Orthopaedic Shoulder Surgery: Diagnosis and Treatment Methods

Orthopaedic shoulder surgery is the field of orthopaedics concerned with diagnosing and treating conditions affecting the shoulder joint and its surrounding bones, cartilage, muscles, tendons and ligaments.

Summary: The decision to perform shoulder surgery considers the cause of symptoms, examination and imaging findings, and the response to suitable non-surgical treatments together. Not every painful shoulder or tear seen on imaging requires an operation. Activity modification, exercise, physiotherapy, pain management and selected injections may form part of treatment. When surgery is needed, arthroscopic or open techniques are chosen according to the structure requiring repair. Outcomes and recovery vary between individuals; a particular result cannot be guaranteed.

The shoulder comprises mobile structures around the humerus, scapula and clavicle. The same complaint of ‘I cannot raise my arm’ may stem from a tendon tear, joint stiffness, dislocation, osteoarthritis or nerve involvement originating in the neck. Decisions therefore rely not only on an MRI report, but on the course of pain, examination findings, weakness and everyday function.

What Is Orthopaedic Shoulder Surgery and Which Conditions Does It Cover?

Orthopaedic shoulder surgery encompasses assessment of problems affecting the shoulder joint and its surrounding bones, cartilage, tendons, muscles, ligaments and nerves. Shoulder dislocations, rotator cuff tears, labral damage, fractures, osteoarthritis and impingement are assessed within this field. The word ‘surgery’ does not mean that every patient will have an operation.

Although the shoulder functions as a single joint, it depends on coordination between several anatomical joints and the functional connection between the scapula and rib cage. A problem in one of these structures may cause pain, restricted movement, weakness, catching or a sensation that the shoulder may dislocate.

The main groups of conditions are:

• Rotator cuff disorders: Tendon strain, partial tears or full-thickness tears
• Shoulder dislocations and instability: Dislocation of the joint, recurrent dislocations or a feeling of instability
• Labral and ligament injuries: Damage to the cartilage ring around the joint or the ligaments that provide stability
• Cartilage wear: Deterioration of the articular surfaces and shoulder osteoarthritis
• Fractures: Injuries involving the humerus, clavicle or scapula
• Impingement and tendon problems: Mechanical interaction of tendons with surrounding tissues during certain movements
• Problems in children and adolescents: Trauma, growth plate injuries and sports-related loading

Diagnosis considers age, activities, the dominant arm, examination and imaging findings together. Outcomes of any surgical or interventional procedure may vary between individuals.

How Are Shoulder Pain and Restricted Movement Diagnosed?

The diagnosis of shoulder pain combines the symptom history, physical examination and appropriate imaging. Questions address pain onset, its relation to trauma, its night-time pattern and the movements that worsen it. Active and passive range of motion, muscle strength, joint stability and nerve and vascular function are checked.

Assessment does not focus solely on the painful point. Nerve involvement originating in the neck, elbow problems and certain conditions around the chest may mimic shoulder pain.

• History: The clinician investigates whether symptoms began suddenly or gradually and whether they relate to a fall, traction or repetitive overhead movements.
• Movement examination: The patient's active movements are compared with passive movements performed by the doctor. Restriction of both may suggest stiffness, while greater limitation of active movement may suggest impaired muscle or tendon function.
• Strength and stability: The rotator cuff, ligaments and shoulder stability are assessed using different manoeuvres.
• Pain monitoring: A numerical pain scale may be used during follow-up, but the score alone does not establish a diagnosis or determine whether surgery is needed.
• Imaging: X-rays may help assess bones and joint relationships, ultrasound can examine tendons during movement, and MRI can assess muscles, tendons, the labrum, ligaments and cartilage.

A change seen on imaging is not always the source of symptoms. The report should be correlated with painful movements on examination, weakness and difficulties in daily life. Assessment should not be delayed if trauma is followed by deformity, inability to move or inability to bear weight.

What Are the Non-Surgical Treatments for Shoulder Conditions?

