biceps brachii and coracobrachialis, has been successfully treated nonoperatively, though its natural history and the role of nonoperative management were previously undefined [15]. Physeal-specific MRI reveals minimal growth plate disturbance following all-inside anterior cruciate ligament reconstruction in skeletally immature athletes relative to a physeal-sparing technique, with no evidence of significant complications for either technique [17]. Complications from operative approaches to intercondylar fractures of the humerus were varied and mostly minor, though anatomical restoration of the trochlea is important for restoring elbow function [80]. Future long-term, high-volume studies are needed to provide more insight into the outcomes of arthroscopic Bankart repair with inferior glenohumeral ligament tightening using the antegrade suture passer [89]. Further research is needed to evaluate biomechanical strength, long-term outcomes, union rates, and degree of bone resorption for arthroscopic iliac crest bone grafting to the anterior glenoid [94]. Ten anatomical risk factors associated with subacromial impingement and rotator cuff tears are not unique to humans among great apes, indicating an alternative primary aetiological factor developed during human evolution [101]. Major amputations for malignant neoplasms of the extremities are often performed as a desperate measure after other methods fail, with results influenced by the natural history of the cancer and delays in surgery [114]. Coxa vara evaluation should include a search for family history, trauma, infection, and associated skeletal abnormalities [4].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or driving. However, short-term follow-up data indicates that patients treated surgically for Sprengel deformity maintain improved shoulder function and appearance [5]. Similarly, patients with and without anterior deltoid muscle reflection in reversed shoulder arthroplasty showed similar functional outcomes at short-term follow-up [10]. Open reduction of interposed tissues can result in a good functional outcome, at least in the short term, for irreducible isolated anteromedial radial head dislocation [12]. Distal clavicle autograft for addressing glenoid defects in revision total shoulder arthroplasty shows promising short-term outcomes with improved shoulder function and stability [75]. Early results of glenohumeral joint preservation procedures for young, active patients with osteoarthritis indicate satisfactory short-term outcomes [118].

Full activity (months): The evidence does not specify a precise month range for full activity or return to sport. Human motor endplates persist and retain their structures even after the 6-month window of opportunity for meaningful functional recovery has elapsed [86]. Surgical excision of a fully ossified transverse humeral ligament resulted in immediate resolution of symptoms, with durable improvement noted at the 1-year follow-up [117].

Complete recovery / outcome plateau (months): Longer term radiographic and clinical analysis is needed to confirm findings and theoretical benefits for future revision surgeries regarding stemless humeral components in anatomic total shoulder arthroplasty [7]. Further studies with long-term follow-up are needed to determine whether the grafted area maintains structural and functional integrity after autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [11]. Longer follow-up is required to confirm the reliability of arthroscopic treatment for chronic anterior instability with hyperlaxity using the Trillat technique with endobutton fixation [84]. Multicenter studies extending over long periods of time are needed to accurately define the results and prognoses associated with operatively treated displaced glenoid cavity fractures due to their rarity [116].

Rehabilitation protocol: The natural history of neonatal brachial palsy patients with absent biceps function at three months of age provides a benchmark for comparing outcomes with microsurgical repair [14]. Glenoid ossification and fusion progress in a predictable and chronological manner in pediatric and adolescent shoulders [113].

Functional milestones: The age of the patient at the time of initial shoulder dislocation is the most consistent and significant factor influencing prognosis, with recurrence rates of 83% in patients under twenty years and 12% in patients over fifty years [121]. Time from symptom onset greater than 5.5 years and critical shoulder angle greater than 38 degrees were significant independent factors of acromiohumeral interval reversibility in patients with massive rotator cuff tears [119].

