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Diagnosis, Outcomes & Rehabilitation

Clinical assessment of shoulder pathology, patient-reported outcome measures (PROs), and evidence-based rehabilitation protocols for optimizing functional recovery.

117 citationsUpdated Sep 2026

Illustration: Diagnosis, Outcomes & Rehabilitation

Overview¶

Rehabilitation following shoulder pathology lacks a universal consensus regarding the definition of accelerated protocols or the selection of outcome measures [1]. A comprehensive evaluation approach prior to and throughout treatment assists clinicians in selecting appropriate interventions based on patient need [5]. Combining pathoanatomic causes with movement impairments provides a more focused rehabilitation approach for the painful shoulder [5]. While specific guidelines exist for conditions such as reverse total shoulder replacement and proximal humeral fractures to maximize functional outcomes and mitigate risks [44, 53], available data remain insufficient to establish a gold standard protocol for rotator cuff impingement [55]. Consequently, postoperative rehabilitation following reverse shoulder arthroplasty should be individualized due to the lack of strong evidence [42].

Prognostic factors for response to physiotherapy include baseline pain severity, disability, and psychological factors, though evidence quality is generally low [9]. Short-term repeat assessment of pain better predicts long-term disability improvement than short-term change or baseline scores [3]. For rotator cuff tears, improvement in outcomes is observed up to 16 sessions of physical therapy, after which outcomes plateau [2]. The majority of functional and symptomatic improvements following rotator cuff repair occur within the first year, with minimal clinically meaningful gains between 1 and 2 years [4]. Functional outcomes after arthroscopic rotator cuff repair improve during midterm follow-up regardless of retear [15].

Specific clinical scenarios influence rehabilitation timing and modality. At more than 2 years after surgery, earlier repairs (less than 6 months) for type II SLAP lesions are associated with better functional outcomes [13]. Only one study showed moderate evidence that early physical therapy promotes a more rapid return of short-term improvement in function and pain following total shoulder arthroplasty [14]. Patients using a home-based protocol showed largely similar functional scores and healing to those with supervised physical therapy after arthroscopic repair of massive rotator cuff tears [6]. An objective criteria-based diagnosis and rehabilitation model may minimize time required to regain functional capacity in work-related shoulder injuries [12]. Conservative treatment for the cervico-thoracobrachial crossing syndrome improves efficacy by reducing surgical indications [49].

Anatomy & Pathophysiology¶

Osseous Anatomy¶

The proximal humerus comprises the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [74]. The articular head is spherical with a diameter of 37 to 57 mm [74]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [74]. Humeral version averages 29.8 degrees, ranging from 10 to 55 degrees [74], while the humeral head is inclined approximately 130 degrees with respect to the humeral shaft [74]. Alternatively, the humeral head averages 19 degrees of retroversion and 41 degrees of inclination [77], and is retroverted 30 degrees relative to the transepicondylar axis of the humerus [93]. Head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [93]. The anatomic neck is located at the junction of the articular surface and the tuberosities [74], directly below the humeral head, and serves as an attachment for the shoulder capsule [93]. The surgical neck is a more distal, indistinct region below the tuberosities but above the humeral shaft [74], and is more often involved in fractures than the anatomic neck [93]. Fractures involving the anatomic neck carry a worse prognosis regarding potential disruption of vascular supply and avascular necrosis compared to other proximal humeral regions [74].

The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [74], while the lesser tuberosity serves as the attachment site for the subscapularis tendon [74]. The bicipital groove lies between the greater and lesser tuberosities, serving as a pathway for the long head of the biceps [74]. The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [74]. The transverse humeral ligament is an important stabilizer of the biceps tendon [93]. The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [77]. The humeral head ossification center appears at 4 to 6 months, the greater tuberosity at 1 to 3 years, and the lesser tuberosity at 3 to 5 years [77]. These centers fuse to the shaft at age 17 to 20 years [77].

The scapula is attached to the axial skeleton by the clavicle via the acromioclavicular and sternoclavicular joints [76]. It is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion [76]. The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [93]. It is anteverted on the chest wall approximately 30 degrees relative to the body [93]. The basic part of the scapula is the triangular body, with its base situated superiorly and its apex inferiorly when viewed anteroposteriorly [76]. The glenoid is connected with the flat body of the scapula by the scapular neck [76]. The hook-shaped coracoid process curves forwards from the superior surface of the scapular neck [76]. The scapular spine arises from the posterior surface of the scapular body and ends in a flattened bony process, the acromion, which curves forwards [76]. The scapular spine is an osseous ridge that separates the supraspinatus and infraspinatus fossae [77]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [77]. Failure of fusion of these centers results in os acromiale, most commonly between the mesoacromion and meta-acromion [77, 93]. Ossification of the scapular body begins at the eighth week of gestation [77].

The highest concentration of bony mass in the scapula is found in the glenoid, the scapular neck including the base of the coracoid process, and the lateral border of the scapular body [76]. Two bony pillars extend between the glenoid and the scapular body to transmit compressive forces from the glenoid fossa [76]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [76]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [76]. These two pillars, connected by a markedly thinner medial border, form the basic load-bearing structure of the scapular body, constituting the biomechanical body of the scapula [76]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [76]. The weakest area of the circumference of the biomechanical body is the spinomedial angle, where the scapular spine connects to the medial border [76]. In most scapular body fractures, one of the main fracture lines passes through the spinomedial angle [76].

The clavicle is the first bone to ossify at the fifth week of gestation and is the only long bone to ossify by intramembranous ossification [77, 93]. It is also the last to fuse, with the medial epiphysis fusing at age 20 to 25 years [77, 93]. Fracture of the clavicle is the most common musculoskeletal birth injury [93]. The primary blood supply to the clavicle is periosteal, with no nutrient artery present [77]. The coracobrachialis muscle and the short head of the biceps tendon originate from the coracoid process [77], while the pectoralis minor muscle inserts onto the medial coracoid process [77]. Grashey radiographs are taken obliquely at 30 degrees for a true anteroposterior view of the scapula [93].

Glenoid & Labral Anatomy¶

The glenoid is a convex structure of shallow depth shaped like an inverted pear [74]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [77]. The glenoid averages 5 degrees of retroversion in relation to the axis of the scapular body [77]. The glenoid articular surface and labrum combine to create a socket approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [90]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [90]. The fibrocartilaginous glenoid labrum deepens the socket by 50% and provides a bumper to translation [93]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [77]. Labral anatomic variants include the sublabral foramen and the Buford complex [93]. The Buford complex is characterized by the absence of the anterosuperior labrum and a cordlike middle glenohumeral ligament [93].

Ligamentous & Capsular Anatomy¶

The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure that imparts stability to the shoulder girdle [74]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath the coracoacromial arch [74]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [93]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [93]. The coracoacromial ligament is the arthroscopic landmark for a complete release of the rotator interval for adhesive capsulitis [93].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [77]. It contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [77]. Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [77], while contracture of the rotator interval is seen with adhesive capsulitis [77]. Tightening of the rotator interval decreases posterior and inferior translation [90].