Non-surgical treatment includes activity modification, individually tailored exercise, physiotherapy, pain management and injections in selected cases. Alongside reducing pain, the aims are to maintain movement, improve muscle control and support everyday function. Not every patient needs to try every option; an appropriate plan is based on the diagnosis.

Some rotator cuff tears can be managed non-surgically; age, trauma history, tear characteristics and weakness influence the choice (PMID 37003656). Findings from studies comparing surgical and conservative approaches should also be interpreted in the context of patient characteristics and follow-up conditions (PMID 27385156).

• Activity modification: Repetitive overhead movements and heavy loads may be reduced temporarily. Safe movement is maintained because prolonged complete immobilisation of the shoulder can increase stiffness.
• Exercise and physiotherapy: Work focuses on range of motion, scapular control, rotator cuff endurance and coordination around the shoulder. Exercises are performed as demonstrated by the physiotherapist or doctor.
• Pain management: Cold or heat applications and suitable medicines may be considered. Prescription medicines, blood thinners and other treatments should not be altered or stopped on the person's own initiative.
• Injections: Corticosteroids may be considered for short-term relief in selected cases. Suitability, potential benefits and risks are assessed according to the diagnosis; different injection types do not have the same level of evidence.
• Reassessment: The plan is reviewed if weakness persists despite reduced pain, movement becomes more restricted or function deteriorates.

Treatment approach	Main aim	Situations in which it is considered
Activity modification	Reducing irritating loads	Pain and strain that increase with loading
Exercise and physiotherapy	Improving movement, strength and control	Tendon problems, stiffness and instability
Injection	Managing symptoms during an appropriate phase	Cases considered suitable after examination
Regular follow-up	Monitoring changes in strength and function	Patients with persistent or worsening symptoms

An injection is also an invasive procedure; risks such as infection, bleeding and a temporary increase in symptoms should be discussed during individual assessment.

When Is Shoulder Surgery Considered?

Shoulder surgery is considered when structural damage significantly impairs function, recurrent instability develops, or suitable non-surgical approaches are insufficient or inappropriate. The decision is not based solely on pain or MRI findings; weakness, tissue damage, age and everyday needs are considered together.

Situations that may prompt surgical assessment include:

• A substantial tendon rupture, displaced fracture or joint damage after trauma
• Recurrent shoulder dislocations and instability during everyday movements
• Persistent or progressive loss of strength and function associated with a tear
• Marked restriction of movement due to advanced joint wear
• Symptoms affecting daily life despite individually tailored rehabilitation
• Suspected infection or nerve or vascular involvement

Muscle strength can be graded during examination, but a single strength score does not determine the decision to operate. Monitoring may be considered for someone who can use the arm functionally despite a tear on imaging. Sudden weakness after trauma or a displaced injury may require earlier surgical assessment.

Alongside the potential benefits of the planned procedure, infection, bleeding, nerve or vascular injury, stiffness, clot formation, failure of the repair to heal and the need for further surgery should be discussed. Although venous thromboembolism may be uncommon in shoulder surgery, it is a serious complication (PMID 34535553). A particular outcome cannot be guaranteed.

What Is Shoulder Arthroscopy and How Is It Performed?

Shoulder arthroscopy is a minimally invasive technique that uses a camera to view the joint and surrounding structures, with surgical instruments introduced through small portals. Under anaesthesia, the damaged structures are assessed; tendon repair, labral or ligament fixation and procedures addressing problems inside the joint may be performed when needed.

Depending on the planned procedure, the patient may be positioned sitting up or lying on their side. Positioning, anaesthesia and the choice of portals are fundamental to safe access (PMID 23728958).

The main steps are as follows:

1. The shoulder and side to be operated on are confirmed, and anaesthesia and positioning preparations are completed.
2. Small portals are created for the camera and fine surgical instruments.
3. The cartilage, labrum, ligaments, tendons and surrounding joint structures are examined systematically.
4. Repair is performed according to the damage identified in planning and confirmed during the procedure.
5. The portals are closed, and sling use and rehabilitation are planned according to the procedure performed.

