Soft tissue lesions of the shoulder

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.”

General principles

• The majority of shoulder pain is the result of rotator cuff disease, a spectrum of pathophysiology ranging from subacromial impingement to complete tears of rotator cuff tendons (most commonly the supraspinatus).
• Other sources of pain include the: ^[1][2][3]
  • Biceps tendon
  • Glenohumeral joint capsule
  • Subacromial bursa
  • Acromioclavicular (AC) joint
  • Glenohumeral joint

Management approach ^[4][5]

• Perform a thorough orthopedic shoulder examination.
• Perform a neurovascular examination of the entire arm.
• Obtain standard x-rays in all patients. ^[5][6]
• Consider MRI or ultrasound imaging if the diagnosis remains unclear. ^[6][7]
• Begin conservative management, unless there is an indication for surgery.
• Consult orthopedics urgently for the following: ^[8]
  • Suspected joint infection, e.g., warmth, red skin, systemic symptoms
  • Unreduced dislocation
  • Acute traumatic rotator cuff tear
  • Mass on examination or imaging

Overview of soft tissue injuries and pain syndromes

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

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

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).

• Painful active and/or passive abduction ^[4][5]
  • May be aggravated by internal and/or external rotation
  • Localization of pain over the deltoid with shoulder abduction suggests rotator cuff disease.
  • Anterior superior pain suggests acromioclavicular joint pathology.
• Patient apprehension before shoulder movement
• Tenderness, e.g., subacromial
• Limited ROM (active and/or passive)
• Weakness

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

• Orthopedic shoulder examination should include the following:
  • Shoulder mobility testing
  • Shoulder impingement tests
  • Shoulder instability tests
  • Rotator cuff examination
  • Proximal biceps tendon examination
• Neurovascular examination
  • Check upper extremity capillary refill time and pulses at the radial artery, ulnar artery, and brachial artery.
  • Identify signs of median nerve palsy, radial nerve palsy, ulnar nerve palsy, or axillary nerve palsy.

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:
  • Degenerative changes or narrowing of the subacromial space (e.g., due to structural abnormalities of the acromion)
  • Calcification of the supraspinatus tendon in calcifying tendinitis
  • Alternative causes of shoulder pain (e.g., pathological fracture)

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]

• Provides real-time imaging during provocation maneuvers and is used to guide interventional treatment
• Accuracy comparable to MRI for rotator cuff tears, bursitis, and other shoulder soft tissue lesions ^[9][19]
• Findings may include:
  • Damage to the soft tissue structures (bursae, rotator cuff tendons)
  • Bicep tendon rupture, subluxation, or dislocation (e.g., acromioclavicular or glenohumeral joints)

• Fracture and/or dislocation
• Osteoarthritis
• Brachial plexus neuritis
• Cervical radiculopathy
• Thoracic outlet syndrome
• Fibromyalgia

The differential diagnoses listed here are not exhaustive.

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

• Utilize the POLICE principle for acute injuries or inflammation.
• Manage acute pain, e.g., NSAIDs.
• Modify activities, especially those involving overhead movements.
• Consult physical therapy.
• Consider subacromial glucocorticoid injections for refractory chronic pain.

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

• Indications ^[5]
  • Acute injury with full-thickness rotator cuff tear and/or shoulder dislocation
  • Acute labral injuries with recurrent shoulder dislocation ^[22][23]
  • Chronic full-thickness rotator cuff tear(s) in individuals < 65 years of age
  • Symptoms that persist after 3–6 months of conservative treatment ^[20]
• Technique: depends on the specific condition
  • Arthroscopic surgery, e.g., decompression of subacromial impingement
  • Open arthrotomy, e.g., open rotator cuff repair
  • Manipulation under anesthesia, e.g., for adhesive capsulitis

