What’s New in Shoulder and Elbow Surgery

The aim of this Guest Editorial is to highlight recent advancements in the study and practice of shoulder and elbow surgery for the practicing orthopaedic surgeon. Rotator Cuff Nonoperative Management Nonoperative management remains a primary method of treatment for rotator cuff tears, with platelet-rich plasma (PRP) and corticosteroid injections as components of this treatment option. A recent systematic review and meta-analysis reviewed 9 studies with 537 patients. The authors found no difference in pain, function, complications, or retear rates when repair with and without PRP was analyzed1. Another systematic review and meta-analysis examined 9 randomized controlled trials (RCTs) that compared PRP with corticosteroids to treat rotator cuff disease in 469 patients2. The Constant score, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score were reviewed at short-term, intermediate-term, and long-term follow-ups. Corticosteroids were superior in the short term, and PRP was demonstrated to be more beneficial in the long term. Perioperative management during rotator cuff repair continues to evolve. Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors have been a mainstay, but their utilization in the immediate postoperative period following rotator cuff repair remains controversial. A recent systematic review and meta-analysis examined whether NSAIDs or COX-2 inhibitors influenced healing rates, functional outcomes, or patient satisfaction after rotator cuff repair3. The authors included 7 RCTs with 507 patients. NSAIDs did not affect the cuff healing rate, but NSAID use significantly improved postoperative pain and functional outcomes. Postoperative pain and functional outcomes were not different with COX-2 inhibitors. Zoledronic acid has also been the subject of recent investigation. A recent prospective, single-blinded randomized study enrolled 138 female patients with postmenopausal osteoporosis undergoing rotator cuff repair. Tendon healing was evaluated with ultrasound at 6 weeks and 24 months. The results demonstrated that zoledronic acid reduced the retear rate but did not significantly influence the clinical standardized outcomes4. Finally, the use of a brace compared with a simple sling was examined with a systematic review and meta-analysis5. The authors reviewed 275 articles, but only 4 articles (302 patients) met inclusion criteria. There was no advantage in brace compared with sling use in standardized outcome scores, a visual analog scale (VAS) for pain, and shoulder range of motion. The authors suggested that a simple sling may be a superior choice because of the potential cost savings. Surgical Technique and Biologic Augmentation Improving the biologic environment for rotator cuff repairs may improve healing rates and outcomes. A recent RCT compared 60 patients treated with arthroscopic rotator cuff repair with and without bone marrow stimulation. Fifty of the patients were available at the 2-year follow-up. Clinical outcomes and retear rates were not different in the 2 groups6. A similar finding was demonstrated in a recent systematic review and meta-analysis with 4 Level-I studies and 1 Level-II study. The authors found that the healing rate of rotator cuff repairs was similar, regardless of the use of bone marrow stimulation7. Partial cuff repair or augmentation remains a component of cuff management. A recent prospective randomized trial examined repair compared with debridement for partial subscapularis tears, and the authors demonstrated no difference in pain scores, standardized outcomes, and range of motion at 5 years8. A recent systematic review examined large tears treated with patch augmentation. Six studies totaling 193 patients were examined, and the authors found that patch augmentation may be associated with lower retear rates9. In their meta-analysis, Hurley et al. also found that patch augmentation reduced retear rates10. The material chosen to supplement a rotator cuff repair is still evolving. In a recent RCT, 124 patients with posterosuperior tears underwent either a procedure involving a bioinductive collagen implant or repair. The authors demonstrated that the use of a bioinductive implant reduced the retear rate at 12 months11. Finally, in a recent systematic review of RCTs, acromioplasty was demonstrated to potentially reduce the risk of reoperation12. Despite the multiple advances in operative technique and perioperative management, irreparable rotator cuff tears continue to remain a clinical challenge. The use of tendon transfers and grafts and the emergence of spacer options provide potential solutions to this complicated problem. Two recent systemic reviews examined tendon transfers. A systematic review of the lower trapezius transfer identified 7 studies with 159 patients. The results demonstrated that the lower trapezius transfer improved the clinical outcome in patients with irreparable rotator cuff tears and noted that the rate of complications and reoperations was comparable with alternative approaches13. An alternative technique is the latissimus