Other Considerations: Posterior bone loss occurs at a mean of 30° off the long axis of the glenoid in a posteroinferior direction, which is historically different from anterior bone loss [18, 19]. Anterior bone loss occurs parallel to the long axis of the glenoid [19]. Subacromial notching rates are low following reverse shoulder arthroplasty with a 135° inlay humeral component and a lateralized glenoid [83]. When subacromial notching occurs, it is not associated with functional outcomes or range of motion at short-term follow-up [83]. The prognosis for synovial sarcoma of the sternoclavicular region is not entirely hopeless in all instances, as indicated by a patient living and well seven years after operation [115]. Findings on the effect of technological innovations in reverse total shoulder arthroplasty on periprosthetic acromion and scapular spine fracture rates should be interpreted in the context of time-related confounding, including surgeon experience and practice evolution [120].

Key Evidence

• [L4] However, a clear and standardized definition of these landmarks is needed to ensure consistency across measurements. (10.1016/j.jseint.2024.09.027)
• [L4] Coracoid pain is a rare symptom with diverse soft tissue and bony causes; clinicians should consider specific anatomical pathologies and use diagnostic investigations and treatments tailored to the identified etiology. (10.1111/sae.12017)
• [L4] A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis. (10.1016/j.arthro.2011.03.025)
• [L5] Evaluation should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify coxa vara and select optimal treatment. (10.5435/00124635-199803000-00003)
• [L5] Recent long-term studies indicate that patients treated surgically maintain improved shoulder function and appearance. (10.5435/jaaos-20-03-177)
• [L5] A comprehensive clinical approach emphasizing the evaluation of the extent of the anatomic injury and understanding its mechanical consequences regarding shoulder and arm function is a key in the development of guidelines for developing operative or non-operative treatment protocols and for establishing outcomes of the treatment protocols. (10.1177/17585732221122335)
• [L4] Longer term radiographic and clinical analysis with this cohort will be needed to confirm these findings and theoretical benefits for future revision surgeries. (10.1016/j.jseint.2022.12.020)
• [L5] Although many treatment techniques remain in their infancy and further follow-up is necessary before universal adoption, they provide a novel means of addressing difficult-to-treat and complex shoulder girdle pathologies. (10.1016/j.jhsa.2015.06.123)
• [L5] The purpose of this article is to review the evolution of the Walch classification, understand the rationale behind the modifications, and discuss potential future developments. (10.5435/jaaos-d-20-00880)
• [Abstract] Patients with and without the anterior deltoid muscle reflected in RSA surgery showed similar functional outcomes at short-term follow-up. (10.1016/j.jse.2022.01.080)
• [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
• [Case_report] Open reduction of interposed tissues can result in a good functional outcome, at least in the short term. (10.1177/17585732211039459)
• [L5] Operative repair should be reserved for cases with unassailable indications, as anatomical reconstruction is not necessary for satisfactory function and results of early and delayed repair are substantially the same. (10.2106/00004623-196244050-00010)
• [Case_report] The authors detail the successful results of a nonoperative treatment approach, noting that the natural history and role of nonoperative management for this condition were previously undefined. (10.1016/j.xrrt.2023.10.007)
• [L4] The authors routinely recommend CT scan to assess the extent of the fracture and perform surgical planning. (10.1016/j.jseint.2020.10.015)
• [L4] Physeal-specific MRI reveals minimal growth plate disturbance following AE reconstruction relative to a PTP technique; however, both techniques reveal no evidence of significant complications. (10.1016/j.arthro.2014.04.010)
• [L4] Posterior bone loss occurs at a mean of 30° off the long axis of the glenoid in a posteroinferior direction, which is historically different from anterior bone loss. (10.1177/2325967120s00377)
• [L4] Posterior bone loss occurs at a mean of 30° off the long axis of the glenoid in a posteroinferior direction, which is historically different from anterior bone loss, which occurs parallel to the long axis of the glenoid. (10.1177/0363546519876282)