The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [90]. It is deep to the tendinous insertion of the cuff and blends with the capsule and supraspinatus tendon to form part of the roof of the biceps sheath [90]. The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [77].

The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [77]. It is the primary restraint to inferior humeral subluxation in 0 degrees of abduction [90] and the primary stabilizer to anterior and posterior stress in 0 degrees of abduction [90]. The superior glenohumeral ligament and coracohumeral ligament form a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [77].

The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45 degrees of abduction [77]. It limits external rotation when the arm is in the lower and middle ranges of abduction [90], but has little effect when the arm is in 90 degrees of abduction [90].

The inferior glenohumeral ligament is composed of a thick anterior band, a less thick posterior band, and a thinner intervening axillary pouch [90]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90 degrees of abduction and external rotation [77]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [77]. With external rotation, the inferior glenohumeral ligament hammock slides anteriorly and superiorly, tightening the anterior band and fanning out the posterior band [90]. With internal rotation, the hammock slides posteriorly and inferiorly, tightening the posterior band and fanning out the anterior band [90]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [90].

Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [77]. Static restraints also include articular anatomy, the glenoid labrum, glenohumeral ligaments, capsule, and negative intraarticular pressure [93]. Dynamic stabilizers of the glenohumeral joint include the rotator cuff and biceps tendon [93]. The rotator cuff stabilizes the glenohumeral joint via joint compression [77]. Scapulothoracic mechanics contribute to glenohumeral stability [93].

Joint Articulations¶

The glenohumeral joint is a ball and socket joint with the greatest range of motion in the body [93]. It is composed of four articulations: sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [90]. The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [77]. It is a double gliding joint with an articular disc [93]. The posterior sternoclavicular joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [77]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability of the sternoclavicular joint [93]. The sternoclavicular joint rotates 30 degrees with shoulder motion [93].

The scapula has only one true diarthrodial articulation, the acromioclavicular joint [77]. The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [77] and is a plane/gliding joint with a fibrocartilaginous disc [93]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [77]. Acromioclavicular ligaments prevent anteroposterior displacement of the clavicle [93]. The posterior and superior acromioclavicular ligaments are considered the strongest [93]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [77] and prevent superior displacement of the distal clavicle [93]. The conoid ligament is medial and the trapezoid ligament is lateral within the coracoclavicular complex [77]. The trapezoid ligament is anterolateral and located approximately 25 mm from the acromioclavicular joint [93]. The conoid ligament is posteromedial, stronger, and located approximately 45 mm from the acromioclavicular joint [93].

Vascular & Neural Anatomy¶

The primary blood supply to the humeral head is provided by the anterolateral ascending branch of the anterior humeral circumflex artery [77]. The terminal intraosseous portion of the anterior humeral circumflex artery enters the humeral head at the proximal aspect of the intertubercular groove as the arcuate artery [77].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [77]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to the ligament [77]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [77]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [77]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [77].

Muscular Anatomy & Kinematics¶

Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [77]. Extrinsic muscles of the shoulder primarily control movement of the scapula and include the rhomboids, levator scapulae, trapezius, and serratus anterior [90]. Intrinsic muscles of the shoulder control the glenohumeral joint and include the rotator cuff muscles, deltoid, pectoralis major, teres major, latissimus dorsi, and biceps brachii [90].

The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [90]. The infraspinatus and teres minor fuse near their musculotendinous junctions [90]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [90]. The roof of the biceps sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor [90].

Classification¶

Scapular Dyskinesis: Scapular dyskinesis is defined as an alteration in the normal position or motion of the scapula during coupled scapulohumeral movements [17]. It represents a nonspecific response to shoulder dysfunction, as no specific pattern of dyskinesis is associated with a specific shoulder diagnosis [17]. Classification of scapular dyskinesis patterns and positions can help to determine treatment [17].

Stanmore Classification: The Stanmore Classification classifies shoulder instability into Type 1 (traumatic with structural pathology), Type 2 (atraumatic with structural pathology), and Type 3 (atraumatic with no structural pathology but abnormal muscle pattern) [212]. Surgical treatment is generally recommended for patients closest to Type 1, while non-operative treatment is recommended for those in the Type 2 or 3 categories [212].

Diagnostic Triage System: A diagnostic triage system for shoulder pain classifies patients into red flags, specific pain, and non-specific pain [38]. Red flags refer to serious diseases such as systemic, infectious, neoplastic conditions, fractures, or dislocations that masquerade as musculoskeletal conditions [38]. Specific shoulder pain is classified as symptoms referring to a pathology with a clear structural, patho-anatomic, or patho-physiologic origin [38]. Non-specific shoulder pain is classified as clinical features that do not belong to the categories of red flags or specific pain [38].

Sugaya MRI Classification: The Sugaya MRI classification system was used to stratify patients by repair status in a study of early postoperative outcomes [109]. No differences in clinical scores existed between patients stratified by the Sugaya MRI classification system at 16 weeks postoperatively [109].

Owen, Sugaya, and Hayashida Classifications: The Owen, Sugaya, and Hayashida classifications for subscapularis tendon retears on MRI showed poor intra- and inter-rater agreement [134]. Dichotomized, trichotomized, and combined versions of the Owen, Sugaya, and Hayashida classifications did not lead to superior rater agreements [134].

Samilson Classification: The Samilson classification was used to assess osteoarthritis in a cohort of athletes 14 years after arthroscopic Bankart repair [191]. Using the Samilson classification, severe osteoarthritis was not found in the cohort, although signs of osteoarthritis occurred in 28.1% of patients [191].

Other Considerations: The Rotator Cuff Healing Index is a scoring system designed to predict the adequacy of rotator cuff repair and assist in deciding treatment options [146]. The Fudan University Shoulder Score is a scoring system developed based on the views of patients and physicians, verified to be valid, reliable, and responsive [148]. The DASH questionnaire modules differentiated well among 11 diagnostic groups of upper extremity disorders, allowing for the development of functional activity problem profiles for each group [135]. The Constant-Murley shoulder assessment score requires redesign with better standardization before being used to validate other assessments or compare outcomes between different testers [137]. The SANE (Single Alpha-numeric Evaluation for Shoulder Patients) is valid for a range of common shoulder diagnoses to assess patient outcomes across operative and nonoperative treatment [29]. Five different shoulder outcome questionnaires were able to discriminate between differences in severity of shoulder dysfunction [32]. Preoperative PROMIS PF scores were responsive to the functional improvements observed clinically in total shoulder arthroplasty patients [21]. Shoulder physical functions were mapped to American Shoulder and Elbow Surgeons and Patient-Reported Outcomes Measurement Information System scores [66]. The DASH 7 is a short activity-related scale for measuring shoulder function in patients with subacromial pain [210]. The content validity of the DASH 7 was defined according to the COSMIN taxonomy as the degree to which the instrument's content adequately reflects the construct to be measured [210]. The Multiple Angle Testing Method can assess the strength of various muscle groups following disease or surgery and detect old muscle injuries that have escaped detection by existing methods of diagnosis [57].