dorsi tendon transfer. In a recent systematic review and meta-analysis, the authors identified 618 publications, but only found 11 eligible articles with a total of 421 patients. The results demonstrated a significant improvement in patient-reported outcome measures (PROMs), pain scores, range of motion, and strength at the intermediate term (4 to 9 years) to the long term (>9 years)14. Despite the success of tendon transfers, alternative treatments continue to demonstrate efficacy. The mini-open fascia lata interposition graft was compared with arthroscopic partial rotator cuff repair in an RCT. At 2 years, the authors found that the interposition group had better University of California Los Angeles (UCLA) shoulder scores, internal rotation, and external rotation, and lower retear rates in comparison with partial repair15. Another emerging alternative is the subacromial balloon spacer. A systematic review and meta-analysis identified 17 studies with a total of 894 shoulders. The short-term results suggested that the balloon spacer was a safe and effective treatment, but clinical heterogeneity, concomitant procedures, and control of patient selection limited the ability to make a conclusive assessment16. Although these treatment options offer a potential solution for irreparable rotator cuff tears, a comparison of techniques is needed to determine the best treatment option. In a systematic review and network meta-analysis, 23 studies with 1,178 patients were examined. Multiple techniques were compared, including superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, balloon interposition, reverse total shoulder arthroplasty (TSA), and graft interposition. The authors found that, for patients <70 years of age without notable arthritis or pseudoparalysis, reverse TSA offered the least benefit in forward elevation17. Overall, the treatment of irreparable rotator cuff tears is still an area of growing literature, and the treating surgeon should carefully consider the multiple available treatment options. Shoulder Arthroplasty Two articles recently reviewed the rehabilitation protocols for patients following shoulder arthroplasty. In a prospective RCT, Khalil et al. showed that a subscapularis-specific rehabilitation program after anatomic TSA did not improve outcomes18. Schick et al. showed that patients who were in a formal outpatient physical therapy program after reverse TSA had better external rotation strength at the final follow-up (at least 6 months) than those who participated in a home exercise program only19. All other outcome measures, including PROMs, were similar between the 2 groups. Three studies examined different ways to perform shoulder arthroplasty. In a systematic review and meta-analysis, Bethell et al. showed that subscapularis repair during reverse TSA yielded lower instability rates with medialized implant designs but not with lateralized designs20. In a randomized trial of 3D-printed glenoid drill guides based on preoperative computed tomographic (CT) scans, in-house manufacturing of guides yielded better correction of version and less difference in accuracy of correction of version when larger corrections were required21. No differences were noted in correct placement of the glenoid components with respect to inclination. Southam et al. randomized patients to determine whether lateralization of the glenosphere impacted outcomes22. In their study of 27 patients who underwent lateralized reverse TSA and 26 patients who underwent non-lateralized reverse TSA, there were no differences in PROMs, range of motion, scapular notching, acromial fractures, and strength at the 2-year follow-up. In patients who had acromial and scapular spine stress fractures after reverse TSA, Cui et al. performed a systematic review and meta-analysis to determine the clinical outcomes of conservatively treated fractures23. Their review of 13 studies demonstrated that patients with these fractures had worse functional outcomes when compared with patients who did not have such a fracture after the surgical procedure. Outcomes were worst in those patients with scapular spine fractures. To determine if the time to the surgical procedure impacted the outcomes of patients who underwent reverse TSA for fracture, Lu et al. performed a systematic review and meta-analysis24. Their review of 16 studies demonstrated better clinical outcomes in terms of range of motion, PROMs, and complication rates in patients who underwent acute reverse TSA compared with reverse TSA after nonoperative treatment or after prior open reduction and internal fixation. Periprosthetic joint infections remain a challenging and often catastrophic event, making risk reduction a critical need in shoulder arthroplasty research. Wright et al. evaluated the effect of hydrogen peroxide on deep culture Cutibacterium acnes positivity rates25. In their RCT, the authors found that the inclusion of hydrogen peroxide application to the dermis following surgical incision yielded a small reduction in deep culture C. acnes positivity in patients undergoing shoulder arthroplasty. In a systematic