• [L5] This article reviews the relevant anatomy, etiology, clinical evaluation, diagnostic testing, and treatment of scapular winging, discussing the differences in diagnosis and management between scapular winging arising from neurogenic causes and traumatic muscular detachment. (10.1016/j.jhsa.2018.08.008)
• [L4] This variant does not appear to contribute to shoulder pathology because standard treatment of concomitant diagnoses resulted in resolution of symptoms. (10.1016/j.jse.2011.05.006)
• [L5] Small but significant asymmetries exist between the dominant and nondominant shoulders in terms of kinematics. (10.1016/j.jse.2013.08.020)
• [L5] Despite technology innovations, a precise, easy to use and low-cost non-invasive method able to draw and analyze the kinematics of the shoulder complex has not been developed yet. (10.1177/17585732221090226)
• [L5] This comprehensive review highlights the importance of a thorough understanding of shoulder physical examination and specific diagnostic tests, emphasizing history-taking and examination to ensure diagnostic accuracy and optimize patient outcomes for surgeons. (10.5435/jaaos-d-25-00024)
• [L5] The biomechanics of the shoulder relies on careful balancing between stability and mobility, with anatomic total shoulder arthroplasty aiming to reproduce premorbid kinematics and reverse shoulder arthroplasty achieving stability through a semi-constrained design. (10.1302/2058-5241.6.210014)
• [L5] This article reviews the key features and treatment options of the more commonly encountered benign and malignant shoulder bone and soft-tissue tumors and tumor-like conditions to help determine the diagnosis and treatment plan. (10.5435/jaaos-d-17-00449)
• [L2] The frequency of each type of injury in this new classification is presented and a technique for viewing 3D images is suggested which maximizes their usefulness. (10.1016/j.jse.2009.03.001)
• [L5] An improved understanding of the fascial anatomy and innervation pattern of the teres minor muscle may help clinicians who treat patients with symptomatic isolated teres minor muscle atrophy. (10.1016/j.jse.2011.12.005)
• [L5] This study provided normative kinematic values of scapulothoracic movements in the shoulder girdle. (10.1016/j.jseint.2022.09.014)
• [Case_report] This case highlights the importance of thorough musculoskeletal assessment and supports encouraging outcomes from operative fixation when there is significant articular displacement. (10.1016/j.xrrt.2025.08.007)
• [L5] Recognition of these anatomical details and variations is essential for accurate diagnosis and surgical decompression to avoid iatrogenic injury. (10.1016/j.hcl.2007.05.001)
• [L4] Surgical treatment of established nonunion has proved efficacious in terms of symptomatic improvement and restoration of function. (10.5435/00124635-199601000-00001)
• [L4] Recognizing these variations is crucial for understanding the etiology and ensuring adequate surgical decompression. (10.1007/s00167-003-0378-3)
• [L4] Atypical mycobacterium infections of the musculoskeletal system follow a chronic course, and biopsy with microbiological analysis is essential for definitive diagnosis. (10.1177/1758573219859466)
• [L3] This pathologic anatomy is not addressed by current soft-tissue stabilization procedures and may contribute to instability recurrence. (10.1016/j.jse.2019.01.009)
• [L4] The new classification of the suprascapular triad topography and quantitative analysis of the space available for the path of the suprascapular nerve are important for a better understanding of the possible morphological conditions that may promote suprascapular nerve entrapment, especially those with a type III arrangement. (10.1007/s00167-014-2937-1)
• [L4] This review explores the causes of scapula winging, with an overview of the relevant anatomy, proposed aetiology and treatment, with particular focus given to lesions of the long thoracic nerve, which is reported to be the most common aetiological factor. (10.1111/sae.12033)
• [L5] Scapular dyskinesis is a relatively new concept in the assessment of shoulder pathology and is likely a major contributor to shoulder pain, particularly in cases of recalcitrant shoulder pain and dysfunction. (10.1177/1758573215595949)
• [L4] When patients with clinical suspicion of rotator cuff tear present with combinations of these radiographic signs, a prompt MRI examination and a referral to a shoulder specialist are recommended. (10.1016/j.jseint.2020.09.015)
• [L4] Rhabdomyosarcoma of the hand is a distinct clinical entity that is often painless. (10.2106/00004623-196143050-00007)