Background

• Definition
  • A syndrome of pain during shoulder abduction, forward flexion, and/or extreme adduction associated with narrowing of the subacromial space
  • Encompasses a spectrum of pathologies, including rotator cuff disease, subacromial bursitis, and biceps tendinopathy ^[2]
• Etiology: repetitive overhead activity or other overuse injuries
• Pathophysiology ^[2]
  • Extrinsic compression: Narrowed subacromial space causes bursitis and tendonitis.
  • Intrinsic compression: Degenerative tendonitis causes glenohumeral changes that narrow the subacromial space.
  • Stages
    1. Degeneration leads to the formation of edema and bleeding in the area of the rotator cuff tendons and subacromial bursa.
    2. Fibrosis of the bursa
    3. Tendon tear or rupture, intermittent bursitis, and pseudoparalysis of the arm

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

• Positive provocative clinical examination
  • Neer test
  • Hawkins test
  • Painful arc test
• X-rays: may show narrowing of acromiohumeral distance, osteoarthritis
• MRI: provides definitive evidence of tendinitis and/or impingement ^[24]
• Subacromial lidocaine injection test ^[25][26]
  • Indication: inability to differentiate between subacromial impingement syndrome and other causes of shoulder pain and/or restricted ROM, e.g., rotator cuff tear, frozen shoulder, glenohumeral joint arthritis ^[27]
  • Technique: subacromial injection of 5 mL of lidocaine or bupivacaine ^[26]
  • Interpretation: Pain relief following injection suggests subacromial impingement syndrome.

Treatment ^[2]

• All patients: Begin conservative therapy of shoulder soft tissue lesions.
• Surgical treatment: if there is no improvement after conservative treatment (e.g., arthroscopic decompression, acromioplasty)

Complications

• Adhesive capsulitis
• Otherwise dependent on underlying pathology
  • See “Rotator cuff disease.”
  • See “Subacromial bursitis.”
  • See “Biceps tendinopathy.”

General principles ^[28][29]

• Rotator cuff disease is a poorly defined collection of traumatic injuries and/or degenerative changes to rotator cuff tendons.
• It includes a spectrum of conditions ranging from tendonitis to rotator cuff tears.
• Comorbid adjacent lesions are common, e.g., subacromial bursitis, biceps tendinopathy.
• Clinical features vary depending on the underlying conditions and course.
  • Subacromial impingement syndrome is a common (but not universal) manifestation of rotator cuff tendinopathy and calcific tendonitis of the shoulder.
  • Loss of active rotator cuff function suggests a rotator cuff tear.

Rotator cuff tendinopathy ^[29][30]

• Definition
  • Inflammatory and/or degenerative changes of one or more rotator cuff tendons
  • Encompasses the spectrum of rotator cuff disease between impingement and rotator cuff tear
• Etiology: acute injury and/or chronic degeneration from overuse
• Clinical features
  • Can present as subacromial impingement syndrome
  • Subacromial tenderness on palpation
  • Referred pain in the deltoid area with overhead activities
  • Possible atrophy of the supraspinatus and infraspinatus muscles
• Diagnosis ^[30]
  • Often a clinical diagnosis based on provocation testing
    • Painful arc test (early finding)
    • Empty can test
    • Infraspinatus test
    • Belly press test
  • MRI or ultrasound findings provide a definitive diagnosis.
• Treatment: : Follow conservative therapy of shoulder soft tissue lesions.
• Complications ^[28]
  • Muscle atrophy or fatty degeneration
  • Rotator cuff tear, rupture, and/or retraction
  • Adhesive capsulitis

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]
  • Positive drop-arm test suggests supraspinatus tear.
  • Provocation tests that may be abnormal (depending on the affected tendon)
    • Empty can test
    • Lift-off test
    • Belly press test
    • Infraspinatus test
  • POCUS: may show full or partial-thickness tears ^[11]
  • X-ray: superior displacement of the humeral head (high-riding humeral head)
  • Ultrasound or MRI: definitive test to determine the location and extent of the rupture
• 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
  • Tear progression ^[5]
  • Adhesive capsulitis

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]