review and meta-analysis, Rodrigues-Lopes et al. showed that if an infection did occur, patients who underwent 1-stage revision had a lower complication rate (6.11% compared with 21.26%) and a lower reinfection rate (1.14% compared with 8.81%) than patients who underwent 2-stage revision26. Shoulder Instability To compare the rates of recurrent instability after either a Latarjet procedure or an arthroscopic Bankart repair, Masud et al. performed a Bayesian network meta-analysis27. Their study combined 52 studies and demonstrated that the Latarjet procedure had a lower overall recurrent instability rate and that the recurrent instability rate for arthroscopic Bankart repair increased with glenoid bone loss of 10% to 20% compared with 0% to 10%. The presence of a Hill-Sachs lesion or an osseous Bankart lesion increased a patient's risk of experiencing recurrent instability regardless of the procedure performed. In terms of return to sport, Hurley et al. performed a systematic review that demonstrated that there is wide variability of reported rates of return to sport at the preoperative level (61% to 94.1% in arthroscopic Bankart repair studies and 72% to 96.8% in Latarjet procedure studies)28. Overall, there was no difference between patients who underwent arthroscopic Bankart repair and those who underwent a Latarjet procedure in terms of return to sport or in terms of the time frame for return. To better understand fixation and outcomes after a Latarjet procedure, multiple authors performed systematic reviews. DeClercq et al. reviewed the radiographic outcomes at 12 months to compare conventional radiographs and CT scans29. Their study showed high rates of arthritis (pooled mean, 28%), graft osteolysis (30%), nonunion (5.1%), graft malpositioning (14.75%), implant issues (5%), and bone-block fracture (2.1%). Most of these outcomes were detected by radiographs, although osteolysis was identified at higher rates with CT scans. To compare techniques for osseous augmentation, Cozzolino et al. performed a proportional meta-analysis focused on recurrence, complication, and reoperation rates between arthroscopic Latarjet procedures and arthroscopic free bone-block procedures30. Their analysis found similar recurrence, reoperation, and complication rates between the 2 groups. Subgroup analysis showed a higher complication rate with screws than with flexible fixation. Hali et al. performed a systematic review that showed similar biomechanical load to failure and clinical outcomes in suture button fixation compared with screw fixation31. Patients who had screw fixation had a higher rate of graft resorption. Jegatheesan et al. performed a different review of 11 studies and found that the population of patients undergoing a primary Latarjet procedure and those who underwent a Latarjet procedure after some other prior surgical procedure did not demonstrate any difference in rates of complications, reoperations, or recurrent instability, clinical outcomes, or range of motion32. Patients who underwent a Latarjet procedure after a previous unsuccessful procedure did have a higher infection rate (2.6%) than patients who underwent a primary Latarjet procedure (1.2%). Regional Pain Management Regional anesthesia has revolutionized pain management in perioperative shoulder surgery care. Many options exist for anesthetic agents and regional block locations. Kim et al. examined the addition of an eighth cervical nerve root block to an interscalene block in a prospective RCT33. The primary outcome was posterior portal pain on incision, and the secondary outcome was the bilateral pupil diameter as an indication of Horner syndrome. The inclusion of a C8 block at the time of the interscalene block was found to result in less posterior portal incision pain but an increased incidence of Horner syndrome, and there was no difference in postoperative pain between the groups. A separate study compared a continuous catheter suprascapular nerve block and a superior trunk block for arthroscopic shoulder surgery34. The worst and resting pain scores were poorer in the suprascapular nerve block group compared with superior trunk block, although there was a higher rate of hemidiaphragmatic paresis in the continuous superior trunk block group. Tranexamic Acid (TXA) Use in Shoulder Surgery TXA has been utilized broadly in many surgical specialties for the purpose of decreasing surgical blood loss. The most recent systematic review on this topic in shoulder arthroplasty included 14 studies with 1,131 patients35. TXA was associated with a significant reduction in total blood loss volume, drain output, and hemoglobin changes, shorter operative time, and lower risk of hematoma formation. The TXA group also had a better postoperative VAS pain score. Suter et al. sought to evaluate the utility of TXA to decrease blood loss with the aim of effecting improved visibility in arthroscopy36. Their study randomized patients undergoing shoulder arthroscopy to 1 of 4 arms: (1) saline solution arthroscopy fluid alone, (2) epinephrine in arthroscopy fluid, (3) 1-g intravenous TXA, or (4) epinephrine