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Degenerative Conditions

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

148 citationsUpdated Oct 2026

Overview

Thoracolumbar degenerative conditions require management strategies that address the underlying degenerative cascade [1]. While total disk replacement demonstrates short-term success, long-term effects require further investigation [1]. Arthrodesis remains the best surgical treatment for the persistently painful degenerative back, though it carries increased morbidity, mortality, and a risk of non-union [15]. In the upper extremity, rotator cuff disease is widespread with prevalence increasing with age [50]. Both surgical and nonsurgical treatments can be effective for rotator cuff disease [50], and surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease [8]. Patients with degenerative rotator cuff disease demonstrate clinically relevant differences in pain and functional outcomes compared to nonoperative treatment following surgical intervention [8]. Untreated chronic rotator cuff tears can lead to arthrosis [50], for which salvage options exist [50].

For glenohumeral degenerative joint disease, shoulder arthroplasty is effective within a relatively short time frame in improving patients' assessment of both shoulder function and overall health status [16]. Clinical outcomes after reverse total shoulder replacement are best observed in patients with degenerative diseases [3], while outcomes are lowest in patients undergoing secondary interventions [3]. Reverse total shoulder arthroplasty provides comparable clinical outcomes at 2 years across indications of irreparable rotator cuff tear, rotator cuff tear arthropathy, and primary osteoarthritis [42]. Reverse arthroplasty can achieve highly favorable outcomes for glenohumeral osteoarthritis with an intact rotator cuff [52]. For patients with frank degenerative arthritis or extensive humeral head involvement, the prognosis is poor and earlier consideration of arthroplasty is indicated [5].

Knee degenerative joint disease is a common condition requiring understanding of pathology, diagnosis, and treatment options to provide evidenced-based care [2]. Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression [19], and joint replacement is indicated for end-stage osteoarthritis disease [19]. Joint replacement procedures relieve pain and improve function more than other current operative treatments for osteoarthrosis [144], although they are limited by the inability of synthetic materials to duplicate the properties of articular cartilage [144]. Procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease [144]. In the hip, few asymptomatic hips with normal findings on initial radiographs are at risk for pain or radiographic abnormalities in patients with non-traumatic osteonecrosis [12]. When disease develops in these asymptomatic hips, deterioration is slow and operative intervention is rarely indicated [12].

Anatomy & Pathophysiology

General Degenerative Mechanisms

Lifelong moderate use of normal joints does not increase the risk of degeneration [22]. Conversely, high-impact and torsional loads may increase the risk of degeneration in normal joints [22]. 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 [22]. The degeneration of normal articular cartilage is not simply the result of aging and mechanical wear [22]. Age-related changes in chondrocyte function suggest that age-related changes in articular cartilage contribute to the development and progression of osteoarthritis [22].

The joint must be viewed as an organ, with multiple tissues including the synovium, tendon, and subchondral bone contributing to the disease process [206]. Native articular cartilage exists in a state of relative cellular quiescence and homeostasis [206]. Traumatic insults tip this state out of equilibrium [206]. Momentary mechanical trauma on the articular surface during shoulder dislocation results in focal injury to the cartilage matrix and chondrocyte apoptosis [206]. The interaction between biologic and mechanical changes determines the risk and rate of progression of posttraumatic osteoarthritis [206].

Spine

Two theories explain Charcot spine arthropathy. The neurovascular theory proposes that autonomic dysfunction due to neurological injury 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 on anatomical stability factors [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 because of 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 glenoid is a convex structure of shallow depth shaped like an inverted pear [74]. The glenoid cavity is a shallow socket, approximately one third the size of the humeral head [76]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [79]. The glenoid averages 5 degrees of retroversion in relation to the axis of the scapular body [79]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [95]. Glenoid version averages 1.5 degrees of retroversion with a range of 10.5 degrees anteversion to 9.5 degrees retroversion [91]. Glenoid inclination averages 4.2 degrees with a range of -7 to 20 degrees [91]. The glenoid diameter ranges from 18 to 30 mm superiorly and 21 to 35 mm inferiorly in the anteroposterior direction [91]. The superoinferior height of the glenoid ranges from 30 to 48 mm [91]. Glenoid surface area ranges from 4 to 6 mm [91].

The articular head of the humerus is spherical with a diameter of 37 to 57 mm [74]. The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [74]. Humeral version averages 29.8 degrees with a range of 10 to 55 degrees [74]. The humeral head is retroverted an average of 30 degrees [76]. The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [95]. Humeral head version ranges from 0 to 55 degrees of retroversion [91]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [74]. The neck-shaft angle of the proximal humerus measures an average of 135 degrees [76]. The humeral head averages 19 degrees of retroversion and 41 degrees of inclination [79]. Humeral head inclination ranges from 30 to 55 degrees [91]. Head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [95].

The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [77]. The scapula is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion over the chest wall [77]. The scapula spans second through seventh ribs and serves as an attachment for 17 muscles [95]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [95]. The lateral pillar of the scapula connects the inferior border of the glenoid with the inferior angle [77]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [77]. The two bony pillars of the scapula form a triangle that constitutes the biomechanical body of the scapula [77]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [77]. The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [77].

The clavicle is the first bone to ossify at the fifth week of gestation [79]. The clavicle is the only long bone to ossify by intramembranous ossification [79]. The medial epiphysis of the clavicle is the last ossification center to fuse, at age 20 to 25 years [79]. The primary blood supply to the clavicle is periosteal, with no nutrient artery present [79]. Ossification of the scapular body begins at the eighth week of gestation [79]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [79]. Failure of fusion of acromial ossification centers results in os acromiale [79]. Os acromiale is incomplete fusion of secondary ossification centers, most commonly between mesoacromion and meta-acromion [95].

The formation of the humerus begins with the appearance of the cartilage anlage by the fifth week of gestation [83]. The primary ossification center for the humerus appears at about the sixth week [83]. The ossification center for the humeral head is usually present at birth [83]. The greater tuberosity ossification center appears by 1 to 3 years of age [83]. The lesser tuberosity ossification center appears by 5 years of age [83]. Proximal humeral ossification centers fuse by 5 to 7 years of age to form the humeral head [83]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [83]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to adult values by 11 years of age [83]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis [83]. The proximal humeral physis accounts for approximately 40% of the growth of the entire upper extremity [83].

