• Clinical science

Soft tissue lesions of the shoulder

Abstract

Soft tissue lesions of the shoulder are usually caused by the narrowing of the subacromial or subcoracoid space and subsequent entrapment of soft tissues. These structural changes in the shoulder joint are often the result of overuse (e.g., engaging in overhead activities) and degenerative or inflammatory processes. The main symptom of soft tissue involvement is shoulder pain related to movement, which is often caused by pinching or “impingement” of soft tissues, most commonly of the supraspinatus tendon, during a 60–120° abduction of the arm. Further symptoms include nocturnal pain, pain on palpation, and stiffness of the joint. Chronic entrapment of the tendons can lead to tendinitis, which increases the risk of tendon rupture, especially of the rotator cuff tendons. Soft tissue injuries of the shoulder are usually diagnosed clinically. Additional imaging tests (X-ray, MRI) can be used to determine the extent of damage/involvement. Management involves avoiding overhead activities, NSAIDs, and physical therapy. Intra-articular corticosteroid injections and surgical measures may be required in refractory cases.

Definition

Narrowing of the subacromial and/or subcoracoid space with entrapment of soft tissue structures; especially involves the rotator cuff and subacromial bursa

Etiology

  • Overuse; : activities involving repetitive overhead activity (e.g., basketball, volleyball)
  • Degenerative processes (especially in the elderly)
  • Inflammation
  • Systemic diseases (e.g., diabetes mellitus )
  • Iatrogenic: surgical interventions, with or without introduction of foreign bodies into the subacromial space (e.g., surgical implants)
  • Seen especially in people with concomitant alterations of anatomical structures , most commonly of the

References:[1][2]

Clinical features

Subacromial impingement syndrome

Rotator cuff tendinitis

Frozen shoulder (adhesive capsulitis)

  • Definition: inflammation and fibrosis of the joint capsule leading to contracture of the joint
  • Clinical features
    • Severe restriction and limitation of both active and passive range of movement of the glenohumeral joint in all planes (especially external rotation)
    • Dull shoulder pain
    • Presents with the three stages
      • Stage 1: “Freezing or painful stage” → minimal synovitis with pain, causing a limitation of motion
      • Stage 2: “Frozen or transitional stage” → pain decreases but proliferative synovitis with contraction of the capsule and adhesion of the axillary recess continues
      • Stage 3: “Thawing stage” → inflammation decreases, movement slowly improves
    • Self-limiting; course; however, improvement may take more than a year

Calcifying tendonitis

  • Definition: calcium deposits; of unknown etiology; mostly in the area of insertion of the supraspinatus muscle tendon
  • Clinical features
    • Often no or mild pain, intermittent flares possible
    • Limited ROM if large calcium deposits occur
  • Diagnosis: evidence of calcium deposits on x-rays
  • Stages
    1. Pre-calcific stage
    2. Calcific stage
    3. Post-calcific stage with dissolution of the calcium deposits (complete healing in 70% of the patients)
  • Complication: calcific bursitis resulting in pain and stiffness of the shoulder; radiologic evidence of calcium deposits in the subacromial bursa

Biceps tendinitis

  • Definition: inflammation of the proximal long head of the biceps tendon at its insertion on the glenoid
  • Clinical features
    • Anterior shoulder pain; that becomes worse with lifting
    • Tenderness along the anterior humerus
  • Complications: biceps tendon tear or rupture
  • Associated conditions: rotator cuff tears

References:[3][1][4][5][6]

Diagnostics

Clinical examination

This section provides a brief overview of possible clinical findings. For detailed explanations of the clinical tests, see orthopedic examination of the shoulder.

  • Pain and limited movement
    • Subacromial pain triggered by manual exertion of pressure below the acromion
    • Painful active and/or passive abduction, possibly aggravated by internal and/or external rotation
  • Signs of narrowed subacromial space and of impingement
    • Painful arc: pain with abduction of the arm between 60–120°
    • Neer test: The internally rotated and outstretched arm is passively elevated, while the scapula is simultaneously stabilized; the movement causes pain.
  • Signs of muscular involvement: See examination of the rotator cuff.

Instrumental diagnostics

References:[7][8][9][10][11]

Treatment

  • Conservative treatment
    • Acute
      • Avoid activities involving overhead movements
      • Anti-inflammatory and analgesic medications (NSAIDs)
      • Physical therapy
    • Chronic cases; may require subacromial glucocorticoid injections
  • Surgical treatment
    • Impingement: arthroscopic decompression, possibly open acromioplasty if evidence of acromion narrowing is apparent
    • Rotator cuff tear: arthroscopic or open rotator cuff repair
    • Removal of calcium deposits with needling or extracorporeal shock wave therapy

Glucocorticoid injections should be administered with caution since they can lead to tendon degeneration!

References:[5][8]

Complications

Rotator cuff tear

  • Etiology
    • Chronic degenerative tear seen in older adults (> 50 years)
    • Acute injury seen mostly in athletes
    • Inflammatory: complication of rotator cuff syndrome
  • Clinical features
    • Most commonly affects the supraspinatus tendon
    • Acute ruptures: acute severe pain and loss of strength
    • Degenerative ruptures: chronic pain; loss of strength less pronounced
    • Restriction of ROM (depending on which muscle is involved)
  • Diagnostics
    • Clinical examination (see “Diagnostics” above)
    • X-ray: superior displacement of the humeral head (high-riding humeral head)
    • Ultrasound and MRI to evaluate the extent and location of the rupture
  • Treatment
    • Treatment of degenerative rupture; , especially in elderly, inactive patients, can be conservative (see “Conservative treatment” above).
    • Surgical repair of the rotator cuff; is recommended in cases of traumatic rupture; , especially in physically active patients , or treatment-refractory cases.

References:[12][13]

We list the most important complications. The selection is not exhaustive.