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ShoulderSeries#2:SupraspinatusTendinitis
EssentialPrinciples
ByBenBenjamin
OriginallypublishedinMassageBodyworkmagazine,June/July2004.
Copyright2004.AssociatedBodyworkandMassageProfessionals.Allrights

Sidebars:
RelatedArticles:
ShoulderSeries#1:Infraspinatus
Tendinitis
ShoulderSeries#3:Subscapularis
Tendinitis

reserved.

Part1ofthisthreepartseriesbeganwiththeapplicationofwhatIcalltheEssential
Principlesregardingpain,injury,andthebody'shealingprocesstowhatare
commonlycalled"rotatorcuff"injuries.Clientswhocometouswithshoulderpain
canbeparticularlydifficulttotreatbecausetheirpainsymptomsoftenpresenta
confusingpicture.Therapistsmayfeeltheyaretreatingsuchclientsinahitormiss
fashion,notknowingexactlywhatwillhelp.
Part2continuesourexplorationofhowtheEssentialPrinciplescanhelpus
distinguishexactlywhichrotatorcuffstructureisinjured.Inthisarticle,wewill
discusshowtodifferentiatethesupraspinatusfromtheotherrotatorcufftendons

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andhowbesttoapproachitstreatment.

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TheNatureofInjuryin
SupraspinatusTendinitis
Supraspinatustendonstrainisa
verycommoncauseofpaininthe
shoulder.Thistendoncanbeinjured
inmanyways.Swimming,lifting
heavyobjects,orcarryingaheavy
suitcaseormassagetableareafew
ofthewaystogetthisinjury.
Athletesoftensuffersevereinjury
tothistendonandolderindividuals
sometimesruptureit,makingit
impossibleforthemtolifttheirarm
outtotheside.
LenniArmstrongIllustration

Thesupraspinatusisasmallandgenerallyweakmusclewhichrunsalongtheupper
portionofthescapulainthesupraspinousfossaandattacheslaterallytothetopof
thehumerusatthesuperiorfacetofthegreatertubercle.Thetendonfibersusually
strainandtearatthetenoperiostialjunctionthetendoncanalsotearwhereit
attachestothemuscleatthemusculotendinousjunction.Injurytothetendon
usuallyoccursateitherthesuperficialdistalend(thepartofthetendonattachment
nearertheskinsurface)oratthedeepdistalendofthetendon(thedeeppartof
thetendonnearthebone).Thesupraspinatustendonisflatinappearanceand
approximatelyaquarterinchinwidth.Thebodyofthetendonisaboutaninchlong
andisconcealedundertheacromion.
Thesupraspinatusmuscleinitiatesabduction,allowingyoutomovethearmaway
fromthesideofthebodyupto15or20degrees,orabout12inchesfromthebody,

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beforeothermusclestakeovertheaction.Abovethislevelthesupraspinatuskeeps
working,butminimally.Itisoftencalledthesuitcasemusclebecauseitisespecially
usedwhencarryingasuitcaseheldawayfromthesideofthebody,tryingto
preventthesuitcasefrombangingintotheoutsideofone'sknee.Apersonusesthis
muscleoftenwhenperformingcertainoutwardcircularmassagestrokes,andmany
massagetherapistsandbodyworkersareafflictedwiththisinjury.
Thisinjuryoftenoccursfornoapparentreason,andtheexactcausemaybe
difficulttopinpoint.Thesupraspinatusmuscleisveryweakinmostpeople,andif
calledontodoasudden,strenuousactivity,itcaneasilytear.Thetendoncanbe
injuredjustaseasilywhenyouscrubapotwithunusualvigoraswhenyouengage
instrenuousathleticactivity.Supraspinatustendinitismightalsooccurasaresultof
aseverefall,wherethehandisplacedinfrontofthepersontobreakthe
momentum.

PainasaSignal
Whatevertheprecipitatingevent,thepaininsupraspinatustendinitisisusuallyfelt
severalhoursaftertheactivity,aswithmanytendonstrains.Painmaybe
experiencedwhenthearmisextended,atshoulderheight,outtothesideofthe
body,orwhenreachinghighoverhead.Whentheinjuryisreallysevere,paincan
bereferredallthewaydowntothewrist.Inmildercases,thepainstaysinthe
upperarmorasavaguepainintheshoulder.
Whenyouperformtheassessmenttestsforthisinjury,theclientwilloftenfeelpain
indifferentplacessuchasdownthebackoftheupperarm,inthebellyofthe
biceps,theforearm,and/orinthedeltoidarea.Therefore,duringtesting,don'tpay
toomuchattentiontowherethepainisfeltaslongasitissomewhereinthearmor
shoulder.Eventhoughthepainisfeltelsewhere,itisusuallybeingcausedbya
microtearattheattachmentofthetendontothebone,inanareaapproximately
onequarterinchsquare.