The anatomic neck is directly below the humeral head and serves as an attachment for the shoulder capsule [95]. The surgical neck is more distal and more often involved in fractures [95]. The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [79]. The posteromedial metaphysis, a portion of the physis, and the epiphysis are intracapsular [83]. A large part of the proximal humeral physis is extracapsular, making it susceptible to traumatic injury [83]. The proximal humeral physis is irregularly shaped, with its apex located on the posteromedial portion of the proximal humerus [83]. The periosteum is thicker and stronger in the posteromedial portion of the proximal humerus compared to the anterolateral portion [83].

Shoulder Ligamentous & Soft Tissue Anatomy

The scapula in humans is suspended by muscles alone and has shifted caudally from the cervical position in lower animals [87]. Broadening of the infraspinatus fossa has changed the vector of muscle pull from the axillary border of the scapula to the glenoid fossa [87]. This adaptation allows the infraspinatus and teres minor muscles to be more effective as depressors and external rotators of the humeral head [87]. The acromion has enlarged in humans compared to pronograde animals, reflecting the increasing role of the deltoid muscle in shoulder function [87]. The coracoid process has increased in size over time [87]. With the shoulder in 90 degrees of abduction, the coracoid extension over the glenohumeral joint can mechanically limit anterior translation of the humerus relative to the glenoid [87].

The coracoid process has attachments to the coracoacromial ligament, coracoclavicular ligaments, conjoined tendon, and pectoralis minor [95]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency [95]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [95]. The sternoclavicular joint is a double gliding joint with an articular disc [95]. The sternoclavicular joint is the only true joint connecting the upper extremity with the axial skeleton [95]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability [95]. The sternoclavicular joint rotates 30 degrees with shoulder motion [95].

The acromioclavicular joint is a plane/gliding joint with a fibrocartilaginous disc [95]. The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [79]. The posterior and superior acromioclavicular ligaments are considered the strongest [95]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [79]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [79]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint [95]. The conoid ligament is located approximately 45 mm from the acromioclavicular joint and is stronger than the trapezoid ligament [95].

The glenohumeral joint is a ball and socket joint with the greatest range of motion in the body [95]. Static restraints of the glenohumeral joint include articular anatomy, glenoid labrum, glenohumeral ligaments, capsule, and negative intraarticular pressure [95]. Dynamic stabilizers of the glenohumeral joint include the rotator cuff and biceps tendon [95]. The fibrocartilaginous glenoid labrum deepens the socket 50% and provides a bumper to translation [95]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [79]. Labral anatomic variants include sublabral foramen and Buford complex [95]. The Buford complex is characterized by the absence of the anterosuperior labrum and a cordlike middle glenohumeral ligament [95].

The capsule of the glenohumeral joint extends from the glenoid rim, progressing laterally toward the surgical neck of the humerus and blending with the tendons of the rotator cuff musculature [83]. Static stability of the glenohumeral joint is maintained by capsulolabral attachments and intracapsular ligamentous thickenings [83]. The rotator cuff and periscapular musculature afford dynamic stability to the glenohumeral joint [83]. The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [79]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [79]. Laxity of the rotator interval results in inferior laxity, while contracture of the interval is seen with adhesive capsulitis [79].

The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [79]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [79]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45 degrees of abduction [79]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation in 90 degrees of abduction and external rotation [79]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [79]. The transverse humeral ligament is an important stabilizer of the biceps tendon [95].

The subscapularis originates from the anterior scapula and inserts anteriorly onto the lesser tuberosity [83]. The greater tuberosity provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor [83]. The deltoid forward flexes and abducts the shoulder, coalescing into a common tendinous insertion onto the lateral upper third of the humeral shaft [83]. The pectoralis major powers adduction and internal rotation due to its tendinous insertion anteriorly onto the lateral wall of the bicipital groove [83]. The pectoralis major forms the roof of the distal continuation of the bicipital tunnel [83].

Shoulder Vascular & Neural Anatomy

The primary blood supply to the humeral head is provided by the anterolateral ascending branch of the anterior humeral circumflex artery [79]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [79]. 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [83]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [83].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [79]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to it [79]. The suprascapular artery passes superior to the superior transverse scapular ligament and the suprascapular nerve passes inferior to it through the notch [95]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and infraspinatus muscles [79]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [79]. At the spinoglenoid notch, both the artery and nerve are inferior to the inferior transverse scapular ligament [95]. Entrapment, traction, or compression at the spinoglenoid notch causes denervation of the infraspinatus muscle [79].

Shoulder Kinematics

Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [79].

Classification

Minami Classification: This system classifies osteochondritis dissecans (OCD) of the elbow into three grades. Grade 1 is a stable lesion with a translucent cystic shadow in the capitellum [45]. Grade 2 is defined by a clear zone between the OCD and adjacent subchondral bone [45]. Grade 3 is defined 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 elbow OCD. 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 of rotator cuff muscles in five stages. Stage 0 is normal muscle with no fatty deposits [47]. Stage I has some fatty streaks present [47]. Stage II has more muscle than fat [47]. Stage III has equal muscle and fat [47]. Stage IV has more fat than muscle [47]. The Goutallier classification system and the Quartile system performed equally well in assessing fatty degeneration of the gluteus muscles, showing excellent levels of interrater and intrarater agreement [123]. The Goutallier/Fuchs classification system can be reliably and reproducibly applied to the evaluation of abductor tendon tears of the hip [193]. This system for hip abductor tendon tears appears to correlate with patient-rated outcomes after repair [193].

Fuchs MRI Staging System: This system aligns with Goutallier stages II and III for fatty degeneration of rotator cuff muscles. Stage II corresponds to more muscle than fat, and stage III corresponds to equal muscle and fat [47].

Samilson and Prieto Grading System: This system grades glenohumeral arthropathy based on the size of the inferior glenohumeral osteophyte [234]. Inter- and intraobserver reliability varied between fair and poor when using radiographs in neutral rotation [234]. Kappa coefficients showed a trend to increase in positions of internal rotation (10° and 20°) and external rotation (30° and 40°) [234]. Two Samilson grades could be applied to the same osteophyte in 46% of specimens due to variability from rotation [234]. The Modified Samilson and Prieto classification was used to grade preoperative glenohumeral osteoarthritis in a study of rotator cuff repairs [203]. In that study, total progression of glenohumeral osteoarthritis occurred in 19 of 146 patients (13.0%) [203].

Rosenberg Classification System: This system classifies glenohumeral osteoarthritis based on all radiological signs of osteoarthritis, including joint space narrowing, sclerosis, and cysts [234].

Royal Berkshire Hospital Classification: This system categorizes coracoacromial ligament (CAL) degeneration into four grades. Grade 0 is a normal appearance of the CAL [240]. Grade 1 is minor fraying [240]. Grade 2 is major fraying [240]. Grade 3 is defined by visualization of the bare bone under the CAL [240].

