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
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


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]


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

  1. Weber S, Chahal J. Management of Rotator Cuff Injuries. J Am Acad Orthop Surg. 2020; 28 (5): p.e193-e201.doi: 10.5435/jaaos-d-19-00463 . | Open in Read by QxMD
  2. Hsu J, Keener JD. Natural History of Rotator Cuff Disease and Implications on Management. Operative Techniques in Orthopaedics. 2015; 25 (1): p.2-9.doi: 10.1053/j.oto.2014.11.006 . | Open in Read by QxMD
  3. Dang A, Davies M. Rotator Cuff Disease: Treatment Options and Considerations. Sports Med Arthrosc. 2018; 26 (3): p.129-133.doi: 10.1097/jsa.0000000000000207 . | Open in Read by QxMD
  4. Perry SM, Getz CL, Soslowsky LJ. After rotator cuff tears, the remaining (intact) tendons are mechanically altered. J Shoulder Elbow Surg. 2009; 18 (1): p.52-57.doi: 10.1016/j.jse.2008.07.003 . | Open in Read by QxMD
  5. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  6. Small KM, Adler RS, Shah SH, et al. ACR Appropriateness Criteria® Shoulder Pain-Atraumatic. J Am Coll Radiol. 2018; 15 (11): p.S388-S402.doi: 10.1016/j.jacr.2018.09.032 . | Open in Read by QxMD
  7. Armstrong A. Evaluation and Management of Adult Shoulder Pain. Med Clin North Am. 2014; 98 (4): p.755-775.doi: 10.1016/j.mcna.2014.03.004 . | Open in Read by QxMD
  8. Karjalainen TV, Jain NB, Heikkinen J, Johnston RV, Page CM, Buchbinder R. Surgery for rotator cuff tears. Cochrane Database Syst Rev. 2019.doi: 10.1002/14651858.cd013502 . | Open in Read by QxMD
  9. Reinholz AK, Till SE, Arguello AM, Barlow JD, Okoroha KR, Camp CL. Advances in the Treatment of Rotator Cuff Tears. Clin Sports Med. 2023; 42 (1): p.69-79.doi: 10.1016/j.csm.2022.08.003 . | Open in Read by QxMD
  10. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008; 77 (4): p.493-7.
  11. Lazarides AL, Alentorn-Geli E, Choi JHJ, et al. Rotator cuff tears in young patients: a different disease than rotator cuff tears in elderly patients. J Shoulder Elbow Surg. 2015; 24 (11): p.1834-1843.doi: 10.1016/j.jse.2015.05.031 . | Open in Read by QxMD
  12. Kim MS, Kim IW, Lee S, Shin SJ. Diagnosis and treatment of calcific tendinitis of the shoulder. Clin Shoulder Elbow. 2020; 23 (4): p.210-216.doi: 10.5397/cise.2020.00318 . | Open in Read by QxMD
  13. Merolla G, Singh S, Paladini P, Porcellini G. Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment. J OrthopTraumatol. 2015; 17 (1): p.7-14.doi: 10.1007/s10195-015-0367-6 . | Open in Read by QxMD
  14. Chianca V, Albano D, Messina C, et al. Rotator cuff calcific tendinopathy: from diagnosis to treatment. Acta Biomedica. 2018; 89 (1-S): p.186-196.doi: 10.23750/abm.v89i1-S.7022 . | Open in Read by QxMD
  15. Murphy RJ, Carr AJ. Shoulder pain.. BMJ Clin Evid. 2010; 2010.
  16. Harrison AK, Flatow EL. Subacromial Impingement Syndrome. Am Acad Orthop Surg. 2011; 19 (11): p.701-708.doi: 10.5435/00124635-201111000-00006 . | Open in Read by QxMD
  17. Zhao J, Luo M, Liang G, et al. Risk Factors for Supraspinatus Tears: A Meta-analysis of Observational Studies. Orthop J Sports Med. 2021; 9 (10): p.232596712110428.doi: 10.1177/23259671211042826 . | Open in Read by QxMD
  18. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008; 77 (4): p.453-60.
  19. McNally EG, Rees JL. Imaging in shoulder disorders. Skeletal Radiol. 2007; 36 (11): p.1013-1016.doi: 10.1007/s00256-007-0351-1 . | Open in Read by QxMD
  20. Kulkarni R, Gibson J, Brownson P, et al. Subacromial shoulder pain. Shoulder Elbow. 2015; 7 (2): p.135-143.doi: 10.1177/1758573215576456 . | Open in Read by QxMD
