Soft tissue lesions of the shoulder involve the shoulder's ligaments, tendons, cartilage, and/or capsule. The rotator cuff is the most commonly affected structure. Rotator cuff disease includes a range of pathologies from tendinopathy to rotator cuff tears and is commonly associated with subacromial bursitis and biceps tendinopathy. Many patients present with , caused by inflammation of subacromial structures (e.g., rotator cuff tendons, subacromial bursa, and ) and subsequent narrowing of the subacromial space. Other frequently encountered soft tissue lesions of the shoulder include adhesive capsulitis, calcific tendonitis, and labral tears. Soft tissue lesions may result from overuse (e.g., repetitive overhead arm movements in young athletes) or degenerative or inflammatory processes. Symptoms of soft tissue lesions of the shoulder include pain with movement (usually shoulder abduction), nocturnal pain, tenderness, and/or restricted range of motion (ROM). A clinical diagnosis can often be made after an orthopedic shoulder examination that utilizes provocation tests for specific shoulder injuries. Imaging tests, primarily MRI, are usually obtained to make a definitive diagnosis and/or plan for surgery, if necessary. Management is typically conservative: activity modification, NSAIDs, and physical therapy. Intraarticular corticosteroid injections and/or surgery may be required if symptoms do not resolve with conservative measures. Early surgical intervention is indicated for labral tears causing instability and acute or large rotator cuff tears, especially in active individuals.
- The majority of shoulder pain is the result of rotator cuff disease, a spectrum of pathophysiology ranging from subacromial impingement to complete tears of rotator cuff tendons (most commonly the supraspinatus).
- Other sources of pain include the: 
Management approach 
- Perform a thorough .
- Perform a neurovascular examination of the entire arm.
- Obtain standard x-rays in all patients. 
- Consider MRI or ultrasound imaging if the diagnosis remains unclear. 
- Begin conservative management, unless there is an indication for surgery.
- Consult orthopedics urgently for the following: 
Overview of soft tissue injuries and pain syndromes
|Overview of shoulder soft tissue lesions |
|Affected structures||Positive provocation tests and examination findings||Imaging|
|Rotator cuff tear|
| || |
|Calcific tendonitis|| || |
|Adhesive capsulitis || || || |
|Acromioclavicular joint injury|
- Overuse: especially with activities involving repetitive overhead arm movement, e.g., baseball, volleyball
- Degenerative processes (especially in older individuals)
- Systemic diseases (See “Adhesive capsulitis.”)
- Postoperative changes, e.g., inflammation, fibrous tissue, implants
The following are nonspecific features. Provocative clinical examination and diagnostic tests are usually required to identify the underlying condition (see “Overview of shoulder soft tissue lesions).
- Painful active and/or passive abduction 
- Patient apprehension before shoulder movement
- Tenderness, e.g., subacromial
- Limited ROM (active and/or passive)
The clinical examination can guide early management (see “Overview of shoulder soft tissue lesions”). Imaging is usually obtained to confirm the diagnosis and/or rule out alternative diagnoses. 
should include the following:
- Check upper extremity capillary refill time and pulses at the , and .
- Identify signs of , , , or .
- Initial imaging for all patients
- Required views: standard AP, AP glenoid , trans-scapular lateral , and axillary 
- Often normal
- Findings may include:
- Gold standard imaging for evaluation of the shoulder
- Indications: diagnostic uncertainty or symptoms that persist following conservative treatment
- Supports surgical planning
- Provides real-time imaging during provocation maneuvers and is used to guide interventional treatment
- Accuracy comparable to MRI for rotator cuff tears, bursitis, and other shoulder soft tissue lesions 
- Findings may include:
The majority of patients with soft tissue injuries of the shoulder can be managed initially with . 
Conservative therapy of shoulder soft tissue lesions
- Utilize the for acute injuries or inflammation.
- , e.g., NSAIDs.
- Modify activities, especially those involving overhead movements.
- Consult physical therapy.
- Consider subacromial glucocorticoid injections for refractory chronic pain.
- Indications 
- Technique: depends on the specific condition
- Etiology: repetitive overhead activity or other overuse injuries
- Extrinsic compression: Narrowed subacromial space causes bursitis and tendonitis.
- Intrinsic compression: Degenerative tendonitis causes glenohumeral changes that narrow the subacromial space.
- Pain on movement that is worsened by overhead activities (e.g., combing hair or reaching up to a cupboard)
- Nocturnal exacerbation of pain, especially when lying on the affected shoulder
- Pain and restriction of active movement between 60 and 120°
- Symptoms typically develop over weeks to months. 