Clinical Presentation¶

History and Symptomatology¶

A comprehensive history is the first and arguably the most important aspect of evaluating a patient with a suspected rotator cuff tear [37]. Rotator cuff tears can be asymptomatic, even when of substantial size, and the amount of shoulder discomfort experienced by a patient is not related to the size of the rotator cuff tear [37]. Pain may not be the primary symptom of rotator cuff failure, which may also produce weakness, stiffness, crepitus, or instability [37]. Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology [50]. Patients who present with a painful shoulder problem have often endured their symptoms for months or years as a result of cuff degeneration rather than injury [37]. In contrast, acute rotator cuff tears from a distinct injury causing weakness often do well and have good healing potential with early surgery [37].

Symptoms radiating past the elbow into the distal extremity, numbness, tingling, and burning may indicate an extrinsic etiology such as cervical radiculopathy [26]. Neck pain, numbness and tingling in the arm, symptoms radiating below the elbow, or medial scapular pain may be a sign of cervical radiculopathy [37]. Approximately 50% of patients with shoulder pain report persistent problems 6 months after onset, and approximately 40% report incomplete recovery at 1 year [106]. Scapulothoracic dissociation is a rare, traumatic disruption of the scapulothoracic articulation caused by severe direct force applied over the shoulder accompanied by traction applied to the upper extremity [110]. A presumptive diagnosis of scapulothoracic dissociation is based on a history of violent trauma and the presence of massive soft tissue swelling over the shoulder girdle [110]. A pulseless upper extremity indicating complete vascular disruption and a complete or partial neurologic deficit indicating brachial plexus injury are suggestive of scapulothoracic dissociation [110].

Physical Examination¶

Scapular dyskinesis is an alteration in the normal position or motion of the scapula during coupled scapulohumeral movements [17]. Scapular dyskinesis appears to be a nonspecific response to shoulder dysfunction because no specific pattern of dyskinesis is associated with a specific shoulder diagnosis, though it can be identified and classified by specific physical examination [17]. The deltoid extension lag sign gives objective information about the extent of deltoid dysfunction, and repeated application of this sign over time allows precise follow-up of neural recovery [52]. The Multiple Angle Testing Method can assess the strength of various muscle groups following disease or surgery, determine the effectiveness of therapy, and detect old muscle injuries that have escaped detection by existing methods of diagnosis [57]. Passive range of motion measurement can reliably determine passive range of motion in patients with adhesive shoulder capsulitis [61].

There is no consistent evidence that any physical examination test used in the assessment of the shoulder demonstrates acceptable levels of reliability [106]. There is insufficient evidence to recommend the Shoulder Symptom Modification Procedure as a reliable or validated evidence tool for physical examination of patients with shoulder problems [106]. Identification of whether a patient presents with pain or stiffness as their predominant symptom further guides treatment selection [24].

Diagnostic Assessment and Prognosis¶

Age is thought to be a strong predictor of rotator cuff healing if operative intervention is a consideration, with older patients less likely to achieve a durable repair [37]. Activity level and expectations of treatment are an essential part of the overall decision-making process and discussion with the patient [37]. Hand dominance, smoking, genetic predisposition, medical comorbidity, and social factors affecting rehabilitation after potential surgery are variables that should be taken into account when deciding between nonoperative and operative care [37]. Prognostic factors for response to physiotherapy include baseline pain severity, disability, and psychological factors, though the evidence quality was generally low [9]. Pain intensity, neck pain, and longer duration of complaints predict poorer outcome in patients with shoulder pain [58]. Patients with a worse prognosis may be monitored more frequently and the treatment plan modified if complaints persist [58]. Fear of movement and emotional distress are prognostic factors for disability in patients with shoulder pain [104].

Superior outcomes in arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy were associated with better preoperative clinical and MRI status, and early recognition and timely intervention result in better shoulder motion and improved joint alignment in these patients [30]. Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores were responsive to the functional improvements observed clinically in total shoulder arthroplasty patients [21]. A self-administered web application demonstrated high agreement with experienced physical therapists in diagnosing shoulder disorders, including disease phase and specific disorder identification [107].

Outcome Measures¶

The Single Alpha-numeric Evaluation for Shoulder Patients (SANE) is valid for a range of common shoulder diagnoses to assess patient outcomes across operative and nonoperative treatment for shoulder complaints [29]. All five shoulder outcome questionnaires compared in a cross-sectional study were able to discriminate between differences in severity of shoulder dysfunction [32]. The Shoulder Pain and Disability Index has been validated in patients with non-specific shoulder pain [38]. The SA-Q questionnaire has potential clinical implications for detected changes concerning the different items during rehabilitation for scapula alata [121]. Investigations of the measurement properties of EQ-5D indicate good reliability and validity as well as moderate responsiveness in patients with upper extremity conditions [122]. Combining a general health outcome measure, a general shoulder measure, a disease- or condition-specific shoulder measure, and an activity measure allows for broad patient assessment [124]. Established clinical scores did not reflect sport-specific impairments after arthroscopic Bankart repair [27]. Centre of pressure measurement detected sensorimotor functional deficits following surgical treatment of the shoulder joint in patients with confirmed successful clinical and functional outcomes [45].

Investigations¶

Plain radiography: Standardized plain films are almost always sufficient for shoulder care, providing information that CT scans cannot obtain [36]. The primary purposes of imaging are to establish diagnosis, determine pathoanatomy severity, assist surgical planning, and illustrate the condition to the patient [36]. Proper radiographic technique is as critical as surgical technique for achieving desired outcomes [36]. The standard shoulder series includes orthogonal views: a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [126]. The true AP view in the scapular plane is taken with the x-ray beam perpendicular to the scapula and the arm in neutral rotation with slight abduction to reveal proximal humeral migration [126]. This view visualizes the anterior greater tuberosity in profile, superoinferior humeral head position, osteophytes, joint space narrowing, medial humeral displacement relative to the lateral acromial line, bone quality, loose bodies, and humeral head collapse or deformity [36, 126]. The AP view is taken with the beam perpendicular to the coronal plane and visualizes the posterior greater tuberosity and lesser tuberosity in profile [126]. The axillary view, referred to as the “truth view,” is taken with the arm in functional elevation in the plane of the scapula, oriented to show the spinoglenoid notch and scapular neck [36]. It demonstrates glenohumeral relationships in functional elevation, glenoid bone amount, shape, version, and humeral head relationship to the glenoid fossa [36]. Joint space narrowing and posterior subluxation or “functional decentering” are most evident on this view compared to images with the arm at the side [36]. The degree of posterior subluxation can be measured by the position of the humeral head center relative to the scapular plane, the glenoid face, or the point of contact of the articular surfaces [36]. The point of contact reflects the centering of the net humeral joint reaction force; malcentering leads to posterior instability, glenoid wear, and “rocking horse” loosening of prosthetic components [36]. The scapular Y view visualizes the coracoacromial arch, coracoacromial spurs, scapular body abnormalities, and acromial shape [126]. It is a reliable alternative for evaluating glenohumeral subluxation and dislocation [126]. Normal acromiohumeral distance is 7 to 14 mm, glenohumeral joint space width should be symmetric superiorly and inferiorly, and coracoclavicular distance is normally 1.1 to 1.3 cm [126]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked); type III correlates with rotator cuff disease but lacks a direct causal relationship and shows poor interobserver reliability [126]. For proximal humerus fractures, the Neer trauma series consists of an AP view, a lateral view in the scapular plane (tangential Y-view), and a Velpeau modified axillary view, allowing evaluation in three perpendicular planes [114]. The axillary view is essential for evaluating glenoid articular surface and humeral head relationship anteriorly and posteriorly [114]. Specific views include the Serendipity view for the sternoclavicular joint, the West point view for anterior glenoid bone loss, the Zanca view for the AC joint, the Stryker notch view for Hill-Sachs lesions, and the apical oblique view for glenoid rim fractures [126]. Conventional radiographs are appropriate for trauma, dislocation, night pain, or chronic pain, and can identify arthritis, calcific tendinitis, and distal clavicle osteolysis [123, 126].