ScarTissueandChronicPaininSupraspinatusTendinitis
Thisinjurycanpersistforyearsifnotaccuratelyassessedandtreated.The
EssentialPrincipleofadhesivescartissueformationexplainshowthiscanhappen.
Let'ssaythatasayouthyourclienttoresomeofthesupraspinatustendonfibers
duringatournamentswim.Shemighthavefeltsomepainatthetime,buttheinjury
seemedtohealcompletelyonitsown.Unfortunately,itislikelythatsomeadhesive
scartissuefromthathealingremainedinthetendon.Yearslater,theclientran
throughtheairportcarryingherheavysuitcaseandthennoticedasoreshoulderfor
aweekorso.Whatshedidn'tknowwasthatmoreofthetendonfiberstorearound
heroriginalinjury,andtheareaofweakadhesivescartissueincreased.Thenlast
winter,shefellforwardontheiceandcaughtherselfwithherarmssincethen,
she'sexperienceddailyshoulderpain.Thebuiltupadhesivescartissuelefther
subscapularismuscleinaweakandvulnerablecondition,sothatwhencalledupon
inanemergency,themusclecouldnotdoitsjobandsufferedfurtherinjury.
Ingeneral,whenaclientcomestoyouwiththistypeofshoulderpain,alwayshave
herseeaphysiciantocheckforseriousunderlyingconditionsorinjuries.Ifafallor
traumabroughtontheinjury,itiswisetohavethepersongoforanXraytoseeif
thereisafracture.WhentheXrayisread,depositsofcalciumaresometimes
foundinthesupraspinatustendon.Itisoftenassumedthatthesedeposits,rather
thananinflammationinthetendon,arethecauseofpain,andsurgerymaybe
recommended.Supraspinatuspainthatisduetocalciumdepositsinthetendonis
unusualbutissuccessfullytreatedbysurgery.Thereareoftencalciumdeposits
present,too,whichcausenopain.

InjuryVerification
Theprecisedifferentiationofthevariousrotatorcuffinjuriesisveryimportantif
treatmentistobeadministeredcorrectly.Asmentionedearlier,theterm"rotator
cuffinjury"isnotallthathelpfulinidentifyingtheexactlocationoftheinjuryso
treatmentcanbeeffective.
Theimportantpositivetestforsupraspinatustendinitisispainfeltonresisted
abduction.Ifthetendonisinjuredatthedeepdistalendofthetendon,therewill
alsobepainonthetestcalled"passiveelevationofthearm."Thistest,described
here,compressesthedeeperfibersofthetendonbetweentheheadofthehumerus