Outerbridge Classification: This system grades articular cartilage lesions from grade I to IV [73]. The International Cartilage Repair Society (ICRS) Hyaline Cartilage Lesion Classification System is a modification of the Outerbridge classification and is currently used as the international standard [73].

Brooker's Classification: This system grades heterotopic ossification. In patients with ankylosing spondylitis undergoing total hip arthroplasty, 41 of 129 hips (31.7%) developed heterotopic ossification according to Brooker's classification [238]. No hips in that study were graded as class III or IV heterotopic ossification [238].

Other Considerations: A four-stage classification scheme for transchondral fractures (osteochondritis dissecans) of the talus was presented in 1959 [152]. A new concise MRI classification of haemodialysis-related amyloidosis of the shoulder was proposed in 2016 [143]. Factors associated with calcium reabsorption in the shoulder include the Gartner classification, disease duration, and blood flow around calcium deposits [156]. The Walch classification for glenohumeral osteoarthritis has been evaluated for prognostic value before and after shoulder arthroplasty [153]. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses than the Walch classification [153]. A new four-category, 7-point classification system for hemophilic arthropathy demonstrated interobserver reproducibility and correlation with joint function equivalent to the Pettersson et al. system [118]. This new system is easier to apply and more sensitive in discriminating advanced arthropathy than the Arnold and Hilgartner system [118]. Five main types of coracoacromial ligaments were identified in a morphological study, with no statistical correlation found between coracoacromial ligament type and rotator cuff degeneration [178]. The NASS Evidence-Based Clinical Guideline on the Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders reviews the diagnosis and treatment of cervical radiculopathy [6]. The Walch classification was significantly different at baseline between degenerative condition and fracture cohorts in a Dutch Arthroplasty Register analysis of reverse total shoulder arthroplasty [237].

Clinical Presentation

General Degenerative Joint Disease

The degeneration of articular cartilage within the clinical syndrome of osteoarthritis is one of the most common causes of pain and disability in middle-aged and older people [22]. Nontraumatic pathologic conditions of the upper extremity, including neuropathy, vascular disease, and degenerative arthritis, can have a profound effect on function and quality of life [41]. Osteoarthritis and rheumatoid arthritis are degenerative conditions associated with a high degree of disabilities [36].

Cervical Spine

Degenerative cervical conditions are common and present with axial neck pain, radiculopathy, or myelopathy [7]. Degenerative cervical myelopathy represents a spectrum of related disorders affecting the aging spine that results in progressive cervical spinal cord compression [6]. The pathophysiology of cervical disk degeneration involves a cascade of events following spinal cord compression, including ischemia, destruction of the blood–spinal cord barrier, demyelination, and neuronal apoptosis [6].

Thoracolumbar Spine

Management strategies for thoracolumbar conditions must address the degenerative cascade [1]. The clinical presentation of Charcot spine arthropathy varies dependent on the presence of biological processes in the different stages of Charcot joint arthropathy [4]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion for spondylolisthesis [20].

Shoulder

Rotator cuff tears represent a spectrum of disease progressing from tendinitis to cuff arthropathy, with prevalence increasing significantly with age [35]. Degenerative rotator cuff tearing typically occurs in older patients [128]. Asymptomatic degenerative rotator cuff tears progress in patients 65 years and younger [44]. Rotator cuff tears—even ones of substantial size—can be asymptomatic [128]. The amount of shoulder discomfort experienced by the patient is not related to the size of the rotator cuff tear [128]. Pain may not be the primary symptom of rotator cuff failure, which may also produce weakness, stiffness, crepitus, or instability [128]. Gender, age, duration of symptoms, accompanying medical disease, cuff tear size, and degenerative indicator of cuff tear have no effect on stiffness occurring with rotator cuff tear [102].

Osteoarthritis of the acromioclavicular (AC) joint is a common condition causing anterior or superior shoulder pain, especially with overhead and cross-body activities [103]. AC joint osteoarthritis most commonly occurs in middle-aged individuals because of degeneration to the fibrocartilaginous disk that cushions the articulations [103]. 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 [103]. Symptomatic AC osteoarthritis must be differentiated from instability and subtle instability, which may have similar symptoms [103]. Plain radiographs can reveal degeneration of the AC joint, but diagnosis cannot be based on this alone because similar radiographic findings can be seen in asymptomatic individuals [103]. Osteoarthritis patients had a broad range of symptoms with 33% being asymptomatic [32]. 32% of patients with painful AC joints had a normal X-ray [32]. Imaging abnormalities of the acromioclavicular joint and subacromial space are common in asymptomatic shoulders [96].

Rapidly destructive arthrosis presents with unique radiographic features, MRI findings, and a specific clinical course characterized by rapid humeral head collapse [43]. Clinical outcomes after reverse total shoulder replacement varied according to the underlying indication, with the best results observed in patients with degenerative diseases [3]. The diagnosis of primary osteoarthritis of the shoulder is defined as shoulder pain and radiographic evidence of grade III osteoarthritic changes or higher (joint space narrowing, osteophytes, and subchondral sclerosis at the glenohumeral joint) with absence of findings or a history to indicate an etiology of trauma, infection, avascular necrosis, inflammatory arthropathy, or previous reconstructive shoulder surgery [107]. Diagnostic criteria for symptomatic shoulder osteoarthritis include a history of activity-related pain, restricted range of motion, and minimal pain with rotator cuff testing [109].

Hip

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 [29]. Few asymptomatic hips with normal findings on initial radiographs are at risk for pain or radiographic abnormalities [12]. Clinical features are not very reliable for the diagnosis of acetabular labrum tears in sports patients with groin pain [38]. FAI morphology is common in young adults and predisposes to later osteoarthritis [23].

Knee

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 [9].

Hand and Wrist

The degeneration of the articular disc in the human triangular fibrocartilage complex increases with age [110]. Diagnostic indications for basal joint arthroscopy include the assessment of painful post-traumatic basal joint lesions of cartilage and ligaments, and the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis [24].

Elbow

Classification of the lesion is critical because current management guidelines for osteochondritis dissecans of the elbow are dependent on the type of lesion present and on its stability [45].

General Diagnostic and Imaging Considerations

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 [27]. 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 [33]. Radiographic evidence of osteoarthritis does not necessarily correlate with poor function [39]. 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 [30]. Bone and cartilage debris in the synovial membrane is not absolutely specific as it can occur in advanced degenerative arthritis [30]. The final diagnosis of palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time [17]. Diabetic neuropathy must be considered when a diabetic patient complains of symptoms not typical of an orthopaedic syndrome [114]. Careful clinical assessment can differentiate between causes of shoulder pain and guide best management in patients after a cerebrovascular accident or traumatic brain injury [100].