MRI: Magnetic resonance imaging is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [123]. It is useful for identifying osteonecrosis of the humeral head or bone tumours [105]. T1-weighted MRI reveals Hill-Sachs lesions, while T2-weighted MRI provides better visualization of full-thickness rotator cuff tears [123]. MRI accuracy for identifying labral and rotator cuff tears ranges from 70% to 100% [117]. Multi-planar imaging allows detailed evaluation of the glenoid, labrum, joint capsule, and rotator cuff [117]. In anterior shoulder instability, MRI complements physical examination and standard radiographs for soft tissue evaluation [117]. For multidirectional instability (MDI), MRA can demonstrate a patulous capsule on coronal, sagittal, and axial imaging [117]. MRA is also helpful in evaluating rotator interval lesions and associated findings such as glenoid dysplasia, increased capsular cross-sectional area, and increased glenoid retroversion, which are associated with posterior labral tears and symptomatic instability [117]. Parada et al. demonstrated that glenoid retroversion was significantly increased in patients with symptomatic posterior labral tears, though no significant association was found between instability and increased humeral head subluxation [117]. The diagnosis of MDI is clinical, and the need for expensive or invasive imaging should be weighed against the information gained [117].

CT: Computed tomography is helpful for planning fracture surgery and shoulder joint replacement [105]. It is frequently used to evaluate shoulder fractures, assess bony lesions in recurrent instability, or for preoperative templating for shoulder arthritis [123]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in shoulder instability [126]. While CT may offer increased precision in measuring glenoid version, this precision does not improve surgical quality or clinical outcome [36]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [36]. Three-dimensional reconstructions can reveal fine anatomical details but rarely change arthroplasty planning or conduct [36].

Arthrography: Arthrography involves injecting contrast agent during MRI or CT to enhance joint imaging and identify normal structures and pathology [123]. Magnetic resonance arthrography (MRA) is the benchmark for evaluating labral tears and is rarely indicated for rotator cuff pathology [123]. MRA refers to MRI of a joint injected with intra-articular contrast, such as diluted gadolinium or saline, under strict aseptic technique [117]. By distending the joint capsule, MRA outlines cartilage, ligaments, and labrum, increasing sensitivity for detecting tears [117]. In acute dislocation, joint effusion may outline structures similarly, making arthrogram unnecessary [117]. MRA increases both sensitivity and specificity for detecting capsulolabral–ligamentous complex injuries compared to traditional MRI [117]. Smith et al. found greater diagnostic accuracy for MRA over MRI in detecting glenoid labral lesions (MRA sensitivity 88% and specificity 93% vs. MRI sensitivity 76% and specificity 87%) [117]. When MRI or MRA is contraindicated, CT arthrography is indicated [123].

Ultrasonography: Ultrasonography is a simple, accurate, and low-cost test for identifying rotator cuff tears and calcific tendinitis [105, 123]. It provides immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [123]. It can be used to guide injections or barbotage of calcific deposits [105]. Ultrasonography can measure the subacromial space, detect rotator cuff muscle atrophy, and evaluate impingement in various positions and motions [123]. It is highly operator-dependent and less useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [123].

Arthroscopy: Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, glenoid labrum detachment, and rotator cuff tears [105]. It may be valuable in making the diagnosis of rotator cuff injuries in the acute setting [114].

Other Considerations: A robust imaging approach recognizes that the shoulder is a three-dimensional structure not represented by a single planar view, critical relationships change with arm position, pathology may involve multiple bones and soft tissues, and overlying structures or metallic implants may complicate imaging [115]. Surgeons must develop a judicious approach to avoid "over-imaging," which can waste time, money, and radiation dosage [36, 115]. Unless a specific research protocol is in place, only necessary scans or reconstructions should be obtained [36]. Many “axillary views” sent for consultation are taken without standardization, making it impossible to determine important glenohumeral features [36]. Initially, all patients are usually asked to have AP and lateral plain radiographs related to their chief report [123]. Plain radiographs are often the only required studies for assessing acute shoulder trauma, including fractures or dislocations [123].

Treatment¶

General Principles & Prognosis¶

A comprehensive evaluation approach prior to and throughout treatment assists clinicians in selecting appropriate treatments based on patient need [5]. For musculoskeletal shoulder pain, prognostic factors for response to physiotherapy include baseline pain severity, disability, and psychological factors, though the evidence quality is generally low [9]. In patients with full-thickness rotator cuff tears, mental health has a stronger association with patient-reported shoulder pain and function than tear size [101]. For neuromuscular diseases, an interdisciplinary approach with regular longitudinal follow-ups provides patients and their families improved day-to-day satisfaction alongside optimal clinical outcomes [18]. The timing of surgical and supportive interventions for these conditions should be chosen carefully and placed in context of the patient’s overall function and point in time of recovery [18]. No treatment has proved to be definitive for a stiff shoulder, and the treatment approach should be tailored to each individual patient [22]. There are currently no clinical practice guidelines for acute pain management in musculoskeletal injury or surgery [94].

