Muscles, tendons and ligaments of the shoulder

Anatomy: Who stabilizes and moves the shoulder?

The core of the shoulder (glenohumeral joint) is guided by the rotator cuff and other tendons as well as a ligament and capsule system. The aim is to keep the head of the humerus centered in the flat socket and to guide movements in a controlled manner.

• Rotator cuff: four muscles/tendons – supraspinatus (abduction, elevation), infraspinatus (external rotation), teres minor (external rotation/fine control), subscapularis (internal rotation, anterior stabilization).
• Long biceps tendon (LBS): runs from the upper edge of the socket (labrum) through the groove on the upper arm (intertubercular sulcus) and stabilizes the front/top of the shoulder, especially during overhead movements.
• Ribbons: v. a. glenohumeral ligaments (superior, middle, inferior) and the coracohumeral ligament – ​​they complement the capsule and limit extreme movements.
• Subacromial sliding layer: Subacromial/subdeltoid bursa reduces friction between tendons (especially supraspinatus) and bony structures (acromion).
• Shoulder blade (scapula): Movement and posture control by the periscapular muscles is crucial for pain-free shoulder function.

Common diseases of muscles, tendons and ligaments of the shoulder

Wear, overload, bottleneck phenomena or acute injuries can affect tendon quality. The following clinical pictures occur particularly frequently in practice:

• Tendinopathies of the rotator cuff: Overload-related tendon pain without or with minor structural changes - often supraspinatus, rarely infraspinatus, subscapularis or teres minor.
• Rotator cuff impingement: mechanical tightness and friction of the tendons/bursa under the acromion, provoking pain during overhead movements.
• Calcifying tendinitis: Calcium deposits in the supraspinatus tendon cause severe stabbing pain at times.
• Partial tear of the rotator cuff: torn or torn fibers, often degenerative; Pain, loss of strength, etc. a. during abduction/external rotation.
• Complete rupture of the rotator cuff: complete tendon detachment; Significant loss of strength, often after trauma - particularly relevant in younger/active patients.
• Pathologies of the long biceps tendon (LBS): inflammation (tendinitis), instability/dislocation of the tendon from the groove or proximal rupture; often combined with cuff lesions.

Detailed information on individual diagnoses can be found in the linked subpages below.

Symptoms: How do I recognize a tendon or ligament problem?

• Pain on the side or front of the shoulder, often radiating to the upper arm.
• Stinging pain during overhead or rotational movements, especially a. when abducting (shoulder height).
• Night pain when lying on the affected side.
• Loss of strength, v. a. when lifting/carrying and during external or internal rotation.
• Restricted movement, noises or snapping (crepitation/snapping phenomena).
• Feeling of instability or “slipping” during certain movements (more often biceps tendon or ligament).

Warning signs that should be clarified promptly by a doctor: sudden pain after trauma, rapidly increasing restriction of movement, significant loss of strength, fever or redness/overheating.

Causes and risk factors

• Overhead work and repetitive micro-movements (crafts, assembly, grooming, hairdressing).
• Sports with throwing/hitting movements (tennis, volleyball, handball, CrossFit/weightlifting).
• Aging processes: decreasing tendon vitality, reduced blood flow, degeneration.
• Anatomical tightness (e.g. acromion shape), bony spurs or thickened bursa.
• Concomitant diseases: diabetes mellitus, thyroid diseases, lipid metabolism disorders; Smoke.
• Postural and scapular control disorders (scapular dyskinesia), muscular imbalances.
• Acute trauma or sudden peak overload (fall, heavy lifting).

Diagnostics: step by step to the cause

In our practice in Hamburg, we initially rely on a careful clinical assessment and targeted diagnostics with as little radiation as possible. We decide individually whether an MRI makes sense based on the examination and course.

Therapy – conservative first

Most problems with the muscles, tendons and ligaments of the shoulder can be improved without surgery. The aim is to relieve pain and restore mobility and resilient function. The specific combination depends on the diagnosis and everyday requirements.