saline solution and intravenous TXA. The authors found that the presence or absence of epinephrine in saline solution had the greatest impact on visual clarity and that intravenous TXA had no effect, with no adverse events reported. Arthroscopic rotator cuff repair is another area where the utilization of TXA has been growing, with multiple recent systematic reviews and meta-analyses. In 1 systematic review and meta-analysis, the authors examined 7 studies (3 Level-I studies and 4 Level-II studies). The pooled analysis demonstrated that TXA significantly improved visualization and operative times during arthroscopic rotator cuff repair without increasing the incidence of adverse events37. Another systematic review and meta-analysis of both Level-I and II studies confirmed this finding. Its authors examined 2 studies in which intra-articular TXA was utilized and 4 studies in which intravenous TXA was utilized and demonstrated a similar conclusion that intravenous TXA can improve visualization and shorten the operative time for arthroscopic rotator cuff repair38. Adhesive Capsulitis Frozen shoulder, or adhesive capsulitis, is a painful contracture of the glenohumeral capsule. Intra-articular corticosteroid injections are 1 facet of treatment options in the clinical management of adhesive capsulitis, although there are varying approaches regarding the dose and injection technique. A systematic review and meta-analysis compared high-dose cortisone injection with low-dose cortisone injection with respect to range of motion, a pain scale, and functional improvement39. The analysis included 274 patients from 4 studies and found no clinically important differences in pain, motion, or functional improvements at 3 weeks, 6 weeks, or 1 year. The authors recommended the use of low-dose cortisone injections, as side effects are more common with high-dose injections. Injection location and technique are other variables. A prospective RCT compared single-site rotator interval injection with multiple-site injection (rotator interval, intra-articular, and subacromial)40. The groups received the same total dose and injection volume. Both groups had improved pain, functional scores, and range of motion. The multisite injection group had better pain scores at 4 and 8 weeks, better flexion and abduction, and better functional scores. Cortisone injections are not the only injection treatment option used in the management of adhesive capsulitis. Hydrodilatation is the intra-articular injection of a volume of saline solution greater than the volume typically used for cortisone injections. One study compared hydrodilatation via a posterior approach with different concentrations and volumes of injectate41. In this RCT, both groups received 4 mL of 40-mg triamcinolone acetonide and 4 mL of 2% lidocaine hydrochloride (xylocaine), but the first group included the addition of 12-mL saline solution (total volume, 20 mL) and the second group included 2-mL saline solution (total volume, 10 mL). Patients were evaluated at baseline, 6 weeks, and 12 weeks. There was a decrease in VAS pain scores and Shoulder Pain and Disability Index (SPADI) scores, and an improvement in range of motion, for both groups over time. The first group saw superior flexion and external rotation until 12 weeks. Another RCT compared the combination of hydrodilatation and physical therapy with physical therapy alone42. Both groups received structured physical therapy. The treatment group received 3 separate ultrasound-guided injections, 2 weeks apart, of 2 mL of high-molecular-weight hyaluronic acid, 4 mL of 2% lidocaine hydrochloride, and 14 mL of normal saline solution. The injection group demonstrated a greater reduction in the Constant score and the SPADI score at 6 and 12 weeks. A third RCT examined combined hydrodilatation, subdeltoid bursa injection with corticosteroid, and physical therapy compared with physical therapy alone43. The combination group had better range of motion, better outcome scores, and lower pain compared with the group undergoing physical therapy alone at the 1, 2, 4, and 6-month time points. PRP injections have been studied in many orthopaedic applications, including in the treatment of primary adhesive capsulitis. A systematic review and meta-analysis examined the effect of PRP on the range of motion, pain, and disability in patients with adhesive capsulitis44. The authors included 14 studies totaling 1,139 patients. Pain, range of motion in multiple planes, and disability were improved at 3 months, whereas pain and disability were improved at 6 months after the injection, with no adverse reaction reported. In some patients with adhesive capsulitis, injections of various types or physical therapy fail to improve motion and pain. For these patients, consideration may be given to the surgical release of the rotator interval and inferior capsule. Some authors have investigated percutaneous interval release. Wahezi et al. completed a prospective randomized controlled crossover study of percutaneous coracohumeral ligament release (PCHLR) for adhesive capsulitis45. Thirty-nine patients