Non-Operative¶

Conservative management remains the first-line strategy for many shoulder pathologies. Improvement in outcomes for rotator cuff tears was observed up to 16 sessions of physical therapy, after which outcomes plateaued [2]. Most injuries to the thrower's shoulder can be effectively treated with a proper nonoperative rehabilitation program [19]. If exercises are effectively administered immediately following diagnosis, they are 95% successful in returning the athlete to his or her prior level of competition without surgery for shoulder instability [16]. Successful nonoperative treatment of superior labral tears results in improved pain relief and functional outcomes compared with pretreatment assessments [92]. Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment [143]. A multimodal nonoperative treatment program is effective for most patients with adhesive capsulitis [179]. Conservative treatment is highly efficient in Stage I and Stage II shoulder impingement diseases [185], with a tendency of improvement lasting over 2 years after intensive conservative treatment of subacromial impingement [164]. Manipulative therapy in addition to usual medical care accelerates recovery and is more effective than usual medical care alone on the long term, but is associated with higher costs [31]. A proposed objective criteria-based shoulder diagnosis and rehabilitation model could be an effective strategy for minimizing the time required to regain functional capacity and recover from symptoms among patients with work-related shoulder injuries [12]. It improves the efficacy of conservative treatment by reducing surgical indications for the cervico-thoracobrachial crossing syndrome [49]. Stable, nondisplaced ligament injuries without significant MRI findings can be treated nonoperatively, with most athletes safely returning to sport within 6–10 weeks and minimal complications [64]. First-line nonoperative care for thoracic outlet syndrome typically includes rest, physical therapy, anti-inflammatory medication, and anticoagulant medication [203]. However, physical therapy interventions targeting scalene and pectoralis muscle tension, posture, and scapular mobility have only been shown to be effective in treating 27% to 34% of patients with a diagnosis of non-thrombotic thoracic outlet syndrome [203]. Approximately 60% of non-thrombotic thoracic outlet syndrome cases did not experience a meaningful reduction in symptoms and disability scores with physical therapy alone and therefore went on to require surgery [203]. Compression neuropathies with intermittent symptoms are generally treated first with physical therapy and splinting prior to proceeding to surgical decompression [88]. There are no appropriately designed prognostic studies to identify predictors of success with physiotherapy in patients with massive irreparable rotator cuff tears [184]. No published RCTs have evaluated physiotherapist-led interventions for patients with glenohumeral osteoarthritis undergoing non-surgical care [189]. The data available in systematic reviews are insufficient to make reliable clinical implications or establish a gold standard rehabilitation protocol for rotator cuff impingement, emphasizing the need for further research on dose-response relationships and supervised exercise [55].

Operative¶

Indications: Operative treatment resulted in greater improvement in Constant scores and significantly decreased pain scores compared to nonoperative management for full-thickness rotator cuff tears [145]. Surgery (after failure of conservative treatment) ranked highest across all range of motion domains for adhesive capsulitis [65]. For the minority of patients with multidirectional instability for whom nonoperative management fails, surgical reconstruction with an open inferior capsular shift can be reasonably recommended [69]. A nondisplaced isolated avulsion fracture of the lesser tuberosity can be treated conservatively [139].

Surgical Approach / Technique: Patients aged ≤20 years did poorly with arthroscopic Bankart repair, with more than half of the patients having recurrence; alternative stabilization techniques should probably be considered for these patients [186]. At > 2 years after surgery, earlier repairs (< 6 months) are associated with better functional outcomes for type II SLAP repair [13].

Post-Operative Rehabilitation: There is strong evidence that early initiation of rehabilitation and early functional loading does not adversely affect clinical outcome following rotator cuff repair, though there is a marginally higher, statistically non-significant incidence of tendon re-tear [161]. Comprehensive rehabilitation, compared to conventional physiotherapy, has shown a statistically and clinically significant difference in improving pain, range of motion, functional disability, quality of life, and treatment effectiveness in patients after arthroscopic rotator cuff repair [95]. After a 5-week rehabilitation program following shoulder surgery, the average function score was 84.5% (range 45-100) in 27 patients [7]. The most common immobilization device prescribed postoperatively for rotator cuff repair is an abduction pillow sling with the arm in neutral or slight internal rotation (70%) [207]. Formal physical therapy is most commonly initiated postoperatively within the first 2 weeks for rotator cuff repair (37%) [207]. The majority of surgeons initiate passive shoulder range of motion within the first 2 weeks (69%) and unrestricted passive shoulder range of motion at 6 to 7 weeks (35%) after rotator cuff repair [207]. Active range of motion is begun by most surgeons at 7 to 10 weeks (61%) after rotator cuff repair [207]. Strengthening (resistance) exercises are most commonly prescribed between 6 weeks and 3 months after rotator cuff repair (56%) [207]. Unrestricted return to all activities is started at 5 to 6 months by nearly half of participants after rotator cuff repair (42%) [207]. Variations in the rehabilitative protocol for rotator cuff repair are based solely on intraoperative findings, such as the condition of the rotator cuff and the quality of the repair [209]. Following a standard single tendon rotator cuff repair under minimal tension, a 30-degree abduction sling is used, and no limits are imposed on postoperative passive mobility [209]. Following repair of multiple tendons or retracted tears, an abduction brace is employed, and the inferior extremes of abduction and elevation and the superior extremes of rotation are limited as determined by the operating surgeon [209]. Initial limitations of motion after rotator cuff repair are gradually relaxed until full passive mobility is gained, usually within 1 month [209]. Following arthroscopic rotator cuff repair, the operated arm is immobilized in a sling for 4 weeks, gentle Codman-Pendulum exercises are started at 4 weeks, active assisted range of motion exercises (except overhead) start at 6 weeks, and resisted isotonic strengthening exercises start at 10 weeks [219]. Task-oriented exercises improve disability of working patients with surgically-treated proximal humeral fractures [218]. The lack of strong evidence warrants the need for future controlled studies; subsequently, postoperative rehabilitation should be individualized following reverse shoulder arthroplasty [42]. At early follow-up, navigated and non-navigated reverse total shoulder arthroplasties yielded similar rates of improvement in range of motion and functional outcome scores [181]. All patients undergoing Latarjet procedure wore a sling for the first week postoperatively, started self-assisted rehabilitation at the beginning of the second week for 3 weeks, and were referred to a physical therapist to start active mobilization in elevation and external rotation after 1 month [168]. Patients undergoing type II SLAP repair were initially placed in a sling for 7 to 10 days [195].

Other Considerations: PROMIS PF scores were responsive to the functional improvements observed clinically in total shoulder arthroplasty patients [21]. Outcome models showed consistent relationships between patient baseline covariates and the 12-month ASES scores and Recovery Period shoulder-related encounters following rotator cuff repair [54].

Complications¶

Rotator Cuff Repair¶

Re-tear: Approximately 25% of rotator cuff repairs re-tear at a mean of about 2 years after surgery [26]. Of patients with rotator cuff re-tears, approximately half will still have a “successful” outcome [26].

Persistent Pain Etiologies: The possible etiologies for pain and shoulder dysfunction after prior rotator cuff surgery are categorized into those that are extrinsic and intrinsic to the shoulder itself [26]. Extrinsic causes include brachial plexopathy, cervical radiculopathy, long thoracic neuropathy, neoplasm, reflex sympathetic dystrophy, spinal accessory neuropathy, suprascapular neuropathy, and thoracic outlet syndrome [26]. Intrinsic causes include acromial stress fracture, acromioclavicular arthropathy, adhesive capsulitis, articular cartilage defect, biceps or labral pathology, deltoid insufficiency, infection, osteoarthritis, persistent subacromial impingement, and rotator cuff defect [26]. Radiation of pain past the elbow into the distal extremity, numbness, tingling, and burning symptoms may indicate an extrinsic etiology such as cervical radiculopathy [26].