Investigations

General Principles and Biomarkers

No currently available osteoarthritis-related biomarker can be considered a surrogate marker for clinical or imaging features for the diagnosis or prognosis of the disease [33]. The diagnosis of osteonecrosis can be challenging due to overlapping clinical presentations with other disorders, particularly in the early stage when radiographs are normal [29]. Bone and cartilage debris in the synovial membrane is not absolutely specific for neuropathic joints as it can occur in advanced degenerative arthritis [30].

Shoulder Imaging

Plain radiography: Standardized plain films are almost always sufficient to garner the information needed for shoulder care, and the temptation to "overimage" should be resisted [28]. The shoulder is a three-dimensional structure that cannot be represented by a single planar view [119]. Critical relationships such as the degree of centering of the humeral head change with the position of the arm [119]. Shoulder pathology may be found in a large number of different bones and soft tissues [119]. Overlying and superimposed structures as well as metallic implants may complicate imaging the structures of interest in the shoulder [119]. At least two X-ray views should be obtained for shoulder imaging: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction [111]. The standard shoulder series should include a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [125]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [125]. The AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [125]. The axillary view is necessary for evaluation of glenohumeral joint instability and enables determination of the humeral head position in the glenoid fossa [125]. The axillary view may detect occult, locked posterior shoulder dislocation in a patient who exhibits a lack of passive external rotation [125]. The axillary view is helpful in evaluation of glenoid morphology in glenohumeral osteoarthritis and provides good visualization of the coracoid process, acromion, and distal clavicle [125]. The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs associated with rotator cuff pathology [125]. The scapular Y view is a reliable alternative for evaluation of glenohumeral subluxation and dislocation [125]. The acromiohumeral distance is normally 7 to 14 mm [125]. The width of the glenohumeral joint space should be symmetric superiorly and inferiorly [125]. The coracoclavicular distance is normally 1.1 to 1.3 cm [125]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked) [125]. Type III acromial morphology has been shown to have a correlation with the presence of rotator cuff disease, but no direct causal relationship has been demonstrated [125]. The Neer classification of acromial morphology has shown relatively poor interobserver reliability [125]. The Serendipity view is indicated for the sternoclavicular joint and is taken with the patient supine, 40° cephalic tilt view centered on sternum [125]. The West point view is indicated for anterior glenoid bone loss and is taken with the patient prone, involved shoulder raised above table level, centered on axilla with beam directed 25° downward and 25° medial [125]. The Zanca view is indicated for the AC joint and is taken as an AP with 10° cephalic tilt centered over AC joint with the patient supine, using only one-half the voltage of a routine shoulder AP view [125]. The Stryker notch view is indicated to evaluate Hill-Sachs lesion after dislocation and is taken with the patient supine, affected arm placed on top of head with fingers toward back of head, beam centered over coracoid process with 10° cephalic tilt [125]. The Apical oblique view is indicated to evaluate for glenoid rim fracture in instability and is taken with the patient seated, cassette placed posterior and parallel to the spine of the scapula, beam directed 45° to the plane of the thorax and 45° caudally [125]. Radiographs provide better reproducibility and accuracy for critical shoulder angle measurement compared to MRI [183]. The critical shoulder angle is associated with rotator cuff tears and shoulder osteoarthritis [183].

MRI: MRI is useful to identify osteonecrosis of the humeral head, bone tumours, labral tears, and rotator cuff tears [111]. The accuracy of MRI for identifying labral tears and rotator cuff tears is enhanced by combining the scan with arthrography [111]. MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [124]. 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 [124]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [124]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [124]. The sensitivity of MRI for detecting full-thickness rotator cuff tears is 100% [125]. The specificity of MRI for detecting full-thickness rotator cuff tears is 68% [125]. The positive predictive value of MRI for detecting full-thickness rotator cuff tears is 85% [125]. The negative predictive value of MRI for detecting full-thickness rotator cuff tears is 100% [125]. The accuracy of MRI for detecting full-thickness rotator cuff tears is 89% [125].

CT: CT scans may offer increased precision in measuring glenoid version, but this precision does not improve the quality of surgery or clinical outcome [28]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [28]. CT is helpful for planning fracture surgery and shoulder joint replacement [111]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [125]. CT arthrography is indicated when MRI or MR arthrography is contraindicated, such as in patients with pacemakers or vascular clips [124].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [111]. Ultrasonography can be useful in guiding injections or barbotage [111]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [124]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [124]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [124]. Ultrasonography can evaluate impingement in various positions and motions due to real-time imaging [124]. 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 [124]. The sensitivity of ultrasonography for detecting full-thickness rotator cuff tears is 98% [125]. The specificity of ultrasonography for detecting full-thickness rotator cuff tears is 80% [125]. The positive predictive value of ultrasonography for detecting full-thickness rotator cuff tears is 90% [125]. The negative predictive value of ultrasonography for detecting full-thickness rotator cuff tears is 95% [125]. The accuracy of ultrasonography for detecting full-thickness rotator cuff tears is 94% [125].

Arthroscopy: Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, detachment of the glenoid labrum, and rotator cuff tears [111].

Other Considerations: 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 [28]. The standardized axillary truth view can show posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [28]. The degree of posterior subluxation can be measured by the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [28]. The point of contact of the humeral articular surface on the glenoid articular surface reflects the degree of centering of the net humeral joint reaction force on the glenoid [28]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [28]. Asymptomatic AC-OA remained asymptomatic in 90% over 7 years [202]. Increased age is the main determinant of radiological changes in shoulder OA, as well as pain [204]. Although progressive radiographic osteoarthritic changes occur after arthroscopic debridement of massive irreparable rotator cuff tears, they do not negatively influence clinical results [160]. The radiographical analysis of reverse shoulder arthroplasty with a minimum follow-up of 10 years showed high prevalence of signs associated with loosening, which did not seem to translate to high complication rates or inferior results [188].

Spine Imaging

MRI: MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement [27]. MRI serves as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities [27]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion [20].

Hip Imaging

MRI: Clinical features are not very reliable for diagnosis of acetabular labrum tears, and magnetic resonance arthrography and hip arthroscopy should be utilized more [38]. 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 [182]. Clinicians must 'treat the patient, not the MRI' regarding hip impingement [182].