• Etiology: See “Calcific tendonitis” in “BCP crystal deposition diseases.”
• Clinical features
  • Primarily affects rotator cuff tendons causing features similar to rotator cuff tendinopathy.
  • Can occasionally affect the long head of the biceps (see “Biceps tendonitis.”)
• Diagnosis
  • X-rays usually show calcium deposits.
  • Ultrasound or MRI are diagnostic but not required if calcium deposits are seen on x-ray. ^[13]
• Treatment
  • Follow conservative therapy of shoulder soft tissue lesions. ^[13]
  • Physical removal of calcium deposits may be considered if symptoms persist after 6 months of conservative management. ^[14][35]
    • Percutaneous ultrasound-guided barbotage of crystals
    • Arthroscopic surgery
    • Extracorporeal shock wave therapy

• Definition: inflammation and fibrosis of the joint capsule leading to contracture of the shoulder joint
• Epidemiology ^[36]
  • ♀ > ♂
  • Onset > 40 years of age
• Etiology ^[15][16][37]
  • Primary adhesive capsulitis (idiopathic): associated with diabetes mellitus, thyroid disorders, scleroderma, Dupuytren contracture, ASCVD
  • Secondary adhesive capsulitis: associated with previous shoulder injury (e.g., shoulder dislocation, rotator cuff disease), prolonged immobilization, arthroscopic surgery
• Stages
  1. Freezing or painful stage: minimal synovitis with pain, causing a limitation of ROM
  2. Frozen or transitional stage: Pain decreases, but synovitis continues (with axillary adhesions and contraction of the capsule).
  3. Thawing stage: Inflammation decreases and movement slowly improves.
• Clinical features ^[11][36][38]
  • Shoulder pain
    • Most commonly involves the nondominant side
    • May be poorly localized; sometimes pain is referred to the deltoid and bicep
    • More severe at night
  • Stiffness that interferes with activities of daily living
  • Severe restriction of active and passive ROM of the glenohumeral joint in all planes, especially:
    • External rotation
    • Passive abduction (restricted to < 90°)
• Diagnosis
  • Can be diagnosed clinically
  • X-rays are usually obtained to rule out underlying pathology.
  • MRI provides a definitive diagnosis but is typically not required.
• Treatment ^[36][37]
  • Physical therapy: early mobilization and exercise
  • NSAIDs
  • Oral corticosteroid (burst and taper) for severe pain
  • Intraarticular corticosteroid injection
  • Surgical treatment if symptoms persist after 9 months of conservative management ^[11]
• Prognosis: self-limiting (improvement typically takes > 1 year)
• Complications: atrophy of the deltoid and spinatus muscles

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]

• Definition: a tear of the superior glenoid labrum and the long head of the biceps tendon ^[39]
• Etiology
  • Overuse injury, e.g., microtrauma from repeated throwing motion (most common)
  • Fall on an extended arm
• Clinical features
  • Shoulder pain
  • Shoulder instability
  • May be asymptomatic
• Diagnostics
  • Clinical evaluation
    • Clinical tests for detecting SLAP lesions are of limited value.
    • Positive Speed test, O'Brien test, and Yergason test may indicate an injury to the long head of the biceps.
  • MRI and/or MRI arthrogram findings provide a definitive diagnosis.
• Treatment
  • Follow conservative therapy of shoulder soft tissue lesions.
  • Arthroscopic surgical repair is indicated if symptoms persist after conservative treatment.

Bankart lesion ^[22][23]

• Definition: a tear of the anteroinferior portion of the glenoid labrum
• Etiology: acute anterior dislocation of the shoulder
• Clinical features
  • Shoulder pain
  • Shoulder instability
  • Recurrent dislocations
• Diagnostics
  • Clinical evaluation
    • Positive anterior apprehension test
    • Positive anterior drawer test of the shoulder
  • MRI findings provide a definitive diagnosis.
• Management ^[22][40]
  • Follow treatment of acute shoulder dislocation for an acute dislocation.
  • Most patients are treated conservatively with sling immobilization and physical therapy.
  • Early surgical repair may be preferred for young active individuals to prevent recurrent dislocations.