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andtheacromion.Ifthereisasocalledpainfularc,thenthetendonisinjuredat
thesuperficialdistalend.Thistestcompressessuperficialfibersofthetendon
betweentheheadofthehumerusandtheacromionwhenthearmisouttotheside
betweenapproximately70degreesand110degreesfromthebody.Ifbothofthese
testscausepain(passiveelevationandthepainfularctest),thenboththedeepand
superficialaspectsofthetendonattachmentareinjured.
Ifresistedabductionistheonlytestthatcausespain,thenthesupraspinatusis
injuredatthemusculotendinousjunction.Thisinjuryisfairlyuncommon,soIwill
notcoverthefrictiontechniqueforitinthisarticle.Itcanbefound,however,inthe
TextbookofOrthopedicMedicine,VolumeII,byDr.JamesCyriax.
Tosummarize:Theprimarytestforthisinjuryisresistedabduction,Test#1below.
Thesecondaryorauxiliarytests,#2and#3,onlytellyoupreciselywhatpartofthe
tendonisinjured(i.e.,thedeeperpartneartheboneorthesuperficialpartright
undertheskinsurface).Withthisinformation,youwillknowhowhardtopress
whenfrictioning.
Test1ResistedAbduction
Withtheclientstanding,thetherapist
placesonehandontheoutsideofthe
client'selbowandtheotherhand
aroundthewaistontheoppositeside
ofthebodytostabilizetheperson.Ask
theclienttopushthearmout
(laterally)towardyouwhileyoupush
intheoppositedirectionofferingan
equalandoppositeresistance.When
theclientpushesout,allowthearmto
moveapproximately2inchesawayfromthebodybeforeofferingequalresistance.
Inthisposition,themuscleisinthemidrangewithmaximummechanicaladvantage
andstrength.
AnotherEssentialPrincipleisthatduringanyresistedtest,thesubjectpushesgently
atfirst.Ifnopainisfelt,havetheclientpushharder.Itisimportantthattheperson
doesnotmovethearmthroughspacewhileyouaredoingtheresistedtest.
Therefore,yourresistanceshouldmatchthestrengthofthesubject.
IfTest#1causesdiscomfortwhileyouarepushing,thesupraspinatusisinjured.
Butiftheclientfeelspainafteryoureleasepressureandletgo,anotherinjuryis
presentmostlikely,thesubscapularisorinfraspinatustendonisinjured.Ifthereis
nostrengthwhatsoeverandtheclientcannotpushoutatallonTest#1,thetendon
mayberuptured.
Test2PassiveElevation
Firstsaytotheclient,"Raiseyourarm
aboveyourhead."Thenplaceoneof
yourhandsontheclient'selbowand
yourotherhandatthebackofthe
sameshoulderwithyourfingers
wrappedaroundthetopofthe
shouldertostabilizethejoint.Nowtell
thepersontorelaxwhileyoupassively
testthearm.Pushthearmbackina
diagonaldirectionbehindtheperson's
head(medialandslightlyposterior)untilyoucometotheveryendoftherangeof
movement.Ifthereisstillnopainfelt,givethearmaslightjerkinthesame
direction.Thisjerkisalwaysdoneattheveryendoftherangeofmotion.Painon
thistestindicatesthatthedeepdistalendofthetendonisinjured.
Test3ThePainfulArc
Asktheclienttoliftthearmveryslowlyout
totheside,palmdown,untilthearmis
abovethehead.Instructtheclienttostopif
thereispain,andthencontinuethemotion
toseeifthepainceases.Apainfularc
meansthereisnopainatthebeginningof
thearc(thefirst70to80degrees),painin
themidrangeofthearc(from70to110
degrees)andnopainatthetopofthearc

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(110to180degrees).Painonthistestindicatesthatthesuperficialdistalendofthe
supraspinatustendonisinjured.

HealingInjuredTissues
SelfTreatmentIfthestrainisminor,severalweeks'restwillprobablybeallthat
isneeded.Ifitissevereorifadhesivescartissuehasalreadyformed,discomfort
maygoonformonths,years,orindefinitely.Ifpainisstillpresenttwotothree
weeksaftertheinjury,thepersonshouldseektreatmentfromaqualifiedhealth
careprovider.
TreatmentThesupraspinatus,asmentionedearlier,isgenerallyinjuredintwo
differentplacesatthedeepdistalendandatthesuperficialdistalend.Inorder
fortreatmenttobeeffective,thetherapistfirsthastofindtheexactlocationofthe
injuryasdescribedearlier.
Inaddition,whendealingwithshoulderinjuries,alwaysremembertheEssential
Principleknownas"referredpain."And,don'tforgettoexplaintheconceptof
referredpaintotheclientsoshedoesn'tthinkyouareworkinginthewrongarea.A
clientwhofeelspaininthebicepswillnotunderstandwhyyouareworkingatthe
topoftheshoulder,unlessyouexplainhowreferredpainworks.
1.FrictionTherapyandMassage.Ihaveusedthismethodoftreatmentonmany
supraspinatustendonswithgreatsuccess.Itisoftenveryeffectivewithina
relativelyshortperiodoftime.Inminorcases,severalweeksoftreatmentis
requiredinmoreseriouscasessixto10weeksmaybenecessary.
TheEssentialPrinciplebehindhowfrictiontherapyworksisthis:Frictiontherapy
breaksdownadhesivescartissuethatpreventsproperhealingwithinmuscles,
ligaments,andtendons.Itseparatesadhesionsandallowsnormalhealingtooccur.
Frictiontherapyalsoincreasesthebloodcirculationtoareasthatnormallyhave
verylittlebloodsupplyitaccomplishesthisthroughamild,controlledtraumatothe
tendonsandligaments.Isuggestthatfrictioningbedoneinonedirectiononlyso
boththeclientandthepractitionercanrestmomentarilybetweeneachstroke.This
methodiskinderandgentlerthanworkinginbothdirectionsatonce.
Toplacethesupraspinatustendoninapositionthatmakesitaccessiblefor
treatment,asktheclienttoputthehandoftheinjuredshoulderbehindtheback
whileinasittingposition,andthenrelaxthearm.Thetendoncanbepalpatedand
treatedonlyinthisposition.Thehumerusmustberotatedanteriorlytobringthe
supraspinatustendonoutfromundertheacromion.Inthisposition,thetendonlies
almostverticalandisaccessibletothetherapist'sfinger.
Ifyoustandinfrontoftheclient,the
thumbcanbeusedtofrictionifyou
standtotheside,theindexfinger
workswell.Standinfrontofthe
client'sshouldertofindthetendon.To
locatetheinjuredsite,findthelateral
edgeoftheacromionwithyourthumb
andworkyourwayalongittothemost
anteriorportionwherethereisasmall
bonyprominenceorbump.(The
acromionistheuppermostportionof