• [L3] The 3D classification system using combined humeroscapular alignment and glenoid erosion can be applied to describe the disease comprehensively. (10.1177/23259671221110512)
• [L4] This classification system allows for the ability to evaluate differing repair patterns and their effects on postoperative clinical outcomes. (10.1177/2325967125s00101)
• [L3] Scapulothoracic motion is an important component of active shoulder motion and function in both healthy shoulders and in those compromised by common pathologies. (10.1007/s00264-018-4027-3)
• [L5] Improved histology was correlated with improved final construct strength at the 12-week time point. (10.1016/j.jse.2019.05.024)
• [L5] Only minor variations in the overall anatomical pattern were found. (10.2106/00004623-197961010-00011)
• [L3] Integration of the bone graft occurs effectively, with no relevant changes observed on radiographic evaluation. (10.5397/cise.2022.01270)
• [Paper] Best results are achieved in patients with previous conservative treatment, structural integrity of the teres minor and limited amount of metaphyseal bone loss. (10.1007/s00402-014-1980-1)
• [L1] Both treatment groups resulted in excellent early functional outcomes. (10.1016/j.jse.2023.02.115)
• [L4] Accurate imaging and assessment of the size and relations of bone defects are crucial for further treatment planning. (10.1302/2058-5241.5.200049)
• [L5] The proposed classification system addresses the surgical management of the glenoid during prosthetic replacement and allows direct follow-up comparison of similarly treated glenoid replacements. (10.1016/j.jse.2011.01.035)
• [L4] The study established a radiological classification system identifying three types of glenoid fossa shape changes and six total deformity types when including upward humeral head migration. (10.1155/2011/239894)
• [L5] This study communicates a proposal of 16 new terms defining grossly visible structures on the scapula that have not yet been described by officially recognized terms, including a call to unify 13 previously contributed terms that have not been codified and are often used interchangeably within different surgical and scientific fields. (10.1016/j.jse.2021.07.020)
• [L4] Nonoperative treatment for Panner disease resulted in favorable outcomes in 7 patients. (10.1177/23259671251372617)
• [L4] At a minimum of 2 years successful correction of scapular anatomy can improve static subluxation and restore subjective and objective shoulder stability. (10.1016/j.jseint.2025.06.018)
• [L4] These differences may be considered when analyzing scapular morphology. (10.1016/j.xrrt.2025.04.001)
• [L4] Further studies are needed to assess both the safety and efficacy of selective denervation of the painful shoulders, while limiting the loss of proprioceptive function. (10.1016/j.jse.2020.07.017)
• [L5] The numerical model is suitable for the shoulder articular contact evaluation. (10.1016/j.otsr.2020.03.004)
• [L5] Changes in the CSA modify glenohumeral joint biomechanics with increasing CSA producing higher shear forces that could contribute to rotator cuff overuse, whereas reducing the CSA results in higher compressive forces that contribute to joint wear. (10.1016/j.jse.2020.03.002)
• [L1] rTSA restores forward elevation primarily via compensatory scapulothoracic motion and deltoid-driven neuromuscular strategies rather than normalization of glenohumeral mechanics. (10.1016/j.jse.2026.03.002)
• [L3] While more advanced measurement techniques that take glenoid concavity into account are more accurate in determining the biomechanical relevance of glenoid bone loss, the reliability of manually performed, more complex measurements was moderate. (10.1177/23259671231222938)
• [L5] Recent changes in device design and implantation methods are driven by biomechanical and clinical outcome-based research to better reproduce elbow kinematics, resulting in more durable and long-lasting joint replacement procedures. (10.1302/2058-5241.2.160064)
• [Paper] The most common mid- and long-term complication is occurrence or progression of osteoarthritis. (10.1007/s00402-015-2242-6)
• [Abstract] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jse.2022.01.037)
• [L4] However, the literature is limited by low-level evidence and high heterogeneity in surgical techniques and outcome measures, necessitating future prospective, standardized studies to optimize patient selection and treatment protocols. (10.1016/j.jse.2026.05.023)
• [L5] A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance. (10.1177/23259671231202533)
