• Clinical science

Soft tissue lesions of the shoulder


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.


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


  • 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


Clinical features

Subacromial impingement syndrome

  • Definition: clinical syndrome caused by compression of tissues around the glenohumeral joint (e.g., rotator cuff tendons, subacromial bursa) when the shoulder is elevated; . It is a spectrum of clinical findings, and can eventually result in complete rotator cuff tear.
  • Clinical features

Rotator cuff tendinitis

Frozen shoulder (adhesive capsulitis)

  • Definition: inflammation and fibrosis of the joint capsule leading to contracture of the shoulder joint
  • Clinical features
    • Severe restriction of both active and passive range of movement of the glenohumeral joint in all planes (especially external rotation)
    • Dull shoulder pain
    • 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
  • Complication: calcific bursitis resulting in pain and stiffness of the shoulder; radiologic evidence of calcium deposits in the subacromial bursa

Biceps tendinitis

  • Definition: tendinitis, tenosynovitis, or tendinosis 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



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



  • Conservative treatment
  • 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!



Rotator cuff tear

  • Etiology
    • Chronic degenerative tear seen in older adults (> 50 years)
    • Acute injury seen mostly in athletes
    • Inflammatory: complication of rotator cuff tendinitis
  • 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 then possibly 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.


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