• Education and activity modification: temporary reduction of painful overhead and load peaks, ergonomic adjustments.
• Physiotherapy with clear objectives: pain reduction, restoration of joint centering, strengthening of the rotator cuff and scapula stabilizers, posture and motor control.
• Home exercises: dosed, regularly performed exercises (eccentric and isometric loads) increase tendon resilience.
• Pain and inflammation management: temporary use of NSAIDs (if tolerated), local measures (cold for acute irritation, heat for chronic irritation).
• Infiltrations: subacromial or peritendinous injection with corticoid/anesthetic can reduce pain in the short term in selected cases - always cautious and indication-related.
• Shock wave therapy (ESWT): ESWT can be considered, especially in calcifying tendinitis; The benefit depends on the size/location of the limescale and the symptoms.
• Regenerative procedures (e.g. PRP): can be considered in individual cases. The evidence varies depending on the diagnosis; Benefits and limitations are discussed transparently in advance.

Important: The success of therapy is based on continuity. A structured rehabilitation program lasting weeks to months is typically necessary before a decision is made about alternatives.

Operational options – when do they make sense?

Surgery is considered if conservative measures do not provide sufficient improvement over a reasonable period of time (usually 3-6 months) or if there is an acute, functionally relevant injury (e.g. traumatic complete rupture with significant loss of strength). The decision is made individually.

• Arthroscopic calcification and bursectomy for treatment-resistant calcifying tendinitis.
• Arthroscopic decompression/soft tissue smoothing for impingement with demonstrable bottleneck factors - after conservative therapy has been exhausted.
• Rotator cuff suture (repair) for symptomatic partial or complete tears - depending on tendon quality, retraction, age and activity level.
• Biceps tendon procedure: tenotomy (division) or tenodesis (fixation) for painful tendinopathy, instability/dislocation or accompanying cuff procedures.

After an operation, structured follow-up treatment is crucial. Realistic expectations and clear rehabilitation goals help to make everyday life less painful, step by step.

Rehabilitation and course

• Early phase: pain control, swelling management, passive/assistive mobility in the pain-free range.
• Development phase: active movements, gradual strengthening of the rotator cuff and scapular stabilizers, coordination and posture.
• Stress phase: function- and sport-specific progression; Load increase as tolerated.
• Timelines: conservatively often 6-12 weeks until significant improvement, full resilience can take longer; after rotator cuff suturing, usually several months (return to sport typically 4–9 months, depending on the extent and type of sport).

Prevention and self-help

• Regular, balanced shoulder training: rotator cuff and scapula stabilizers (e.g. external rotations, low row, serratus activation).
• Load control in sport: good technique, progressive increase, sufficient regeneration.
• Workplace ergonomics: monitor height, arm rests, regular micro-breaks with mobilization.
• Whole-body factors: sleep, stress reduction, avoiding smoking – beneficial for tendon healing.
• Take countermeasures at an early stage: have persistent symptoms clarified by a specialist before they become chronic.

What you can expect in our practice in Hamburg

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we value a thorough examination, understandable information and a clear, individual treatment plan. We primarily focus on conservative measures and accompany you through rehabilitation in a structured manner. Modern diagnostics (including sonography) and a coordinated network of physiotherapy partners support the path back to everyday life, work and sport.

Deepening undersides to muscles, tendons and ligaments of the shoulder

You can find detailed disease and therapy profiles for the following topics on our subpages:

• Supraspinatus, infraspinatus, subscapularis and teres minor tendinopathy
• Partial and complete rotator cuff tears
• Rotator cuff impingement (calcification/tightness)
• Long biceps tendon: inflammation (LBS), dislocation, proximal rupture
• Further shoulder topics: joint structures/cartilage/capsule, instabilities/dislocations

When should I see a doctor?

• After a fall/trauma with a sudden loss of strength or significant limitation of movement.
• Persistent night pain and pain at rest despite rest for more than 2-3 weeks.
• Increasing pain under everyday stress that prevents work or participation in sports.
• Redness, overheating, fever or severe swelling in the shoulder area.