• Clinical science

Soft tissue lesions of the shoulder

Summary

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

References:[1]

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 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
  • Stages [2]
    1. Freezing or painful stage”: minimal synovitis with pain, causing a limitation of motion
    2. “Frozen or transitional stage”: pain decreases but proliferative synovitis with contraction of the capsule and adhesion of the axillary recess continues
    3. “Thawing stage”: inflammation decreases, movement slowly improves

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-ray
  • Stages [3]
    1. Pre-calcific stage
    2. Calcific stage
    3. Post-calcific stage with the dissolution of calcium deposits
  • Complications: calcific bursitis resulting in pain and stiffness of the shoulder

Biceps tendinitis

References:[4]

Diagnostics

Clinical examination

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

Instrumental diagnostics

References:[6][7][8]

Treatment

  • 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.

Complications

Rotator cuff tear

  • Etiology
    • Chronic degenerative tear seen in older adults (> 50 years)
    • Acute injury seen mostly in athletes (e.g., infraspinatus tear in baseball pitchers)
    • Inflammatory: a 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 diagnosis (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.

References:[9]

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

  • 1. Zlatkin MB. MRI of the Shoulder. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.
  • 2. Nagy MT, MacFarlane RJ, Khan Y, Waseem M. The Frozen Shoulder: Myths and Realities. The Open Orthopaedics Journal. 2013; 7(1): pp. 352–355. doi: 10.2174/1874325001307010352.
  • 3. Kalaycı CB, Kızılkaya E. Calcific tendinitis: intramuscular and intraosseous migration. Diagn Interv Radiol. 2019; 25(6): pp. 480–484. doi: 10.5152/dir.2019.18593.
  • 4. Wilson JJ, Best TM. Common Overuse Tendon Problems: A Review and Recommendations for Treatment. Am Fam Physician. 2005; 72(5): pp. 811–818. url: http://www.aafp.org/afp/2005/0901/p811.html.
  • 5. 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): pp. 299–301. doi: 10.1067/mse.2000.106918.
  • 6. Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SMA. Does this patient with shoulder pain have rotator cuff disease?. JAMA. 2013; 310(8): p. 837. doi: 10.1001/jama.2013.276187.
  • 7. Bak K, Sørensen AKB, Jørgensen U, et al. The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: Does a subacromial Lidocaine injection help in the clinical diagnosis? A prospective study. Arthroscopy. 2010; 26(6): pp. 734–742. doi: 10.1016/j.arthro.2009.11.005.
  • 8. McFarland E, Bernard J, Dein E, Johnson A. Diagnostic injections about the shoulder. J Am Acad Orthop Surg. 2017; 25(12): pp. 799–807. doi: 10.5435/jaaos-d-16-00076.
  • 9. Oliva F, Osti L, Padulo J, Maffulli N. Epidemiology of the rotator cuff tears: a new incidence related to thyroid disease. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4241421/. Updated November 17, 2014. Accessed February 16, 2017.
last updated 11/26/2020
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