• [L5] Shoulder stability depends on several anatomical and functional factors, with bony structures like the glenoid cavity and humeral head playing a critical role alongside soft tissues. (10.1302/2058-5241.3.180028)
• [L5] The results suggest that the glenohumeral geometry is both gender and population specific, and future joint replacements may be designed to address these differences. (10.1016/j.jses.2017.11.007)
• [Paper] Conservative treatment is sufficient in non-displaced type A post-operative fracture. (10.1007/s00264-015-2972-7)
• [L4] The study describes promising short-term outcomes with improved shoulder function and stability using this technique, though further follow-up and additional cases are needed to confirm long-term efficacy. (10.1016/j.xrrt.2024.10.006)
• [L4] The review outlines current surgical options for proximal humerus reconstruction in oncological patients, highlighting that consensus on the best technique is not established and the choice depends on patient age, clinical picture, functional demands, and potential sacrifice of muscles or nerves. (10.1155/2021/5559377)
• [L3] Consideration must be given to osseous adaptations that occur at the glenohumeral joint when evaluating and treating this population. (10.1177/23259671241260084)
• [L5] The success of total shoulder arthroplasty is dependent on proper patient selection and the surgeon's ability to restore the native anatomy. (10.5435/jaaos-d-21-01119)
• [L4] While complications were varied and mostly minor, the study demonstrates that anatomical restoration of the trochlea is important for restoring elbow function. (10.2106/00004623-198567020-00008)
• [L4] The scope of this article is to present an overview of the fundamentals of conventional surgical treatment options for osteoarthritis of the human skeleton, with emphasis on arthroscopy, preservation, arthrodesis, and replacement. (10.3390/life12070982)
• [L4] Despite overall trends of bone loss, there remains significant variability between individuals, and subject-specific tools for planning surgical procedures in which scapular fixation is required may be beneficial. (10.1016/j.jse.2021.05.011)
• [L3] When subacromial notching occurs, it is not associated with functional outcomes or range of motion at short-term follow-up. (10.1016/j.jseint.2024.01.009)
• [L4] Longer follow-up is required to confirm the reliability of this technique. (10.1177/2325967120s00006)
• [L5] It is likely that only CT scan or MRI is sufficient to analyse osteoarthritis in this joint. (10.1016/j.otsr.2020.08.008)
• [L4] Human motor endplates persist and retain their structures even after the 6-month window of opportunity for meaningful functional recovery has elapsed, suggesting limited utility of animal models for traumatic peripheral nerve injuries. (10.1016/j.jse.2018.11.035)
• [L4] Both non-operative and operative treatments are described with evidence-based support to ensure acceptable functional outcomes. (10.1177/1758573216676786)
• [L3] This should be taken into consideration when using a CT scan to assess a patient with symptomatic SCJ pathology. (10.1016/j.jse.2016.04.029)
• [L4] Future long-term, high-volume studies are needed to provide more insight into the outcomes of these modifications. (10.1016/j.jisako.2023.03.433)
• [L4] Fractures that are significantly displaced can result in adverse healing and long-term functional consequences and should therefore be considered for ORIF. (10.5435/00124635-199501000-00004)
• [L4] They can be difficult to diagnose by less experienced Health Practitioners on plain radiographs and a low threshold for more senior review or additional imaging should be considered. (10.1177/1758573220923122)
• [L3] Measurement of CSA using both X-ray and MRI demonstrates excellent interrater reliability. (10.1016/j.jisako.2025.100803)
• [L4] Nonoperative treatment is the best approach for patients with symptomatic scapulothoracic crepitus. (10.5435/00124635-199809000-00001)
• [Paper] The early results are encouraging, but further research is demanded to evaluate the biomechanical strength, long-term outcomes, union rates, and degree of any bone resorption that may occur over time. (10.1016/j.eats.2016.04.011)
• [L5] Accurate anatomical knowledge is required to carry out the contemplated procedure with the least possible disturbance of function. (10.2106/00004623-194931020-00002)
• [Case_report] MRI is essential for accurate diagnosis and surgical planning in these cases. (10.1016/j.jses.2019.08.001)