Arthroscopy is not just an imaging procedure; it may allow identified problems to be treated during the same operation. However, not every shoulder condition is suitable for arthroscopy. Open surgery may be considered for advanced cartilage loss, certain fractures, extensive bone loss or conditions requiring joint replacement.

Risks of arthroscopy include infection, bleeding, clots, nerve or vascular injury, stiffness, persistent pain, failure of the repair to heal and the need for further surgery. The scope of the procedure depends on tissue quality and coexisting conditions.

How Are Shoulder Dislocations, Ligament Injuries and Muscle Tears Treated?

Shoulder dislocations, ligament injuries and muscle or tendon tears are treated according to the type of damage, joint stability, weakness and the person's movement requirements. Reduction and rehabilitation may be the main approach after a first dislocation. Surgery may be considered for recurrent dislocations, bone loss or marked loss of function.

A new shoulder dislocation should be assessed by trained healthcare personnel. Trying to put the shoulder back into place without assistance can worsen a fracture or vascular or nerve injury. After reduction, circulation, sensation, muscle strength and associated fractures are checked again. Age, mechanism of injury and structural damage are important when treating a first dislocation (PMID 25559018; PMID 34423930).

• Recurrent dislocation: Labral and ligament damage may be repaired arthroscopically or through open surgery. Bone loss can alter the choice of technique.
• Ligament injury: Controlled exercise may be used for partial, stable injuries. Marked instability may prompt surgical assessment.
• Rotator cuff tear: Affects the tendons of the muscles that move and stabilise the shoulder. Trauma, tear depth, tissue quality and weakness guide treatment.
• Rehabilitation: For shoulder instability, rehabilitation works on strength, joint position sense and movement control (PMID 37003660).

One or more signs such as severe pain, deformity, inability to move or inability to bear weight require emergency assessment for a fracture or dislocation.

How Are Shoulder Problems Assessed in Children?

Shoulder problems in children are assessed by considering the mechanism of injury, age, growth plate status, pain location and loss of movement together. In addition to the shoulder, examination checks the neck, elbow, hand circulation, sensation and muscle strength. Imaging is chosen according to suspected fracture, dislocation or soft-tissue injury.

A child's shoulder is not simply a smaller version of an adult shoulder. Because the growth plates are open, trauma may affect the growing region of the bone before damaging ligament tissue.

The following information is important in evaluation:

• Falls, collisions, pulling on the arm or repetitive throwing movements
• Swelling, tenderness, deformity and range of motion
• Circulation, sensation and muscle strength in the hand and fingers
• Previous dislocations or generalised joint laxity
• Type of sport, training load and rest schedule
• Fever, night pain or a recent infection

If a fracture or dislocation is suspected, X-rays from different directions may be needed. Ultrasound and MRI can be used for soft tissues, and CT in selected cases requiring detailed assessment of bone.

Go to an emergency department if one or more signs such as deformity, severe pain, inability to move or bear weight, a cold, pale or bluish hand, new numbness or weakness is present. Treatment may range from observation and rehabilitation to immobilisation or surgery.

Recovery and Return to Daily Life After Shoulder Surgery

Return to daily life after shoulder surgery progresses in stages according to the procedure, healing of the repaired tissue and rehabilitation plan. Even after arthroscopy, the arm needs protection and a controlled increase in loading. There is no fixed period that applies to everyone for sling use, return to work, driving or sport.

In the early period, follow the prescribed treatment and dressing instructions, and support the arm as directed. The timing of passive, assisted or active movements varies with the repair performed; exercises should remain within the limits demonstrated by the surgeon and physiotherapist.

• Sling: How long it is worn and when it can be removed depend on the procedure. A sling may affect balance on stairs, when bathing and when dressing.
• Everyday tasks: Avoid straining the operated arm while dressing or performing personal care; a physiotherapist should demonstrate safe techniques.
• Driving: Do not drive while using a sling, if the arm cannot fully control the vehicle, if emergency braking or avoidance manoeuvres cannot be performed safely, or while affected by medicines causing sleepiness or dizziness.
• Medication safety: Do not stop prescription medicines, antibiotics or blood thinners on your own initiative to enable driving or for any other purpose.
• Return to work and sport: Range of motion, strength, control and the demands of the activity are assessed together.

