What are the indications for shoulder arthroscopy?

Indications for Shoulder Arthroscopy

Shoulder arthroscopy is indicated for patients with labral tears, rotator cuff pathology, shoulder instability, and other intra-articular conditions that have failed conservative management for 3-6 months or have significant functional limitations despite therapy. 1

Primary Indications

Shoulder arthroscopy is recommended for:

1. Labral Tears

   • Anterior labral tears (Bankart lesions) in patients with shoulder instability
   • Superior labrum anterior-posterior (SLAP) lesions
   • Posterior labral tears

2. Rotator Cuff Pathology

   • Partial-thickness rotator cuff tears that fail conservative management
   • Debridement of massive, otherwise unrepairable rotator cuff tears for pain relief
   • Note: Routine repairable full-thickness tears are often better treated by open reconstruction

3. Shoulder Instability

   • Recurrent anterior dislocation or subluxation (92% correlation with anterior inferior labral tears) 2
   • Assessment of glenohumeral ligaments' role in instability
   • Bankart repair for anterior shoulder instability

4. Other Conditions

   • Removal of loose bodies
   • Treatment of calcific tendinitis
   • Irrigation of septic arthritis
   • Acromioplasty for impingement syndrome
   • Synovectomy for rheumatoid arthritis and other synovial conditions
   • Capsular release for adhesive capsulitis (frozen shoulder)

Diagnostic Value

Arthroscopy offers superior diagnostic capabilities compared to conventional imaging:

• More reliable than CT scan, ultrasound, or arthrography 3
• Allows direct visualization of intra-articular structures
• Permits assessment of mechanical derangement inside the joint
• Can identify rotator cuff lesions not detectable by arthrography
• Enables evaluation of biceps tendon pathology

Decision-Making Algorithm

1. Initial Evaluation

   • Begin with plain radiographs (AP view, Grashey view, axillary lateral or scapular Y view)
   • Perform thorough physical examination including range of motion, strength testing, and special tests

2. Advanced Imaging

   • MR arthrography (gold standard for labral tears with 86-100% sensitivity)
   • Standard MRI without contrast (highly effective for soft tissue pathology)
   • CT arthrography (if MRI is contraindicated)

3. Consider Arthroscopy When:

   • Conservative measures have failed after 3-6 months
   • Significant functional limitations persist despite therapy
   • Evidence of instability exists
   • Patient is young and active with high physical demands
   • Accurate diagnosis cannot be established with non-invasive methods

Clinical Pearls and Pitfalls

• Major Advantage: Arthroscopy allows both diagnosis and treatment in the same session 3
• Technical Considerations: Some arthroscopic procedures (like rotator cuff repair or labral stapling) are technically demanding and may have higher complication rates
• Best Results: Simpler procedures like irrigation, trimming of labral flaps, and removal of loose bodies have excellent outcomes 3
• Throwing vs. Non-throwing Athletes: There are significant differences in pathology patterns between these groups, with partial rotator cuff tears being more common in throwers 2
• Diagnostic Accuracy: Arthroscopy has greater diagnostic accuracy than conventional imaging techniques 3, 4
• Surgical Planning: Arthroscopic diagnosis can direct open procedures to the essential areas, minimizing operative trauma 3

Treatment Considerations

• For impingement syndrome, arthroscopic acromioplasty has been shown to be safe, effective, and possibly better than conventional surgery 4
• In older patients with rotator cuff pathology, arthroscopic debridement is very effective at relieving pain 4
• Arthroscopic removal of loose bodies and torn glenoid labrum is recommended over open surgery 4
• The role of arthroscopy in frozen shoulder is not clearly established, though it is a valuable diagnostic tool 4

By following this structured approach to shoulder arthroscopy indications, clinicians can optimize patient outcomes while minimizing unnecessary procedures.