- Clinical science
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.
- Overuse: activities involving repetitive overhead activity (e.g., basketball, volleyball)
- Degenerative processes (especially in the elderly)
- 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
- 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 .
- Pain on movement which is worsened by overhead activities.
- Nocturnal exacerbation of pain, especially when lying on the affected shoulder
- Movement restriction depending on the muscle involved
- Most common symptoms are due to supraspinatus injury or subacromial bursitis
- Can progress to and
- Definition: subacromial bursitis with peritendinitis of the rotator cuff; usually seen as a progression of subacromial impingement syndrome
- Clinical features
- Complication: rotator cuff tear (see below)
- Definition: inflammation and fibrosis of the joint capsule leading to contracture of the shoulder joint
- Severe restriction 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
- Definition: calcium deposits of unknown etiology; mostly in the area of insertion of the supraspinatus muscle tendon
- Often no or mild pain, intermittent flares possible
- Limited ROM if large calcium deposits occur
- Diagnosis: evidence of calcium deposits on x-rays
- Pre-calcific stage
- Calcific stage
- 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
- Definition: tendinitis, tenosynovitis, or tendinosis of the proximal long head of the biceps tendon at its insertion on the glenoid
- Anterior shoulder pain that becomes worse with lifting
- Tenderness along the anterior humerus
- Complications: biceps tendon tear or rupture
- Associated conditions: rotator cuff tears
This section provides a brief overview of possible clinical findings. For detailed explanations of the clinical tests, see.
- Pain and limited movement
- Signs of narrowed subacromial space and of impingement
- Signs of muscular involvement: See .
- Subacromial lidocaine injection test: originally described by Neer as part of the . The test may be helpful in distinguishing between (including subacromial bursitis, rotator cuff tendinitis) and other causes of shoulder pain and restriction (e.g., complete rotator cuff tear, frozen shoulder, glenohumeral joint arthritis). It is not very specific, as it can improve pain in a variety of conditions, but it does improve the specificity of the .
- X-ray to evaluate for:
- Ultrasound and MRI: to evaluate the soft tissue structures (bursae, rotator cuff, and tendons)
- Conservative treatment
- Surgical treatment
Glucocorticoid injections should be administered with caution since they can lead to tendon degeneration!
- Chronic degenerative tear seen in older adults (> 50 years)
- Acute injury seen mostly in athletes
- Inflammatory: complication of rotator cuff tendinitis
- Clinical features
- 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 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.