  21. Nazarian LN, Jacobson JA, Benson CB, et al. Imaging Algorithms for Evaluating Suspected Rotator Cuff Disease: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2013; 267 (2): p.589-595.doi: 10.1148/radiol.13121947 . | Open in Read by QxMD
  22. Wolfson AB. Harwood-Nuss' Clinical Practice of Emergency Medicine. LWW ; 2014
  23. Seo JB, Yoo JS, Ryu JW. Sonoelastography findings of biceps tendinitis and tendinosis. J Ultrasound. 2014; 17 (4): p.271-277.doi: 10.1007/s40477-014-0075-8 . | Open in Read by QxMD
  24. Siegel LB, Cohen NJ, Gall EP. Adhesive capsulitis: a sticky issue. Am Fam Physician. 1999; 59 (7): p.1843-52.
  25. Le HV, Lee SJ, Nazarian A, Rodriguez EK. Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments. Shoulder Elbow. 2016; 9 (2): p.75-84.doi: 10.1177/1758573216676786 . | Open in Read by QxMD
  26. Umer M, Qadir I, Azam M. Subacromial impingement syndrome. Orthop Rev (Pavia). 2012; 4 (2): p.18.doi: 10.4081/or.2012.e18 . | Open in Read by QxMD
  27. McFarland E, Bernard J, Dein E, Johnson A. Diagnostic injections about the shoulder. J Am Acad Orthop Surg. 2017; 25 (12): p.799-807.doi: 10.5435/jaaos-d-16-00076 . | Open in Read by QxMD
  28. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the shoulder region. Am Fam Physician. 2003; 67 (6): p.1271-8.
  29. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. Journal of Shoulder and Elbow Surgery. 2000; 9 (4): p.299-301.doi: 10.1067/mse.2000.106918 . | Open in Read by QxMD
  30. Ramirez J. Adhesive Capsulitis: Diagnosis and Management. Am Fam Physician. 2019; 99 (5): p.297-300.
  31. Redler LH, Dennis ER. Treatment of Adhesive Capsulitis of the Shoulder. J Am Acad Orthop Surg. 2019; 27 (12): p.e544-e554.doi: 10.5435/jaaos-d-17-00606 . | Open in Read by QxMD
  32. Date A, Rahman L. Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies. Future Science OA. 2020; 6 (10).doi: 10.2144/fsoa-2020-0145 . | Open in Read by QxMD
  33. Sherman SC. Simon's Emergency Orthopedics, 8th edition. McGraw Hill Professional ; 2018
  34. Hinsley H, Nicholls A, Daines M, Wallace G, Arden N, Carr A. Classification of rotator cuff tendinopathy using high definition ultrasound. Muscles, ligaments and tendons journal. 2014; 4 (3): p.391-7.
  35. Fischer CA, Weber MA, Neubecker C, Bruckner T, Tanner M, Zeifang F. Ultrasound vs. MRI in the assessment of rotator cuff structure prior to shoulder arthroplasty. J Orthop. 2015; 12 (1): p.23-30.doi: 10.1016/j.jor.2015.01.003 . | Open in Read by QxMD
  36. Gay and Bisexual Men's Health For Your Health: Recommendations for A Healthier You. Updated: September 16, 2022. Accessed: April 21, 2023.
  37. Belk JW, Wharton BR, Houck DA, et al. Shoulder Stabilization Versus Immobilization for First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-analysis of Level 1 Randomized Controlled Trials. Am J Sports Med. 2022; 51 (6): p.1634-1643.doi: 10.1177/03635465211065403 . | Open in Read by QxMD
  38. Loh B, Lim JBT, Tan AHC. Is clinical evaluation alone sufficient for the diagnosis of a Bankart lesion without the use of magnetic resonance imaging?. Ann Transl Med. 2016; 4 (21): p.419-419.doi: 10.21037/atm.2016.11.22 . | Open in Read by QxMD
  39. Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. SLAP lesions: a treatment algorithm. Knee Surgery, Sports Traumatology, Arthroscopy. 2016; 24 (2): p.447-455.doi: 10.1007/s00167-015-3966-0 . | Open in Read by QxMD
  40. Boffano M, Mortera S, Piana R. Management of the first episode of traumatic shoulder dislocation. EFORT Open Rev. 2017; 2 (2): p.35-40.doi: 10.1302/2058-5241.2.160018 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer