• 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][2]

Clinical features

Subacromial impingement syndrome

Rotator cuff tendinitis

Frozen shoulder (adhesive capsulitis)

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

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.

Instrumental diagnostics

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

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!

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 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
  • 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.