• [L5] Regardless of imaging modality, the error in bone loss measurement tends to increase with increased defect size. (10.1016/j.arthro.2016.08.025)
• [Commentary] Clinicians should feel confident in assessing glenoid version on MRI in the absence of CT imaging, as MRI could be comparable to CT even in cases where the entire scapula is not visible on MRI. (10.1016/j.arthro.2019.09.037)
• [L3] Ten anatomical risk factors associated with subacromial impingement and rotator cuff tears are not unique to humans among great apes, indicating an alternative primary aetiological factor must have developed during human evolution. (10.1007/s00264-013-2204-y)
• [L4] MRI determination of PIN position is reliable and consistent with prior cadaveric study. (10.1016/j.arthro.2020.12.118)
• [Letter] They consider a clinical study using radiographs in the true anteroposterior view and degrees of arm rotation with clinical representation necessary to reach consensus. (10.1016/j.jse.2016.07.033)
• [L3] However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment. (10.2106/00004623-198769040-00013)
• [L5] Non-operative treatment is a viable alternative for surgical treatment of isolated greater tuberosity fractures and is associated with good patient reported outcome measures and a low incidence of complications. (10.1016/j.otsr.2021.102919)
• [Case_report] This case highlights that excellent functional outcomes can be achieved with a conservative approach even after extensive soft tissue damage from minor injury. (10.1186/1471-2474-3-1)
• [Case_report] The authors recommend that an avulsion fracture be considered with this injury pattern and if clinically suspected, MRI will determine the pathology and allow early appropriate management. (10.1016/j.injury.2004.11.002)
• [L3] Measuring glenoid version on MRI does not appear to be significantly affected when the entirety of the medial border of the scapula is not included in the imaging field. (10.1016/j.arthro.2019.07.030)
• [L3] The CSA measurements using radiography were highly congruent, but a large measurement deviation occurred between radiographs and true AP views. (10.1016/j.jse.2022.07.017)
• [L4] The MRI-based formula produced estimates nearly as accurate as CT-specific formulas when applied to CT scans, but CT-specific formulas are more accurate. (10.1177/0363546515581468)
• [Letter] The sole assessment of recurrent dislocation to define natural history and treatment rationale is inadequate, and conclusions regarding treatment recommendations cannot be made from a study that did not compare treatment methods. (10.1177/0363546510379343)
• [L4] Glenoid ossification and fusion progress in a predictable and chronological manner. (10.1016/j.arthro.2019.08.011)
• [L4] Major amputations are often performed as a desperate measure after other methods fail, with results influenced by the natural history of the cancer and delays in surgery. (10.2106/00004623-195638020-00001)
• [L4] The patient was living and well seven years after operation, indicating the prognosis is not entirely hopeless in all instances of synovioma. (10.2106/00004623-196345010-00013)
• [L4] Due to the rarity of displaced fractures, only multicenter studies extending over long periods of time will lead to accurate definition of the results and prognoses associated with operatively treated fractures. (10.2106/00004623-199274020-00019)
• [Case_report] Surgical excision of the osseous bridge resulted in immediate resolution of symptoms, with durable improvement noted at the 1-year follow-up. (10.1016/j.xrrt.2025.08.011)
• [L4] Early results indicate satisfactory short-term outcomes, though these procedures have yet to show they can halt arthritic progression. (10.1155/2012/160923)
• [L3] Time from symptom onset greater than 5.5 years and critical shoulder angle greater than 38 degrees were significant independent factors of acromiohumeral interval reversibility. (10.1177/23259671241306121)
• [L3] These findings should be interpreted in the context of time-related confounding, including surgeon experience and practice evolution. (10.5435/jaaos-d-25-01600)
• [L4] The age of the patient at the time of the initial dislocation is the most consistent and significant factor influencing prognosis, with recurrence rates of 83% in patients under twenty years and 12% in patients over fifty years. (10.2106/00004623-195638050-00001)

See Also

• Total shoulder arthroplasty
• Rotator Cuff
• Fractures
• Latarjet Procedure
• Reverse Shoulder Arthroplasty
• Shoulder Instability
• Proximal Humerus Fracture
• Rotator Cuff Repair
• Shoulder Arthroplasty

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