If one or more of the following signs are present, call 112 immediately or go to an emergency department:

• Sudden shortness of breath, chest pain, fainting, coughing up blood, or rapid heartbeat
• Severe pain that is disproportionate to the injury, persistent or rapidly worsening
• Pain that increases markedly with passive movement, tense swelling, numbness or weakness
• Coldness, paleness, discolouration, new numbness or loss of strength in the limb
• New confusion or speech that makes no sense; fever is not required
• Severe pain, deformity, inability to move or inability to bear weight
• Uncontrolled bleeding

One or more of the following signs requires medical assessment the same day:

• One-sided leg swelling, pain, or calf tightness
• Increasing redness, warmth, swelling or discharge at the wound; fever need not be present
• Wound edges opening
• Fever of 38°C or above, persistent fever, chills or deterioration in general condition
• New severe pain or inability to bear weight after a fall or impact

If discharge instructions specify a lower temperature threshold, follow that threshold.

Frequently asked questions

This section gives brief answers to common questions about shoulder pain and surgical assessment. The answers provide general information; treatment cannot be chosen without examination, imaging and knowledge of the person's health. The suitability of non-surgical approaches and the need for surgery are assessed individually.

Does an orthopaedic doctor assess shoulder problems?

An orthopaedic and trauma specialist assesses shoulder conditions, injuries, weakness and restricted movement. Depending on examination findings, X-rays, ultrasound or MRI may be requested. After diagnosis, activity modification, physiotherapy, medication, selected injections and surgical options are considered together with their suitability and risks.

Which doctor should assess a suspected shoulder tear?

An orthopaedic and trauma specialist can be consulted for a suspected muscle or tendon tear. Assessment examines the mechanism of injury, tear location and characteristics, muscle strength, range of motion and loss of everyday function. A tear on imaging does not by itself mean surgery is necessary; the findings are correlated with examination.

Does the orthopaedic department see children?

Orthopaedic departments assess congenital and acquired musculoskeletal problems in children. Childhood shoulder dislocations, fractures, growth plate injuries and sports-related problems require an age-appropriate approach. Depending on the problem, assessment by a specialist working in paediatric orthopaedics may be requested.

What criteria should be considered when choosing a doctor for shoulder surgery?

Specialist qualifications in orthopaedics and traumatology, professional training in shoulder surgery and verifiable academic work may be considered. It is important that the doctor clearly explains the diagnosis, non-surgical options, the reason for the proposed procedure, alternatives and potential risks. Patient reviews, numerical praise and promises of results are not reliable criteria for medical decisions.

What is the difference between shoulder arthroscopy and open surgery?

Arthroscopy accesses the joint through small portals using a camera and surgical instruments; open surgery provides direct access through a larger incision. The choice depends on the condition, bone loss, tear characteristics and required repair. Arthroscopy is not suitable for every situation and does not guarantee a particular outcome.

Do shoulder dislocations always require surgery?

Shoulder dislocations do not always require surgery. After a first dislocation, assessment considers age, fractures or ligament damage, nerve and vascular status, joint stability and the person's activities. Reduction, short-term protection and physiotherapy may be sufficient. Surgery may be considered for recurrent dislocation, bone loss or significant structural damage.

Are shoulder and elbow arthroscopy performed using the same surgical technique?

Shoulder and elbow arthroscopy share the principle of accessing the joint with a camera and small surgical instruments, but they are not the same procedure. Joint anatomy, portals, nerve and vascular structures, patient positioning and the conditions treated differ. The surgical plan, risk assessment and rehabilitation programme are therefore specific to each joint.

This information is for educational purposes and does not replace diagnosis and treatment. Please consult your doctor about your symptoms.