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Soft tissue lesions of the shoulder

Last updated: November 9, 2023

Summarytoggle arrow icon

Soft tissue lesions of the shoulder involve the shoulder's ligaments, tendons, cartilage, and/or capsule. The rotator cuff is the most commonly affected structure. Rotator cuff disease includes a range of pathologies from tendinopathy to rotator cuff tears and is commonly associated with subacromial bursitis and biceps tendinopathy. Many patients present with subacromial impingement syndrome, caused by inflammation of subacromial structures (e.g., rotator cuff tendons, subacromial bursa, and long head of the biceps) and subsequent narrowing of the subacromial space. Other frequently encountered soft tissue lesions of the shoulder include adhesive capsulitis, calcific tendonitis, and labral tears. Soft tissue lesions may result from overuse (e.g., repetitive overhead arm movements in young athletes) or degenerative or inflammatory processes. Symptoms of soft tissue lesions of the shoulder include pain with movement (usually shoulder abduction), nocturnal pain, tenderness, and/or restricted range of motion (ROM). A clinical diagnosis can often be made after an orthopedic shoulder examination that utilizes provocation tests for specific shoulder injuries. Imaging tests, primarily MRI, are usually obtained to make a definitive diagnosis and/or plan for surgery, if necessary. Management is typically conservative: activity modification, NSAIDs, and physical therapy. Intraarticular corticosteroid injections and/or surgery may be required if symptoms do not resolve with conservative measures. Early surgical intervention is indicated for labral tears causing instability and acute or large rotator cuff tears, especially in active individuals.

See also “Biceps tendonitis,” “Subacromial bursitis,” “Acromioclavicular joint injury,” and “Shoulder dislocation.”

Overviewtoggle arrow icon

General principles

Management approach [4][5]

Overview of soft tissue injuries and pain syndromes

Overview of shoulder soft tissue lesions [4][5][9][10]
Affected structures Positive provocation tests and examination findings Imaging

Subacromial impingement syndrome

Rotator cuff tendinopathy

Rotator cuff tear

Bicipital tendonitis

Calcific tendonitis
  • X-ray shows calcific deposits [13][14]
  • US if x-ray is equivocal
  • MRI not routinely used
Adhesive capsulitis [15]
  • Restricted passive ROM
  • Only to rule out an alternative diagnosis [16]
Labral tears
Osteoarthritis
Acromioclavicular joint injury

Shoulder dislocation

Always compare the affected shoulder to the contralateral shoulder when performing an orthopedic shoulder examination.

Etiologytoggle arrow icon

  • Overuse: especially with activities involving repetitive overhead arm movement, e.g., baseball, volleyball
  • Degenerative processes (especially in older individuals)
  • Inflammation
  • Trauma
  • Systemic diseases (See “Adhesive capsulitis.”)
  • Postoperative changes, e.g., inflammation, fibrous tissue, implants

Clinical featurestoggle arrow icon

The following are nonspecific features. Provocative clinical examination and diagnostic tests are usually required to identify the underlying condition (see “Overview of shoulder soft tissue lesions).

Diagnosticstoggle arrow icon

The clinical examination can guide early management (see “Overview of shoulder soft tissue lesions”). Imaging is usually obtained to confirm the diagnosis and/or rule out alternative diagnoses. [6][7][9]

Clinical evaluation

X-ray [6][7]

  • Initial imaging for all patients
  • Required views: standard AP, AP glenoid , trans-scapular lateral , and axillary [11][17]
  • Often normal
  • Findings may include:

MRI [6]

  • Gold standard imaging for evaluation of the shoulder
  • Indications: diagnostic uncertainty or symptoms that persist following conservative treatment
  • Supports surgical planning

Ultrasound [18]

Differential diagnosestoggle arrow icon

Treatmenttoggle arrow icon

The majority of patients with soft tissue injuries of the shoulder can be managed initially with conservative therapy. [5][20]

Conservative therapy of shoulder soft tissue lesions

Adequate pain control is necessary to optimize the results of physical therapy. [21]

Wait at least 4 months between glucocorticoid injections to avoid weakening the tendons. [5]

Surgical treatment

Subacromial impingement syndrometoggle arrow icon

Background

Clinical features

  • Pain on movement that is worsened by overhead activities (e.g., combing hair or reaching up to a cupboard)
  • Nocturnal exacerbation of pain, especially when lying on the affected shoulder
  • Pain and restriction of active movement between 60 and 120°
  • Symptoms typically develop over weeks to months. [24]

Diagnosis [2]

Can be diagnosed clinically

Treatment [2]

Complications

Rotator cuff diseasetoggle arrow icon

General principles [28][29]

Rotator cuff tendinopathy [29][30]

Rotator cuff tear

Rotator cuff tears are often preceded by rotator cuff tendonitis and most commonly involve the supraspinatus tendon. [31]

  • Etiology [28][29]
    • Chronic degenerative tear (most common): usually seen in individuals > 40 years of age and/or performing repetitive overhead movements (e.g., infraspinatus tear in baseball pitchers) [11]
    • Acute traumatic injury (∼ 10% of cases): usually seen following a fall or dislocation, often in young adults [11]
  • Clinical features [11]
    • Acute rupture: sudden severe pain and loss of strength
    • Degenerative rupture: chronic pain; loss of strength is less pronounced than with acute tear
    • Restricted active ROM (especially if passive ROM is normal)
  • Diagnostics [6]
  • Treatment
    • All patients: Optimize conservative therapy of shoulder soft tissue lesions.
    • Acute injury: Immobilize for comfort and consult orthopedic surgery early.
    • Surgical repair ; [5][32][33]
      • Typically considered for:
        • Younger patients (< 65 years old) with:
          • Acute traumatic full-thickness tears
          • Chronic full-thickness tears [33]
        • Significantly reduced arm function
        • High risk of tear progression
        • Insufficient improvement after 3–6 months of conservative treatment [20]
      • Typically inappropriate for:
        • Sedentary and older patients (> 65 years) [5]
        • Most partial-thickness tears
  • Complications

Early surgical repair of rotator cuff repairs is often preferred in young and/or physically active patients. [11][34]

Calcific tendonitis of the shoulder [13][14]

Adhesive capsulitis (frozen shoulder)toggle arrow icon

Glenoid labrum injuriestoggle arrow icon

The glenoid labrum can be damaged by an acute injury or overuse of the shoulder and arm.

Superior labrum from anterior to posterior lesion (SLAP lesion) [39]

Bankart lesion [22][23]

Referencestoggle arrow icon

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