Prognostic Factors: Patients with labor-intensive occupations will most often be symptomatic following rotator cuff repair [26]. Patients with lower education level and a Workers’ Compensation claim are more likely to do poorly after rotator cuff repair [26]. Preoperative functional status and a history of failed rotator cuff repair are significant predictors of postoperative outcomes after latissimus dorsi transfer for irreparable massive rotator cuff tears [169].

Rehabilitation & Management: A thorough well-designed postoperative or postinjury rehabilitation program may prevent most complications [171]. If complications arise after shoulder surgery, a team approach working to develop an evidenced-based treatment program designed specifically for the underlying complication can successfully treat these issues [171].

Scapular Fractures¶

Malunion: Malunion is the most common complication of nonoperative treatment of scapular fractures [130]. Healing of extra-articular scapular fractures in a nonanatomical position changes the relationship between the glenoid and the scapular body, consequently altering the course of muscles of the rotator cuff [130]. Malunion of scapular fractures is subjectively manifested by feelings of weakness, pain, and limitation of the range of motion [130]. Malunion of scapular fractures may result in subacromial impingement syndrome [130]. Fractures of the glenoid that have healed in displacement result in incongruity, instability, or both, and subsequently in degenerative glenohumeral joint disease [130]. Malunion of a scapular body fracture is generally well tolerated, however, painful scapulothoracic crepitus has been described on occasion [128]. Fractures of the glenoid neck with significant translational displacement can give rise to glenohumeral pain and dysfunction related to altered mechanics of the surrounding tissues [128].

Nonunion: Nonunions of the scapular body are rare [130]. Rib nonunion may be a rare cause of chronic pain after a scapular fracture [130].

Nerve Injury: In fractures of the scapular neck, the suprascapular nerve may become entrapped in the fracture line [130]. Suprascapular nerve injury in scapular neck fractures is manifested by atrophy of the infraspinatus [130].

Surgical Complications: Complications associated with surgical management of scapula fractures include infection (both superficial and deep), intraoperative neurovascular injury, loss of fixation, and others [128]. Operative complications for scapular fractures include hematoma, infection, fixation failure, nonunion, incongruity, implant prominence, and posttraumatic degenerative disease [130].

Rehabilitation & Compliance: A poorly managed postoperative rehabilitation program for scapula fractures can lead to unnecessary shoulder stiffness [128]. Suboptimal shoulder range of motion caused by unwillingness to follow the postoperative physical therapy program is a complication related to poor patient compliance in scapula fractures [128]. Hardware failure associated with failure to observe postoperative instructions is a complication related to poor patient compliance in scapula fractures [128].

General Rehabilitation & Outcomes¶

SLAP Lesions: At > 2 years after surgery, earlier repairs (< 6 months) for type II SLAP lesions are associated with better functional outcomes [13].

Total Shoulder Arthroplasty: Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications following total shoulder arthroplasty [62]. Although there is a significant and longitudinal improvement in shoulder function and pain relief after total shoulder replacement, long-term follow-up of fifteen to twenty years demonstrated a high revision rate in this cohort [60]. Revision reverse total shoulder arthroplasty leads to an improvement in patient-reported outcome measures and pain levels and demonstrates high durability at mid-term follow-up with low complication and failure rates [111].

Partial-Thickness Rotator Cuff Tears: At 6 months postoperatively, superior functional outcomes were observed in the delayed repair group compared with the immediate repair group for partial-thickness rotator cuff tears [63].

Scapular Dyskinesis: Scapular dyskinesis may increase the functional deficit associated with shoulder injury by altering the normal scapular role during coupled scapulohumeral motions [17]. Treatment of scapular dyskinesis is directed at managing underlying causes and restoring normal scapular muscle activation patterns by kinetic chain–based rehabilitation protocols [17].

Other Considerations: Manipulative therapy in addition to usual medical care accelerates recovery of shoulder complaints and is more effective than usual medical care alone on the long term, but is associated with higher costs [31]. 3 months follow-up is too early for outcome evaluation using five shoulder outcome measures [59].

Recovery¶

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

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

Complete recovery / outcome plateau (months): For two-part fractures of the neck of the humerus, delayed rehabilitation by 3 weeks of shoulder immobilization produces a slower recovery, which continues for at least 2 years after the time of injury [220]. In repaired rotator cuffs, structural status remained unchanged between 6 and 19 months, although functional status improved with time after 6 months [119].

Rehabilitation protocol: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty and has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living [142]. For instability, if exercises are effectively administered immediately following diagnosis, they are 95% successful in returning the athlete to his or her prior level of competition, without surgery [16].

Functional milestones: After a 5-week rehabilitation program, the average function score for 27 patients was 84.5% (range 45-100) using the shoulder function-modified kohn-score [7].

Other Considerations: Scapular dyskinesis is a nonspecific response to shoulder dysfunction because no specific pattern of dyskinesis is associated with a specific shoulder diagnosis [17]. Significant deficits in the literature regarding adhesive capsulitis include a paucity of randomized controlled trials, failure to report response to treatment in a stage-based fashion, and an incomplete understanding of the disease's natural course [222]. Worse functional outcomes were associated with worse PROMIS Depression and Anxiety; however, more severe two-year PROMIS Anxiety was the strongest predictor of worse functional outcomes in shoulder surgery patients [140]. Nonmodifiable risk factors, such as age less than 20 years and duration of symptoms greater than 5 months, significantly affect risk of recurrence after arthroscopic instability repair [221]. Outcomes following anatomic total shoulder arthroplasty have proven to be durable and reproducible [33]. The deltoid extension lag sign gives objective information about the extent of deltoid dysfunction and, when repeated over time, allows precise follow-up of neural recovery [52]. Some measures of shoulder range of motion showed a moderate to high level of agreement between patient-reported measurements and the physician's measurements [73].