Knee and General Joint Imaging

MRI: MRI provides valuable clues for diagnosing tenosynovial giant cell tumour and lipoma arborescens, but definitive diagnosis relies on histopathological confirmation [161]. While CT and MRI can assist in diagnosis of acetabular roof lesions, incisional biopsy is required in most cases for definitive histopathological confirmation [198].

Arthroscopy: Diagnostic indications for basal joint arthroscopy include the assessment of painful post-traumatic basal joint lesions of cartilage and ligaments [24]. Diagnostic indications for basal joint arthroscopy include the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis [24]. This minimally invasive approach of in-office diagnostic needle arthroscopy is an effective alternative to traditional diagnostic techniques of diagnostic surgical arthroscopy and magnetic resonance imaging [197].

Treatment

Non-Operative

An initial trial of nonsurgical management is usually warranted for degenerative conditions, typically involving rest, activity modification, anti-inflammatory medications, physical therapy, bracing, or injections [94]. Nonoperative treatment is the preferred option in early-stage atraumatic osteonecrosis of the humeral head and may prevent disease progression [157]. It is also helpful for most patients with painful conditions of the acromioclavicular joint, although those with osteolysis may need to modify their activities [167]. For primary and posttraumatic arthritis of the elbow, nonoperative treatment is almost always initiated, with surgery reserved for cases refractory to conservative management [138]. Similarly, nonsurgical measures including activity modification, gentle physical therapy, nonsteroidal antiinflammatory drugs, and immobilization should be considered before proceeding to surgical intervention for distal radioulnar joint arthritis [227].

Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear [190]. Conservative treatment was effective in 77% of patients with a degenerative supraspinatus tear [99]. In a population of patients with degenerative rotator cuff tears, no significant difference in functional outcome was observed between surgical and conservative treatment at 1 year [46]. Nonoperative modalities for shoulder osteoarthritis have been poorly studied, and recommendations for or against certain treatments are not well established [173]. For primary shoulder stiffness, surgical treatment is not recommended as the first-choice treatment; the majority of published studies indicate a period of 3–6 months for initial evidence-based conservative treatment before considering surgical intervention [176]. Physiotherapy or non-surgical treatment should be first line of management for subacromial pain [205]. In secondary care for subacromial pain, patients should be made aware that there is low evidence of benefit for PRP injection, hyaluronic acid injection, dry needling, and electrotherapies (laser, US, ESWT) [205]. Neuropathic arthropathy of the shoulder should be treated nonoperatively with an emphasis on the maintenance of function rather than immobilization [151]. Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care [147]. A supervised stretching programme renders significant short and long-term decrease in symptom for patients with retro-trochanteric pain [228].

Operative

Indications: 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 [8]. In a population of patients with degenerative rotator cuff tears, significant differences in pain and disability favored surgical treatment compared to conservative treatment [46]. If symptoms fail to resolve with non-surgical treatment by six months, there is moderate evidence that surgical treatment could be considered for subacromial pain [205]. Joint replacement is indicated for end-stage osteoarthritis [19]. Arthrodesis is successful in patients with degenerative changes in the glenohumeral joint causing severe pain unrelieved by conservative treatment [131]. Proximal-row carpectomy should be considered after conservative measures fail for diseases of the proximal row, as mild degenerative arthritis is not a contraindication [37]. 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 [179].

Surgical Approach / Technique: Shoulder arthroplasty was effective within a relatively short time frame in improving the assessment of both shoulder function and overall health status in patients with primary glenohumeral degenerative joint disease [16]. Clinical outcomes after reverse total shoulder replacement (RTSA) varied according to the underlying indication, with the best results observed in patients with degenerative diseases [3]. Reverse total shoulder arthroplasty (rTSA) provides comparable clinical outcomes across indications of irreparable rotator cuff tear, rotator cuff tear arthropathy, and primary osteoarthritis at 2 years [42]. Arthroscopic debridement should be considered a palliative measure for patients with mild or moderate glenohumeral arthrosis [21]. It is unknown whether arthroscopy can alter the natural history of degeneration or decrease the probability of disease progression in glenohumeral arthrosis [21]. The American Academy of Orthopaedic Surgeons clinical practice guidelines classify the use of arthroscopy for the treatment of glenohumeral arthritis as grade I, implying that they are unable to recommend for or against this option [89]. A systematic review of the literature showed that arthroscopic debridement for glenohumeral arthritis lacks high-quality evidence to support its routine use [89]. Arthroscopy is the gold standard for the identification and characterization of chondral injury in the shoulder [21]. The presence of incidental early arthritis is not a contraindication to performing procedures for concomitant abnormalities, as long as the surgeon is confident about the primary diagnosis based on thorough preoperative examination and imaging studies [21]. Arthroscopy provides an opportunity to diagnose and treat coexistent soft tissue pathology in patients with osteoarthritis, perhaps eliminating the need for arthroplasty [89]. The benefits of a lower complication rate and quicker return to normal activities after arthroscopy compared with total shoulder arthroplasty make this scenario appealing for patients with coexistent soft tissue pathology [89]. 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 [133]. Immediate and durable improvement of shoulder function can be expected from arthroscopic treatment of synovial chondromatosis of the shoulder, though surgical treatment should be performed before irreversible degenerative changes occur [25]. 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 [57]. 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 [132]. Subacromial decompression may offer satisfactory long-term outcomes for patients with subacromial pain [205]. 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 [205].

Surgical management of articular cartilage and subchondral bone pathology should focus on removing inflammatory mediators and restoring the osteochondral unit [94]. Surgical options for articular cartilage and subchondral bone pathology include arthroscopic débridement, bone marrow stimulation, osteochondral autograft transfer, osteochondral allograft transplantation, autologous chondrocyte implantation, and various newer, emerging techniques [94]. Current clinical treatments for articular cartilage defects have limited ability to repair tissue and often result in mechanically inferior cartilage [127]. 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 [10]. 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 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]. 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 [15].

Implant Selection: 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 [65].

Other Considerations: Neuropathic arthropathy of the shoulder is a contraindication to arthrodesis [151]. 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 [129]. Clinical decision-making for the management of rotator cuff tears can be complex and lacks consensus among orthopedic surgeons [78]. 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 [78]. Patients with rotator cuff disease 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 [78]. There is a lack of high-quality evidence available to surgeons to help guide management of rotator cuff tears [101]. The majority of the clinical practice guidelines set out by the American Academy of Orthopaedic Surgeons are limited or inconclusive regarding rotator cuff disease [101]. The Cochrane reviews fail to provide an evidence basis for the treatment of cuff disease [101].

