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Critical shoulder angle is an effective radiographic parameter that is associated with rotator cuff tears and osteoarthritis: a systematic review
  1. Gabriel Kuper1,
  2. Ajaykumar Shanmugaraj1,
  3. Nolan S Horner1,
  4. Seper Ekhtiari1,
  5. Nicole Simunovic1,
  6. Edwin R Cadet2,
  7. Olufemi R Ayeni1
  1. 1 Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
  2. 2 Raleigh Orthopaedic Clinic, Raleigh, North Carolina, USA
  1. Correspondence to Dr Olufemi R Ayeni, Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, McMaster University, Hamilton, ON L8N 3Z5, Canada; ayenif{at}


Importance The critical shoulder angle (CSA) is a relatively new radiographic parameter correlated with pathologies such as rotator cuff tears and osteoarthritis.

Objective The purpose of this systematic review was to: (1) determine the degree of correlation between the CSA and shoulder pathologies, (2) determine the reliability of measuring CSA between (inter-rater reliability) and within (intrarater reliability) clinicians, (3) assess the accuracy of different imaging modalities used for measuring the CSA and (4) determine the association of CSA with patient outcomes after surgery.

Evidence review The electronic databases MEDLINE, EMBASE and PubMed were searched in March 2018 for relevant studies. The results are presented in a narrative summary.

Findings A total of 26 studies and 4563 patients satisfied the inclusion criteria. The majority of CSAs were measured using radiographs (98.2%) in neutral rotation (72.9%). Significant associations (p<0.05) were found between lower CSAs (<30°) and osteoarthritis, and higher CSAs (>35°) with primary rotator cuff tears and the risk of re-tear following a repair. The CSA has excellent intrarater (intraclass correlation coefficient (ICC) 0.903 to 0.996) and inter-rater reliability (ICC 0.869 to 0.980) when measured with radiographs. High variability in measurements was found when using MRI. The CSA, however, is not a clear, significant independent predictor (p>0.05) of outcomes after the surgical management of shoulder pathologies.

Conclusions and relevance The CSA is an effective radiographic parameter that is associated with rotator cuff tears and osteoarthritis. Lower CSAs (<30°) are associated with osteoarthritis, whereas higher CSAs (>35°) are associated with primary rotator cuff tears and re-tear after arthroscopic repair. Currently, there is a limited predictive value of the CSA in patient-reported outcomes after rotator cuff repair. The CSA is measured with high intrarater and inter-rater reliability for both radiographs and CT scans. Measuring the CSA using radiographs with the arm in the neutral rotation is currently recommended. Future studies are required to further investigate how best use the CSA to guide patient management and its predictive value.

Level of evidence IV.

  • shoulder
  • osteoarthritis
  • rotator cuff
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  • Contributors GNK, AS and NSH: carried out the search, screening process, assessment of study quality, completed the data abstraction. GNK: drafted the manuscript with assistance from AS, NSH, SE and EC. ORA and NSH: conceived the study, and provided key expert input and editing throughout the process. NS: provided feedback on methodological and statistical aspects. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests ORA is an educational consultant for the Speakers Bureau of ConMed.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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