PhotoA

thescapularightabovetheheadof
thehumerus.)(SeePhotosAandB.)
Now,withyourthumbintheexact
centerontheveryfrontedgeofthe
acromion,andheldinahorizontal
position,slideyourthumbinferiorly
downinfrontaboutaquarterinchso
thathalfofyourthumbisonthehead
ofthehumerusandtheotherhalf
remainsontheacromion.Thedistal

PhotoBLocatingthesupraspinatustendon.

endofthetendonisdownonthe
humerusinthisgroovebetweentheacromionandthehumerusyoushouldbe
rightonit.Sincethetendoniscomingverticallydowninfront,youmustapply
frictioninahorizontaldirection(remembertoapplypressureinonedirectiononly).
Asyoufriction,youwillsnapoverthetendonifyouareintherightspot.Placethe

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fingerorthumbonthetendonandperformthefrictionmotionlaterally,withlight
pressureforasuperficialdistalendinjuryandwithmoderatetoheavypressurefor
deepdistalendtendinitis.Continuethefrictionfor6to12minutes,takingbreaksas
needed.Thefirsttimeyoudoitontheclient,workforashortertime(3to5
minutes)untilbothofyougetusedtoit.
Donotgivetheclienttoomuchdiscomfortwhileperformingthefrictiontherapy.
Startwithaverylightpressureandslowlyincreasetheforceasthetendongets
numbedwithyourfriction.Alwayswatchtheclient'sfaceforsignsofpain.Startas
gentlyasyouneedtoyoureffortswillbeinvainifyourclientdoesn'tcomeback
becauseithurttoomuch.Thetreatmentshouldfeelannoying,notpainful.Don'ttry
tofrictionawayallthescartissueinonesessiontakeyourtime.Followingthe
frictioning,massagetheupperarmandshoulderarea.Ifyouknowhowtomassage
thesupraspinatusmuscleinthesupraspinatusfossa,thatishelpfulaswell.Massage
theupperbackandneckalsotoimprovethegeneralcirculation.
Witharelativelyfreshinjury,treatmentofsupraspinatustendinitisusuallybeginsto
beeffectiveintwotothreeweeks.Formorelongstandingcases,treatmentmay
lastfromtwotofourmonths.Frictiontherapyshouldbeadministeredtwiceaweek
andshouldbeperformedinconjunctionwithmassageandtheexerciseprogram
describedbelow.Treatmenttimecanvarydependingontheseverityoftheinjury,
thegeneralhealthoftheclient,andlengthoftimetheinjuryhasbeenpresent.
2.ExerciseTherapy
Thistendonexerciseprogramisveryeffectiveifdoneconsistently.Thestretching
realignsthescartissuefiberssotheycanhealcorrectly,andtheweightcalibrated
exercisessystematicallyincreasethetendonstrength.Thisproceduremustbe
performedeverydayforsixtoeightweeksforittobeeffective.Iftheclient's
personalityissuchthatshewillnotdoitconsistently,thisprogramisnottheoneto
recommend.Inthesecases,trygivingtheclientstrengtheningexercisesonly.
Therearefivestepstotheprogram:warmup,stretch,exercise,stretch,andiceor
heat.
1.Firstwarmupthemuscletendonunitbyhavingtheclientcirclethearmforthree
orfourminutes.Sheshouldstandwiththearm2or3inchesinfrontofherbody
andmakeabig,slowcircleinfrontofher.Besureshemakesacirculararcor
movementthatisnotpainful.
2.Stretchthetendonfivetimesfor30
secondseachtime.Thestretchmimics
passivemedialrotation.Standthe
clientinfrontofadoorknobwithher
backtoit.Havehergripthedoorknob
withherarmbehindherandlunge
slowlyforwardwithonefootinfrontof
theother.Thegrippinghandshouldbe
inlinewiththespineasitstretches
behindher.Eachstretchisheldfor30
seconds.Onlyamildpullingsensation PhotoCStretchthetendonfor30seconds.
shouldbefeltintheshoulder,notpain.
Haveherrestamomentbetweenstretches,andbesuresheholdseachstretchfor
thefull30secondsrepeatingitfivetimes.Forafewweeks,checkthatclientsare
doingthisexercisecorrectly.Theyfrequentlygetitwrong.
3.TheExercise:Thisexercisemimics
resistedabduction.Havetheclientlie
onhersidewiththeinjuredarm
towardtheceiling.Holdingthe
appropriateweight,sheshouldliftthe
armslowlytowardtheceilingabout20
to30degreesonly,thenbringitback
downtohersidewithoutrestingiton
herhip.Ifusingaweightcauses
discomfort,usenoweightatall.Ifno
weightcausesdiscomfort,bendthe
armattheelbowtoabout90degrees
asthisshortenstheleverarmand
effectivelylightenstheweightofthe
armthatisbeinglifted.Alwaysdo