Postoperative rehabilitation for rotator cuff arthropathy varies greatly, with time frames ranging from 12 weeks to 6 months [222]. All included studies on rehabilitation after reverse total shoulder arthroplasty suggested initiation of passive ROM and resistance exercise by week 6 along with full passive and active ROM by week 12 [222]. A randomized control trial demonstrated that both immediate rehabilitation and delayed therapy with immobilization after reverse total shoulder arthroplasty produced statistically and clinically significant improvements in American Shoulder and Elbow Surgeons scores and patient recorded outcome measurements within 6 weeks [222]. A randomized control trial demonstrated no significant difference in dislocation rates or opioid use between immediate rehabilitation and delayed therapy with immobilization after reverse total shoulder arthroplasty [222]. A statistically significant difference in pain existed favoring delayed therapy after reverse total shoulder arthroplasty, but this did not translate to a clinically significant difference [222].

Mesenchymal stromal cells (MSCs) are being tested in patient studies for a wide range of conditions such as osteoarthritis, rheumatoid arthritis, fracture repair, regeneration of articular cartilage, tendon repair and for treatment of degenerative disc disease [40]. The effectiveness of MSCs as a treatment modality for these conditions is still uncertain and market authorisations have been limited [40]. Critical and clear phenotypic parameters for defining MSCs are uncertain [40]. A coherent biological framework surrounding the therapeutic mechanism of action for MSCs is not yet available [40]. Cell manufacturing protocols for MSCs are complex and costly and present substantial challenges in terms of regulatory oversight and standardisation [40]. 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 [89]. Injectable viscosupplementation is not currently approved by the U.S. Food and Drug Administration for injection in joints other than the knee [89].

Complications

Spine

Arthrodesis: Fusion for the persistently painful degenerative back increases morbidity and mortality rates [15] and carries a risk of non-union [15]. Total Disk Replacement: Thoracolumbar total disk replacement demonstrates short-term success but requires further investigation into long-term effects [1]. Charcot Spine Arthropathy: This condition develops in surgically treated paraplegic patients, where repetitive movements for transfer and sitting contribute to its onset [4]. Pathogenesis involves two theories: the neurovascular theory proposes that autonomic dysfunction leads to increased bone resorption in hypervascular subchondral regions, resulting in microfractures and joint destruction [4]; the neurotraumatic theory proposes that loss of proprioception and protective joint mechanisms leads to increased biomechanical loads, synovial hyperplasia, and progressive subdislocation [4]. Over time, osseous debris solidifies around the affected region due to decreased vascularity [4].

Shoulder

Rotator Cuff Repair: Histological degeneration of remnant rotator cuff tendon deteriorates with chronicity [14]. The re-tear rate of Sugaya III tendons between 1 and 2 years postoperatively after arthroscopic repair exceeds 30% [18]. Re-tears are associated with higher tear size and fatty degeneration [18]. A follow-up of at least 2 years is necessary to determine short-term outcomes in patients with severe preoperative fatty degeneration [18]. Arthroplasty: Shoulder arthroplasty for primary glenohumeral degenerative joint disease effectively improves patient assessment of shoulder function and overall health status within a relatively short time frame [16, 59]. Humeral head replacement remains a successful operation for osteoarthritis at long-term follow-up [53]. In stemless ceramic head anatomic shoulder arthroplasty, the severity of osteoarthritis did not show any association with glenoid component survivorship or patient-reported outcome measures at 5 years review [54]. Favourable outcomes of reverse total shoulder arthroplasty for degenerative conditions seen at short-term follow-up are maintained beyond 5 years [55]. Arthroscopy: Arthroscopic debridement for mild or moderate glenohumeral arthrosis is a palliative measure; it is unknown whether arthroscopy can alter the natural history of degeneration or decrease the probability of disease progression [21]. The clinical significance of early chondral lesions and their likelihood of progression in the shoulder is unknown [21]. Adhesive Capsulitis: This self-limiting condition has a natural history of 18–30 months [71]. Persistent limitation occurs in 50% to 60% of patients [66], and in the long term, 41% of patients with frozen shoulder reported some ongoing symptoms [56]. Calcific Tendinitis: Patients with associated endocrine disease have a significantly more protracted natural history and more frequently undergo surgical treatment than those without associated endocrine disease [68]. Avascular Necrosis: In the precollapse stage of humeral head avascular necrosis, core decompression has not been confirmed to prevent or delay natural progression [69]. Shoulder arthroplasty for late-stage humeral head avascular necrosis has fairly good outcomes but undocumented long-term implant survival and complications [69]. Post-Bankart Arthropathy: After arthroscopic Bankart repair for anterior instability, significantly degenerative changes were found at the latest follow-up compared to preoperative examinations [61]. Patients with a higher number of dislocation episodes before surgery are more likely to develop evidence of arthropathy [61]. However, arthrosis of the glenohumeral joint after arthroscopic Bankart repair rarely causes more than minor subjective symptoms or a minor objectively perceived disadvantage during 13 years' follow-up [235]. Other Considerations: Rugby affects the shoulder joint, suggesting that 'rugby shoulder' tends to involve degenerative changes such as osteoarthritis or labral tears [233].

Knee

Rheumatoid Arthritis: In rheumatoid patients, inflammatory disease changes are arrested in about 67 per cent of the knees following synovectomy, while radiographic changes of degenerative joint disease may progress [9]. Total Knee Arthroplasty: An intraoperative load sensor did not improve the early postoperative results of posterior-stabilized TKA for osteoarthritis with varus deformities [60].

Hip

Osteonecrosis: Few asymptomatic hips with normal findings on initial radiographs are at risk for pain or radiographic abnormalities in non-traumatic osteonecrosis [12]. In sickle-cell disease, symptomatic osteonecrosis of the hip has a high likelihood of leading to femoral head collapse [192]. Of 75 hips without collapse at initial evaluation, 65 demonstrated collapse within five years after diagnosis [192]. The average time between diagnosis and collapse was 42 months for stage-I hips and 30 months for stage-II hips [192]. At most recent follow-up, 88 of 92 hips in patients with sickle-cell disease had had surgery because of intractable pain [192]. Arthroplasty Survival: The cumulative procedure failure rate for total hip and knee arthroplasty is approximately 1% per year [164]. Ten years after total hip or knee arthroplasty, patients have approximately a 90% chance of still having a successful, well-functioning joint replacement [164].

Foot and Ankle

Degenerative Arthropathies: Modern medicine does not have a cure for degenerative arthropathies of the foot and ankle [65]. Treatment is based on symptom relief through nonsurgical methods or surgical removal of arthritis via fusion or replacement [65].