Positive provocative clinical examination
- X-rays: may show narrowing of acromiohumeral distance, osteoarthritis
- MRI: provides definitive evidence of tendinitis and/or impingement 
Subacromial lidocaine injection test 
- Indication: inability to differentiate between and other causes of shoulder pain and/or restricted ROM, e.g., rotator cuff tear, frozen shoulder, glenohumeral joint arthritis 
- Technique: subacromial injection of 5 mL of lidocaine or bupivacaine 
- Interpretation: Pain relief following injection suggests subacromial impingement syndrome.
- All patients: Begin .
- Surgical treatment: if there is no improvement after conservative treatment (e.g., arthroscopic decompression, acromioplasty)
- Otherwise dependent on underlying pathology
- See “.”
- See “ .”
- See “ .”
General principles 
- Rotator cuff disease is a poorly defined collection of traumatic injuries and/or degenerative changes to tendons.
- It includes a spectrum of conditions ranging from tendonitis to .
- Comorbid adjacent lesions are common, e.g., subacromial bursitis, biceps tendinopathy.
- Clinical features vary depending on the underlying conditions and course.
- is a common (but not universal) manifestation of and calcific tendonitis of the shoulder.
- Loss of active function suggests a .
Rotator cuff tendinopathy 
- Etiology: acute injury and/or chronic degeneration from overuse
- Clinical features
- Diagnosis 
- Treatment: Follow .
- Complications 
Rotator cuff tear
- Chronic degenerative tear (most common): usually seen in individuals > 40 years of age and/or performing repetitive overhead movements (e.g., infraspinatus tear in baseball pitchers) 
- Acute traumatic injury (∼ 10% of cases): usually seen following a fall or dislocation, often in young adults 
- Clinical features 
- Positive suggests supraspinatus tear.
- Provocation tests that may be abnormal (depending on the affected tendon)
- POCUS: may show full or partial-thickness tears 
- X-ray: superior displacement of the humeral head (high-riding humeral head)
- Ultrasound or MRI: definitive test to determine the location and extent of the rupture
- All patients: Optimize .
- Acute injury: Immobilize for comfort and consult orthopedic surgery early.
Surgical repair ; 
Typically considered for:
Younger patients (< 65 years old) with:
- Acute traumatic full-thickness tears
- Chronic full-thickness tears 
- Significantly reduced arm function
- High risk of tear progression
- Insufficient improvement after 3–6 months of conservative treatment 
- Younger patients (< 65 years old) with:
- Typically inappropriate for:
- Sedentary and older patients (> 65 years) 
- Most partial-thickness tears
- Typically considered for:
- Tear progression 
- Adhesive capsulitis
Early surgical repair of rotator cuff repairs is often preferred in young and/or physically active patients. 
Calcific tendonitis of the shoulder 
- Etiology: See “ ” in “ .”
- Clinical features
- Definition: inflammation and fibrosis of the joint capsule leading to contracture of the shoulder joint
- Epidemiology 
- Primary adhesive capsulitis (idiopathic): associated with diabetes mellitus, thyroid disorders, scleroderma, Dupuytren contracture,
- Secondary adhesive capsulitis: associated with previous shoulder injury (e.g., shoulder dislocation, rotator cuff disease), prolonged immobilization, arthroscopic surgery
Clinical features 
- Most commonly involves the nondominant side
- May be poorly localized; sometimes pain is referred to the deltoid and bicep
- More severe at night
- Stiffness that interferes with activities of daily living
- Severe restriction of active and passive ROM of the glenohumeral joint in all planes, especially:
- Shoulder pain
- Treatment 
- Prognosis: self-limiting (improvement typically takes > 1 year)
- Complications: atrophy of the deltoid and spinatus muscles
Glenoid labrum injuries
Thecan be damaged by an acute injury or overuse of the shoulder and arm.
Superior labrum from anterior to posterior lesion (SLAP lesion) 
- Definition: a tear of the superior glenoid labrum and the long head of the biceps tendon 
- Overuse injury, e.g., microtrauma from repeated throwing motion (most common)
- Fall on an extended arm
- Shoulder pain
- Shoulder instability
- May be asymptomatic
Bankart lesion 
- Definition: a tear of the anteroinferior portion of the glenoid labrum
- Etiology: acute anterior dislocation of the shoulder
- Clinical features
- Management