Key Evidence¶

[L4] There is no consensus on the definition of accelerated rehabilitation or outcome measure selection. [1] (10.1177/17585732221089636)
[L3] Improvement in outcomes was observed up to 16 sessions of physical therapy, after which outcomes plateaued. [2] (10.1016/j.jse.2018.10.001)
[L2] Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. [3] (10.1186/s12891-017-1502-8)
[L4] The majority of functional and symptomatic improvements following RCR occur within the first year, with minimal clinically meaningful gains observed between 1 and 2 years. [4] (10.1016/j.jse.2025.05.020)
[L5] Combining pathoanatomic causes with movement impairments provides a more focused rehabilitation approach, and applying a comprehensive evaluation approach prior to and throughout treatment can assist clinicians in selecting appropriate treatments based on patient need. [5] (10.1016/j.jse.2023.07.013)
[L3] Patients undergoing rehabilitation using a home-based protocol showed largely similar functional scores and healing to those with supervised PT after ARCR of MRCTs at the latest follow-up. [6] (10.1016/j.arthro.2024.06.037)
[L4] After a 5-week rehabilitation program, 27 patients had a new evaluation and the average function was 84,5% (45-100). [7] (10.1016/s1058-2746(95)80325-4)
[L4] Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate. [8] (10.1016/j.jse.2020.07.030)
[L2] The review identified several prognostic factors for response to physiotherapy, including baseline pain severity, disability, and psychological factors, though the evidence quality was generally low. [9] (10.1186/1471-2474-14-203)
[L4] These results support the view that rehabilitation is a valuable intervention when faced with such a patient presentation. [10] (10.1177/1758573213517218)
[L2] Delayed passive rehabilitation does not bring about superior outcomes compared to early rehabilitation. [11] (10.5397/cise.2019.22.4.190)
[L5] The proposed objective criteria-based shoulder diagnosis and rehabilitation model could be a new effective strategy for minimizing the time required to regain functional capacity and recover from symptoms among patients with work-related shoulder injuries. [12] (10.1186/s12891-017-1435-2)
[L3] However, at > 2 years after surgery, earlier repairs ( < 6 months) are associated with better functional outcomes. [13] (10.1177/17585732211015825)
[L1] Only one study showed moderate evidence of early physical therapy promoting a more rapid return of short-term improvement in function and pain. [14] (10.1177/1758573218812038)
[L3] Functional outcomes after ARCR improved during midterm follow-up, regardless of retear. [15] (10.1177/03635465241305742)
[L5] If the exercises are effectively administered immediately following diagnosis, they are 95% successful in returning the athlete to his or her prior level of competition, without surgery. [16] (10.1016/s0894-1130(12)80106-2)
[L5] [17] (10.5435/00124635-200303000-00008)
[L5] Most injuries to the thrower's shoulder can be effectively treated with a proper nonoperative rehabilitation program. [19] (10.1177/03635465020300011201)
[L3] Aspects of treatment that maximize the functional outcome are important in achieving patient satisfaction. [20] (10.1016/j.jse.2007.02.136)
[L3] PROMIS PF scores were responsive to the functional improvements observed clinically. [21] (10.1016/j.jse.2018.08.040)
[L5] Identification of whether a patient presents with pain or stiffness as their predominant symptom further guides treatment selection. [24] (10.1177/1758573215586152)
[L4] Established clinical scores did not reflect these sport-specific impairments. [27] (10.1177/0363546511417407)
[L2] The study demonstrates that the SANE is valid for a range of common shoulder diagnoses to assess patient outcomes across operative and nonoperative treatment for shoulder complaints. [29] (10.1177/0363546518807924)
[L4] Superior outcomes were associated with better preoperative clinical and MRI status, indicating that early recognition and timely intervention result in better shoulder motion and improved joint alignment. [30] (10.1016/j.jse.2009.05.011)
[L1] Manipulative therapy in addition to usual medical care accelerates recovery and is more effective than usual medical care alone on the long term, but is associated with higher costs. [31] (10.1186/1471-2474-11-200)
[L4] All five shoulder outcome questionnaires were able to discriminate between differences in severity of shoulder dysfunction. [32] (10.1016/s1058-2746(95)80210-x)
[L5] Outcomes following anatomic total shoulder arthroplasty have proven to be durable and reproducible. [33] (10.1097/bte.0000000000000075)
[L4] [38] (10.1177/1758573220913246)
[L3] Although worse functional results were found in the group with surgical indication, this difference disappears when adjusting for age as a confounding factor. [40] (10.1016/j.jse.2025.02.026)
[L1] The lack of strong evidence warrants the need for future controlled studies; subsequently, postoperative rehabilitation should be individualized. [42] (10.1177/17585732221144007)
[L5] The review outlines rehabilitation guidelines developed to manage patients who have undergone reverse total shoulder replacement, aiming to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery. [44] (10.1111/j.1758-5740.2011.00138.x)
[L3] Centre of pressure measurement detected sensorimotor functional deficits following surgical treatment of the shoulder joint in patients with confirmed successful clinical and functional outcomes. [45] (10.1007/s00167-021-06751-0)
[L5] It improves the efficacy of conservative treatment by reducing surgical indications. [49] (10.1016/s1297-3203(00)73483-4)
[L2] Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. [50] (10.1016/j.jse.2024.02.024)
[L4] The sign gives objective information about the extent of deltoid dysfunction and, when repeated over time, allows precise follow-up of neural recovery. [52] (10.1016/s1058-2746(98)90217-8)
[L5] Rehabilitation guidelines are proposed to enhance patient satisfaction and provide a framework for physical therapists. [53] (10.1097/bte.0000000000000013)
[L3] Outcome models showed consistent relationships between patient baseline covariates and the 12-month ASES scores and Recovery Period shoulder-related encounters. [54] (10.1016/j.jseint.2026.101763)
[Letter] The authors argue that the data available in the referenced systematic review are insufficient to make reliable clinical implications or establish a gold standard rehabilitation protocol, emphasizing the need for further research on dose-response relationships and supervised exercise. [55] (10.1016/j.jse.2009.03.015)
[L4] It can assess the strength of various muscle groups following disease or surgery, determine the effectiveness of therapy, and detect old muscle injuries that have escaped detection by existing methods of diagnosis. [57] (10.2106/00004623-196345010-00011)
[L1] Those with a worse prognosis may be monitored more frequently and the treatment plan modified if complaints persist. [58] (10.1186/s12891-015-0738-4)
[L2] Our results suggest that 3 months follow-up is too early for outcome evaluation. [59] (10.1186/s12891-021-04483-3)
[L4] Although there is a significant and longitudinal improvement in shoulder function and pain relief after total shoulder replacement, long-term follow-up of fifteen to twenty years demonstrated a high revision rate in this cohort. [60] (10.2106/jbjs.m.00079)
[L3] This method can reliably determine passive range of motion in this patient population and be a reliable outcome measure. [61] (10.1186/s12891-015-0495-4)
[L3] Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications. [62] (10.1177/1758573220922845)
[L2] However, at 6 months postoperatively, superior functional outcomes were observed in the delayed repair group compared with the immediate repair group. [63] (10.1177/0363546518757425)
[L5] Stable, nondisplaced ligament injuries without significant MRI findings can be treated nonoperatively, with most athletes safely returning to sport within 6–10 weeks and minimal complications. [64] (10.1002/ksa.70244)