Wrist

Scaphoid Non-Union: In patients with established scaphoid non-union, osteoarthritis will most likely develop [168]. In 32 patients with scaphoid non-union injured five years or more earlier, arthritis developed in 31 (97 per cent) [168]. The incidence of osteoarthritis in scaphoid non-union increases with time after injury [168].

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 [208].

Recovery

Other Considerations: The evidence base for this section focuses on disease progression, long-term survivorship, and natural history rather than specific post-operative rehabilitation timelines or return-to-work milestones. Consequently, specific timeframes for light activity, full activity, or complete recovery plateau are not defined in the provided data.

Rotator Cuff Degeneration and Tear Progression: The progressive nature of degenerative rotator cuff disease is demonstrated by the survivorship of asymptomatic tears [67]. Histological degeneration of remnant tendon deteriorates with chronicity [14]. In patients with severe preoperative fatty degeneration, a follow-up of at least 2 years is necessary to determine short-term outcomes [18]. Conversely, there was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years in patients treated with acromioplasty without repair for partial-thickness tears [72].

Shoulder Osteoarthritis and Arthroplasty Outcomes: Shoulder arthroplasty was effective within a relatively short time frame in improving the patients' assessment of both shoulder function and overall health status in patients with primary glenohumeral degenerative joint disease [16]. In patients with severe primary osteoarthritis (Walch type B glenoids) treated with stemless ceramic head anatomic shoulder arthroplasty, the severity of osteoarthritis did not show any association with glenoid component survivorship or with patient-reported outcome measures at 5 years review [54]. 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]. The favourable outcomes seen at short term follow-up for reverse total shoulder arthroplasty for degenerative conditions are maintained beyond 5 years [55]. Furthermore, 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 [63].

Adhesive Capsulitis and Other Degenerative Conditions: 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 [66]. In the long term, 59% of patients with frozen shoulder had normal or near normal shoulders and 41% reported some ongoing symptoms [56]. 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 [68].

Spine and General Degenerative Management: 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 [25]. 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 [69]. Shoulder arthroplasty is reserved for late stages with fairly good outcomes but undocumented long-term implant survival and complications [69]. The delay between the beginning of corticosteroid treatment and the different stages of osteonecrosis of the shoulder appeared to be longer than the delay observed in osteonecrosis of the hip related to corticosteroid treatment [58].

Predictors of Osteoarthritis Progression: Osteoarthritis is more common with increasing age and longer follow-up after anterior repair for instability [13]. Predictors of osteoarthritis in unstable shoulders included time from injury to surgery and age [241]. The time course from initial presentation to total shoulder arthroplasty is similar between primary osteoarthritis and rotator cuff arthropathy patients managed conservatively with corticosteroid injections, but there are distinct prognostic factors for progression to total shoulder arthroplasty in both groups [236].

Additional Clinical Notes: A long-term followup study with a large cohort is required to determine if an intraoperative load sensor improves the early postoperative results of posterior-stabilized total knee arthroplasty for osteoarthritis with varus deformities [60]. This study illustrates the importance of the different information expressed by late life prevalence vs. incidence on the factors associated with severe osteoarthritis of the knee and hip [242].