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threesetsof10ofthisexercise.
Fortheexercisepartoftheprogramto
beeffective,onlythethirdsetof10
shouldcausesometirednessorstress
intheshoulder.Thisexercise
challengesthetendonstructureand
causesittostrengthen.Iffatigueor
distressisfeltduringthefirst10or20
repetitions,toomuchweightisbeing
used.Stopandbeginthenextdaywith PhotosDandEGradualstrentheningexercise.
lessweight.Ifnotirednessorstressisfelt,notenoughweightisbeingused.Try
againthenextdaywithalittlemoreweight.Ifanyweightistoomuch,beginwith
noweightatfirstasthismuscleisquiteweakinmostpeople.Ifthatprovestoo
easy,tryonehalfto1poundtobegin.
Onceyouestablishthecorrectweightfortheclient'scondition,usethesameweight
foraweekorsooruntiltheexerciseseemseasy.Then,duringthesecondweek,
increasetheamountofweighttothatwhichwillcausetirednessinthelast10
repetitions(usuallya1poundincrement).Ofcourse,iftheexerciseisstilldifficult,
stayatthesamelevelofweightalittlelonger.Atthebeginningofeachnewweek,
increasetheweightagain.Dothiseachweekforsixtoeightweeks.Mostpeople
needtostartwith1or2poundsandbuildupto5or6poundsoverthenextsixto
eightweeks.
4.Stretchfivetimesfor30secondseach,exactlyasin#2above.
5.Applyiceorheattotheaffectedareaforfiveminutes.
Inorderfortheiceorheattoreach
thetendon,theclientmustliefaceup
withthehandbehindthebackinthe
mediallyrotatedpositionsoasto
exposethetendoninfrontandslightly
belowtheacromion.Theiceorheatis
thenappliedtothefrontofthe
shoulder.
Thisprogrammustbedoneeveryday,
sevendaysaweek,oritwillnotbe

PhotosFProperpositioningforapplyingiceorheat.

effective.Itisusuallydoneonceaday
atfirst,butshouldbedonetwiceadayafterabouttwoweeks.Apersonmayfeel
slightdiscomfortafterwardforseveralhours.Thisfeelingisallrightunlesssoreness
lastsforseveraldays.Ifthediscomfortpersists,discontinuetheprogramuntilthe
personhashadalittlemoretreatmentfromyou.Aftertheclientisfeeling
completelywell,theprogramshouldbecontinuedfortwoadditionalweeks.
Encourageyourclientstoreturntofullactivityveryslowly,ortheywilllikely
reinjurethemselves.

PrinciplesatWork
Asmentionedabove,Ihavehadgreatsuccessusingfrictiontherapyinmyclients
withsupraspinatustendinitis.LearningtheEssentialPrincipleschangedmypractice
dramaticallyforthebetterwiththeseclientsandmanyothers.Worktounderstand
theseprincipleswell,andtheywillhelpyoutoimproveyourpractice,too.
BenBenjamin,Ph.D.,holdsadoctorateineducationandsportsmedicine.Heisthe
founderandpresidentoftheMuscularTherapyInstituteinCambridge,Mass.,and
hasbeeninprivatepracticefor40years.HeistheauthorofListentoYourPain,Are
YouTense?andExerciseWithoutInjury.Hecanbecontactedatbb@mtti.com.
Reference
1CurwinandStanish.Tendinitis:Itsetiologyandtreatment.1984:D.C.Heathand
Company.

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