[L1] Surgery (after failure of conservative treatment) ranked highest across all ROM domains. [65] (10.1016/j.arthro.2020.09.041)
[L4] Shoulder physical functions were mapped to outcome scores. [66] (10.1016/j.jse.2019.08.017)
[L5] For the minority of patients for whom nonoperative management fails, surgical reconstruction with an open inferior capsular shift can be reasonably recommended. [69] (10.5435/00124635-199801000-00007)
[L3] Some measures of shoulder ROM showed a moderate to high level of agreement between patient-reported measurements and the physician's measurements. [73] (10.1016/j.jse.2016.02.010)
[L4] Successful nonoperative treatment of superior labral tears results in improved pain relief and functional outcomes compared with pretreatment assessments. [92] (10.1177/0363546510370937)
[L1] Comprehensive rehabilitation, compared to conventional physiotherapy, has shown a statistically and clinically significant difference in improving pain, ROM, functional disability, quality of life, and treatment effectiveness in patients after ARCR. [95] (10.1016/j.jht.2023.09.009)
[L2] Further studies are needed to determine its effect on the outcome of the treatment of rotator cuff disease. [101] (10.2106/jbjs.o.00444)
[L2] [104] (10.1186/s12891-022-05139-6)
[L3] [106] (10.1136/bmjsem-2018-000342)
[L2] The self-administered web application demonstrated high agreement with experienced physical therapists in diagnosing shoulder disorders, including disease phase and specific disorder identification, highlighting its potential as a screening and evaluation tool in clinical practice and remote rehabilitation. [107] (10.1016/j.xrrt.2026.100693)
[L2] No differences in clinical scores existed between patients stratified by the Sugaya MRI classification system at 16 weeks. [109] (10.1016/j.jse.2015.09.019)
[L4] Revision rTSA leads to an improvement in patient-reported outcome measures and pain levels and demonstrates high durability at mid-term follow-up with low complication and failure rates. [111] (10.1016/j.jsea.2026.100004)
[L4] Use of the patient-centred ULTRA guideline can yield statistically significant improvements in outcome and range of motion for patients undergoing primary RTSA, which are maintained at the two-year post-surgery time point. [112] (10.1177/17585732221133532)
[L4] Although functional status improved with time after 6 months, the structural status of repaired cuffs remained unchanged between 6 and 19 months. [119] (10.1016/j.jse.2011.05.027)
[L4] The SA-Q questionnaire has potential clinical implications for detected changes concerning the different items during rehabilitation. [121] (10.1186/s12891-020-03284-4)
[L2] Investigations of the measurement properties were rare, but indicate good reliability and validity as well as moderate responsiveness in patients with upper extremity conditions. [122] (10.1007/s00402-018-2933-x)
[L5] Combining a general health outcome measure, a general shoulder measure, a disease- or condition-specific shoulder measure, and an activity measure allows for broad patient assessment. [124] (10.5435/00124635-201007000-00006)
[L4] The dichotomized and trichotomized classifications as well as the combined classifications did not lead to superior agreements. [134] (10.1016/j.arthro.2021.12.005)
[L4] The DASH modules differentiated well among the 11 diagnostic groups (ANOVA P-value 0.001) and further differences existed at the item level, so that functional activity problem profiles could be developed for each diagnostic group. [135] (10.1016/j.jhsb.2004.08.008)
[L4] The authors suggest that the score should be redesigned with better standardization before being used to validate other assessments or compare outcomes between different testers. [137] (10.1016/j.jse.2007.06.024)
[L4] A nondisplaced IÁFL can be treated conservatively. [139] (10.1016/s1058-2746(96)80134-0)
[L3] Worse functional outcomes were associated with worse PROMIS Depression and Anxiety; however, more severe two-year PROMIS Anxiety was the strongest predictor of worse functional outcomes. [140] (10.1302/0301-620x.104b4.bjj-2021-1089.r1)
[Paper] Physical therapy plays an important role subsequent to reverse shoulder arthroplasty and has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. [142] (10.1007/s00402-018-2977-y)
[L4] Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment. [143] (10.1007/s00167-016-4226-7)
[L1] Operative treatment resulted in greater improvement in Constant scores and significantly decreased pain scores compared to nonoperative management. [145] (10.1016/j.jse.2017.09.032)
[L3] This scoring system helped predict the adequacy of the repair and assist in deciding the appropriate treatment options. [146] (10.1177/0363546518810763)
[L3] A new shoulder scoring system has been developed based on patients' and physicians' points of view and worldwide applicability and was verified to be valid, reliable, and responsive. [148] (10.1016/j.arthro.2012.11.009)
[L1] There is strong evidence that early initiation of rehabilitation and early functional loading does not adversely affect clinical outcome, though there is a marginally higher, statistically non-significant incidence of tendon re-tear. [161] (10.1177/1758573214567702)
[L2] There is a tendency of improvement lasting over 5 years after operative and over 2 years after intensive conservative treatment of subacromial impingement. [164] (10.1016/s1058-2746(96)80132-7)
[L3] [168] (10.1177/0363546519879929)
[L4] Preoperative functional status and a history of failed rotator cuff repair are significant predictors of postoperative outcomes. [169] (10.1016/j.jse.2015.08.043)
[Paper] A thorough well-designed postoperative or postinjury rehabilitation program may prevent most complications, and if complications do arise, a team approach working to develop an evidenced-based treatment program designed specifically for the underlying complication can successfully treat these issues. [171] (10.1016/j.csm.2017.12.010)
[L3] A multimodal nonoperative treatment program is effective for most patients with adhesive capsulitis. [179] (10.1177/0363546510385403)
[L3] At early follow-up, navigated and non-navigated RSAs yielded similar rates of improvement in range of motion and functional outcome scores. [181] (10.1016/j.jse.2022.07.007)
[L5] There are no appropriately designed prognostic studies to identify predictors of success with physiotherapy in patients with massive irreparable rotator cuff tears. [184] (10.3390/ijerph20075242)
[L3] Conservative treatment is highly efficient in Stage I and Stage II diseases. [185] (10.1016/s1058-2746(96)80283-7)
[L4] Patients aged ≤20 years did poorly with more than half of the patients having recurrence; alternative stabilization techniques should probably be considered for these patients. [186] (10.1007/s00167-017-4504-z)
[L1] No published RCTs have evaluated physiotherapist-led interventions for patients with GHOA undergoing non-surgical care. [189] (10.1177/17585732261450961)
[L4] [191] (10.1016/j.jse.2022.09.019)
[L4] [195] (10.1177/0363546511398648)
[L5] [203] (10.1016/j.asmr.2021.11.007)
[L4] [207] (10.1177/2325967116684775)
[L4] [209] (10.1097/00132589-200306000-00002)
[L4] [210] (10.1016/j.jses.2017.04.001)
[L4] [212] (10.1177/1758573215592266)
[L1] [218] (10.1186/s12891-021-04140-9)
[L4] [219] (10.1016/j.jse.2011.02.009)
[L1] Delayed rehabilitation by 3 weeks of shoulder immobilization produces a slower recovery, which continues for at least 2 years after the time of injury. [220] (10.1016/j.jse.2006.06.003)
[L2] Nonmodifiable risk factors, such as age less than 20 years and duration of symptoms greater than 5 months, significantly affect risk of recurrence. [221] (10.1177/0363546520949840)
[L5] Significant deficits in the literature include a paucity of randomized controlled trials, failure to report response to treatment in a stage-based fashion, and an incomplete understanding of the disease's natural course. [222] (10.1177/0363546509348048)

References¶

[1] Post-operative rehabilitation following traumatic anterior shoulder dislocation: A systematic scoping review. Shoulder & Elbow. 2022. DOI: 10.1177/17585732221089636

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