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] For those patients with frank degenerative arthritis or extensive head involvement, the prognosis is poor, and earlier consideration of arthroplasty is indicated. [5] (10.1016/s1058-2746(99)90089-7)
• [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. [8] (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. [9] (10.2106/00004623-198668020-00004)
• [L4] However, the evidence is limited to Level IV studies, and concerns remain regarding long-term durability and progression of osteoarthritis. [10] (10.1177/17585732261469823)
• [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)
• [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. [12] (10.2106/00004623-199703000-00006)
• [L4] The osteoarthritis is more common with increasing age and longer follow-up. [13] (10.1016/s1058-2746(96)80203-5)
• [L4] Histological degeneration of remnant tendon deteriorated with chronicity. [14] (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. [15] (10.2106/00004623-196345070-00016)
• [L4] The data presented indicate that within a group of patients with primary glenohumeral degenerative joint disease, shoulder arthroplasty was effective within a relatively short time frame in improving the patients' assessment of both shoulder function and overall health status. [16] (10.1016/s1058-2746(95)80203-7)
• [L4] A follow-up of at least 2 years is necessary to determine short-term outcomes, especially in patients with severe preoperative fatty degeneration. [18] (10.1016/j.arthro.2024.12.029)
• [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. [19] (10.1530/eor-2025-0050)
• [L3] Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion. [20] (10.1186/s13018-015-0186-8)
• [L4] [21] (10.1177/0363546510369250)
• [L5] [22] (10.2106/00004623-199704000-00022)
• [L5] FAI is defined as a pathologic mechanical process involving morphologic abnormalities and vigorous motion that damages soft-tissue structures; while FAI morphology is common in young adults and predisposes to later OA, more long-term data are needed to define the natural history of pincer deformities and FAI in younger cohorts. [23] (10.5435/00124635-201300001-00004)
• [Paper] Diagnostic indications include the assessment of painful post-traumatic basal joint lesions of cartilage and ligaments, and the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis. [24] (10.1016/j.hansur.2020.05.014)
• [L4] Immediate and durable improvement of shoulder function can be expected, though surgical treatment should be performed before irreversible degenerative changes occur. [25] (10.1016/j.jse.2008.12.003)
• [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. [27] (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. [29] (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. [30] (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. [32] (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. [33] (10.1186/1471-2474-16-s1-s2)
• [L4] OA and RA are degenerative conditions with high degree of disabilities. [36] (10.1097/00132589-200309000-00005)
• [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. [37] (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. [38] (10.1007/s00167-003-0390-7)
• [L3] rTSA provides comparable clinical outcomes across indications of irreparable rotator cuff tear, rotator cuff tear arthropathy, and primary osteoarthritis at 2 years, supporting its broad applicability. [42] (10.1016/j.jsea.2026.100080)
• [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] In contrast, an expert panel of cartilage surgeons reached a consensus that OCA transplantation was clearly suitable for a variety of specific indications. [51] (10.2106/jbjs.21.01191)
• [L4] The findings suggest that reverse arthroplasty can achieve highly favorable outcomes for this indication. [52] (10.1016/j.jse.2021.06.010)
• [L4] HHR remains a successful operation for osteoarthritis at long-term follow-up. [53] (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. [54] (10.1177/17585732211048120)
• [L3] The favourable outcomes seen at short term follow-up are maintained beyond 5 years. [55] (10.1016/j.jseint.2024.08.105)
• [L3] In the long term, 59% of patients had normal or near normal shoulders and 41% reported some ongoing symptoms. [56] (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. [57] (10.1016/j.jse.2011.11.011)
• [L2] [58] (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. [59] (10.2106/00004623-199602000-00013)
• [L2] A long-term followup study with a large cohort is required. [60] (10.1007/s00167-018-5314-7)
• [L4] [61] (10.1177/0363546511404207)
• [L1] Shoulder function and outcome scores also showed no significant deterioration between 5 and 20 years of follow-up. [63] (10.1016/j.jse.2018.10.005)
• [L2] This study demonstrates the progressive nature of degenerative rotator cuff disease. [67] (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. [68] (10.1016/j.jse.2006.06.007)
• [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. [69] (10.1016/j.jseint.2021.01.011)
• [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. [71] (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. [72] (10.1177/03635465020300021801)
• [L4] [73] (10.1155/2012/160923)
• [L2] [96] (10.1186/s13018-024-05378-4)
• [L2] Conservative treatment was effective in 77% of patients with a degenerative supraspinatus tear. [99] (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. [100] (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. [102] (10.1016/j.jse.2011.04.011)
• [L5] [103] (10.1177/0363546513485359)
• [L1] [107] (10.1016/j.jse.2011.01.041)
• [L4] [109] (10.1177/0363546507300256)
• [L5] The degeneration of the articular disc increases with age and emphasizes its important mechanical function. [110] (10.1007/s00402-021-03795-2)
• [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. [118] (10.2106/00004623-198971020-00010)
• [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. [123] (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. [127] (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. [129] (10.5435/00124635-199807000-00007)
• [L4] Arthrodesis is successful in patients with degenerative changes in the glenohumeral joint causing severe pain unrelieved by conservative treatment. [131] (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. [132] (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. [133] (10.1007/s00167-012-2147-7)
• [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)
• [L2] By the criteria of this study, arthroscopic reconstruction provides results equal to those of the open procedure for patients age 22 and older, would provide a success rate of 90% in patients age 18 to 23 but would only work approximately 80% of the time in patients 18 and younger and is not indicated in patients in this age range. [137] (10.1016/s1058-2746(96)80205-9)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. [138] (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. [139] (10.5435/jaaos-d-23-00669)
• [L3] A new concise MRI classification of HDS was proposed. [143] (10.1007/s00167-016-4033-1)
• [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. [144] (10.2106/00004623-199409000-00019)
• [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. [145] (10.1177/17585732221097415)
• [L1] Non-operative and operative treatments show similar OA proportions at any point of follow-up. [146] (10.1007/s00167-020-06263-3)
• [Paper] Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care. [147] (10.1016/j.csm.2014.01.001)
• [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. [151] (10.2106/00004623-199809000-00010)
• [L4] The article presents a four-stage classification scheme and evaluates various forms of treatment and prognosis. [152] (10.2106/00004623-195941070-00020)
• [L3] Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses. [153] (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. [156] (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. [157] (10.1016/j.xrrt.2022.02.005)
• [L4] Although progressive radiographic osteoarthritic changes occur, they do not negatively influence clinical results. [160] (10.1016/j.arthro.2008.03.007)
• [L4] MRI provides valuable clues, but definitive diagnosis relies on histopathological confirmation. [161] (10.1186/s12891-026-09563-w)
• [L5] Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. [167] (10.5435/00124635-199905000-00004)
• [L4] [168] (10.2106/00004623-198567030-00013)
• [Paper] Nonoperative modalities have been poorly studied, and recommendations for or against certain treatments are not well established. [173] (10.1016/j.csm.2018.05.003)
• [L1] [176] (10.1002/ksa.12017)
• [L4] Five main types of coracoacromial ligaments were identified, with no statistical correlation found between the ligament type and rotator cuff degeneration. [178] (10.1016/j.jse.2007.05.015)
• [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. [179] (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.' [182] (10.1016/j.arthro.2019.05.009)
• [L3] Radiographs provide better reproducibility and accuracy for CSA measurement compared to MRI. [183] (10.1007/s00167-015-3587-7)
• [L4] Interestingly, the radiographical analysis showed high prevalence of signs associated with loosening, which did not seem to translate to high complication rates or inferior results. [188] (10.1016/j.jse.2023.09.015)
• [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. [190] (10.1016/j.jse.2017.10.009)
• [L2] [192] (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. [193] (10.1016/j.arthro.2015.04.101)
• [L5] This minimally invasive approach is an effective alternative to traditional diagnostic techniques of diagnostic surgical arthroscopy and magnetic resonance imaging (MRI). [197] (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. [198] (10.1186/s12891-020-03601-x)
• [L2] Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. [202] (10.1016/j.jse.2019.04.004)
• [L3] [203] (10.1016/j.jse.2018.07.022)
• [L3] This study shows that increased age is the main determinant of radiological changes in shoulder OA, as well as pain. [204] (10.1186/s13018-022-03137-x)
• [L1] [205] (10.1177/17585732251374282)
• [L5] [206] (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. [208] (10.1016/j.jse.2010.05.022)
• [L4] [222] (10.1016/j.jhsg.2023.12.014)
• [L5] [227] (10.5435/00124635-201210000-00002)
• [L4] [228] (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. [233] (10.1016/j.jse.2012.07.015)
• [L4] [234] (10.1007/s001670100205)
• [L4] Arthrosis rarely causes more than minor subjective symptoms or a minor objectively perceived disadvantage during 13 years' follow-up. [235] (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. [236] (10.1016/j.jisako.2023.03.336)
• [L3] [237] (10.1016/j.jse.2023.05.013)
• [L3] [238] (10.1016/j.arth.2015.04.022)
• [L4] [240] (10.1016/j.jse.2016.02.026)
• [L4] Predictors of osteoarthritis included time from injury to surgery and age. [241] (10.1177/03635465030310012001)
• [L2] This study illustrates the importance of the different information expressed by late life prevalence vs. incidence on the factors associated with severe osteoarthritis of the knee and hip. [242] (10.1186/s12891-016-0864-7)

See Also

• Rotator Cuff
• Shoulder Arthroplasty
• Total shoulder arthroplasty
• Os Acromiale
• Fractures
• Cuff Arthropathy
• AC Joint Osteoarthritis
• Shoulder Instability
• Calcific Tendinitis
• Reverse Shoulder Arthroplasty
• Subacromial Decompression
• Rotator Cuff Repair
• Frozen Shoulder

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