were ultimately randomized to either local anesthetic injection or PCHLR with a Tenex needle (Tenex Health). Nine patients in the local anesthetic group crossed over to the PCHLR group at 1 month. For those included in the PCHLR group, external rotation was twice as great, abduction was almost 30% greater, and the Oxford Shoulder Score improved significantly at 1 year compared with the group that received local anesthetic injection alone. Clavicle and Acromioclavicular Joint A rather large number of surgical techniques have been proposed in the management of acromioclavicular dislocations, including techniques securing the distal clavicle to the acromion or to the coracoid in various fashions. Li et al. sought to compare the use of a hook plate with use of a suture button in coracoid fixation for acute acromioclavicular dislocations46. Their systematic review included 14 studies with 363 patients receiving a suture button and 432 patients receiving a hook plate. As the procedures in most of the suture button studies were done arthroscopically, there was a lower estimated blood loss in the suture button group. There was no difference between the groups with respect to the coracohumeral distance or complications, although Constant scores were higher in the suture button group. Although this study reviewed the suture button option and the hook plate, other techniques have also been described. Bi et al. performed a network meta-analysis of RCTs examining 1 of 10 options in the treatment of Rockwood type-3 to 5 acute acromioclavicular dislocations47. The authors reviewed 5,362 studies and included 26 studies representing 1,581 patients, and they found that techniques with acromioclavicular fixation or graft augmentation appeared to yield the best functional outcomes and the lowest coracoclavicular distance and recurrence of joint dislocation at the final follow-up, but involved longer operative times. Calcific Tendinopathy Calcific tendinopathy is a painful condition whose cause is unknown, although multiple theories have been proposed. Multiple noninvasive treatment options are the initial standard of care, but injections and even surgical treatment are considered for recalcitrant cases. The authors of a recent double-blinded RCT sought to determine the effect of ultrasound-guided lavage with corticosteroid injection for calcific tendinopathy48. A total of 222 patients were randomized to 1 of 3 groups: (1) ultrasound-guided lavage of the calcific deposit followed by subacromial cortisone injection, (2) sham lavage followed by cortisone injection, and (3) sham lavage followed by lidocaine injection. All patients performed structured physical therapy for 8 weeks after the injections. Neither lavage plus corticosteroid nor sham lavage plus corticosteroid was superior to sham treatment at 4 months or 2 years. Angileri et al. examined nonoperative treatment compared with operative treatments for calcific tendinopathy49. Their systematic review and meta-analysis examined the outcomes and complications of nonoperative intervention options (extracorporeal shock wave therapy or ultrasound-guided needling) and operative intervention options (surgical excision). Their review included 27 studies involving 2,212 nonoperatively treated patients and 140 operatively treated patients. Both nonoperative treatments and surgical intervention resulted in clinically important improvements in function and pain. However, surgical intervention resulted in larger improvement in functional outcome scores and pain reduction. It is important to note that none of the included studies directly compared nonoperative treatment with operative treatment. Based on the findings, the authors advised that the nonoperative treatments are reasonable to use as first-line treatment, but surgical intervention remains an option for chronic or recalcitrant cases. Elbow Lateral epicondylitis is a frustrating condition for patients and surgeons, given the chronicity of symptoms. Two systematic reviews and meta-analyses recently explored the use of PRP for lateral epicondylitis. Xu et al. included 11 RCTs comparing PRP with cortisone injection50. Between 2 and 6 months, the differences between PRP and cortisone injection were not significant. In the short term (<2 months), pain relief and functional improvements were better with cortisone injections, whereas the longer-term (>6 months) results for functional improvement and pain relief were better with PRP. Hohmann et al. found similar results in their systematic review and meta-analysis51. Their analysis included 13 Level-I or II studies and concluded that PRP was superior to cortisone at 3 and 6 months but not at 1 month. Elbow trauma is a challenging field because of the particular nature of posttraumatic mobilization and the proclivity of the joint toward posttraumatic stiffness. A recent systematic review examined 11 studies comparing early mobilization (active motion before 14 days) with late mobilization (active motion after 14 days)52. The authors determined that early mobilization demonstrated a higher pooled mean Mayo Elbow Performance Score (MEPS) without an increased incidence of instability as compared with later mobilization. Heterotopic ossification is another challenge in managing elbow trauma. One RCT compared indomethacin with placebo medication in 164 patients with elbow trauma53. At 1 year, the authors did not find any difference in the incidence of heterotopic ossification, nor did they see any difference in outcome scores, range of motion, or the incidence of nonunion. A primary surgical aim in elbow trauma is to achieve secure fixation so as to allow early mobilization and prevent the postoperative challenges of stiffness and heterotopic ossification. Multiple fixation methods have been described to achieve this aim for a variety of elbow fracture types. Avisar et al. compared olecranon fracture fixation with tension band and plate fixation in an RCT54. This study ultimately included only 23 patients in the tension-band group and 19 patients in the plate-fixation group. Range of motion and PROMs were not different, but the rate of symptomatic implant removal was higher in the tension-band group and the risk of postoperative infection was higher in the plate-fixation group. Treatment options become more varied in more complex elbow fractures. One multicenter RCT compared elbow hemiarthroplasty with total elbow arthroplasty for unreconstructible distal humeral fractures55. There were no differences in the elbow range of motion or outcome measures (Disabilities of the Arm, Shoulder and Hand [DASH] Questionnaire and MEPS) at the minimum follow-up of 2 years in patients ≥60 years of age. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 2 other articles relevant to shoulder and elbow surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Dubin JA, Mirkin Y, Sax OC, Monarrez R, Chen Z, Bains SS, Hameed D, Mont MA. Core decompression is superior to nonoperative management for humeral head osteonecrosis: a systematic review. J Shoulder Elbow Surg. 2023 Oct;32(10):2192-200. Osteonecrosis of the shoulder remains a very challenging condition for patients due to the substantial pain associated with the condition and for the surgeon, given few predictable treatment options. Dubin et al. sought to compare core decompression with nonoperative treatment for osteonecrosis of the humeral head. The authors performed a systematic review to evaluate these treatments for the following outcomes: progression to further procedures such as shoulder arthroplasty versus lack of need for further intervention, patient-reported pain and functional scores, and radiographic outcomes. A total of 15 studies were included, 9 studies with 291 patients who underwent core decompression and 6 studies with 359 patients who underwent nonoperative treatment. The mean follow-up was 8.1 years for both. In the core decompression group, 76.6% avoided further procedures in stage I through stage III. For stage-III shoulders, 63% avoided shoulder arthroplasty. In the nonoperative management group, 13% avoided further procedures. Clinical outcome measurements improved for 7 of the 9 core decompression studies and 1 of 6 nonoperative studies. The core decompression group showed less radiographic progression (24.2%) compared with the nonoperative group (52.3%). The authors suggest that core decompression is an effective treatment to avoid progression of osteonecrosis and progression to arthroplasty. This study guides the understanding and potential management of a very challenging condition. Lowry V, Lavigne P, Zidarov D, Matifat E, Cormier AA, Desmeules F. A systematic review of clinical practice guidelines on the diagnosis and management of various shoulder disorders. Arch Phys Med Rehabil. 2024 Feb;105(2):411-26. There are a great variety of shoulder conditions causing pain or dysfunction and, given the diversity of pain generators, accurate evaluation, diagnosis, and treatment are critical. Clinical practice guidelines (CPGs) are recommendations designed to optimize patient care, directed by a systematic review of available evidence. Lowry et al. performed a systematic review of CPGs on common shoulder disorders. The authors evaluated the CPG methodological quality with the AGREE II checklist. In their review, the authors found that only 46% of CPGs were high-quality. There were better evidence and agreement on workup or diagnosis for nonoperative treatments than for operative treatments. There was agreement among the CPGs on recommending that magnetic resonance imaging not be utilized to manage early shoulder pain. Likewise, there was agreement among the CPGs that acetaminophen, oral NSAIDs, and rehabilitation including exercises be recommended to treat shoulder pain disorders. CPGs were less consistent across surgical treatments. However, the authors found that CPGs had more consistent agreement with regard to surgical referral in cases in which conservative treatments failed and for a full-thickness acute rotator cuff tear or glenohumeral dislocation in young patients. There remains a need for rigorous evidence-based CPGs to guide the evaluation, diagnosis, and treatment of painful shoulder conditions.