Supraspinatus tendinitis

Introduction
• Supraspinatus tendonitis is a common shoulder
problem, also known as “Shoulder Impingement
Syndrome” or “Painful Arc Syndrome”.
• Supraspinatus symptoms may come on suddenly
after an injury, or build-up gradually on and off
over years with no obvious cause.
• The classic sign of supraspinatus tendonitis is a
painful arc when moving the arm between 60-
120 degrees of abduction as the tendon gets
squashed against the bone in that range.
• Supraspinatus tendon disorders have been
classically described as degenerative processes
starting from an acute tendinitis, progressing to
tendinosis, and eventually resulting in partial or
full thickness tendon rupture. However,
currently the terms tendinitis and tendinosis
should be avoided and the word tendinopathy
should be preferred as recent research shows
that there are minimal or no inflammatory cells
in painful tendons.
 Clinical Relevant Anatomy
• The supraspinatus muscle is of the greatest
practical importance in the rotator cuff, it
derives its innervation from the suprascapular
nerve and stabilizes the shoulder, externally
rotates and helps abduct the arm, by initiating
the abduction of the humerus on the scapula.
• Any friction between the tendon and the
acromion is normally reduced by the
subacromial bursa.
• Supraspinatus lies across the top of the shoulder
blade. The supraspinatus tendon passes through a
narrow channel between the acromion and the head
of the humerus, known as the “sub acromial space”.
• The subacromial space and is only around 7-14mm
deep and is tightly packed with the:

• Supraspinatus Tendon
• Subacromial Bursa: a fluid filled sac that helps
reduce friction through the subacromial space
• Joint Capsule: the upper part of the sac that
surrounds the joint
• Long Head of Biceps Tendon
• The subacromial space is narrows considerably
when the arm is raised around shoulder height,
particularly when internally rotated (thumb
pointing down). The space then opens back up
once the arm is raised higher and externally
rotated (thumb pointing up).
 Structure of the supraspinatus tendon
• Along with the subscapularis, teres minor, and
infraspinatus muscles, the supraspinatus joins to form the
RC which functions to compresses the head of the
humerus into the glenoid fossa of the scapula..
• The tendon of the supraspinatus muscle is a specialized
nonhomogeneous structure subjected to both compressive,
and tensile forces.Moreover, in order to better resist
compression, and to lubricate collagen bundles during
shoulder movements, there is an increased number of
glycosaminoglycans within the supraspinatus tendon when
compared with the distal region of the biceps tendon.
• The supraspinatus tendon of the rotator cuff is
involved and affected tendons of the
musculoskeletal system and becomes
degenerated, most often as a result of
repetitive stresses and overloading during
sports or occupational activities.
• The tendon of the supraspinatus commonly
impinges under the acromion as it passes
between the acromion and the humeral head.
• Sometimes, with wear and tear supraspinatus tendinitis
results, which is commonly associated with inflammation
of the bursa also called subacromial bursitis. There may
even be little tears in the tendon fibres – partial tears or
sometimes even complete tears. It is typically seen in
people aged 25-60.
• Painful Arc Syndrome, also called shoulder impingement
syndrome, subacromial impingement, supraspinatus
syndrome, swimmer’s shoulder, and thrower’s shoulder.
It is a clinical syndrome which occurs when the tendons
of the rotator cuff muscles become irritated and inflamed
as they pass through the subacromial space, the passage
beneath the acromion. This can result in pain, weakness
and loss of movement at the shoulder.
• Tendinitis and partial tears in the supraspinatus
tendon causes a ‘painful arc’ since as the
person elevates his arm sideways, the tendon
begins to impinge under the acromion through
the middle part of the arc, and this is usually
relieved as the arm reaches 180 degrees
(vertical).
• A supraspinatus tendon tear is a common throwing
injury. When you throw something, for example a
Javelin, you use the powerful chest muscles to propel it
forwards. After you have release the Javelin your arm
must decelerate. As a result, huge forces go through the
supraspinatus and other rotator cuff muscles.
• But few people bother to train these muscles. As a
result, a muscle imbalance leaves the supraspinatus
weak in comparison to the powerful ‘throwing
muscles’.
• A heavy fall onto the shoulder can also result in
injuring this muscle. Injury can occur to the tendon as it
inserts into the top of the shoulder on the humerus.
 Throwing Biomechanics
• Throwing, for example, baseball pitching, is one
of the most intensely studied athletic motions.
• Although the focus has been more on the
shoulder, the entire body movement is required to
perform the act of throwing.
Phases
The phases of an overhead throw consist of a:
• wind-up,
• stride,
• cocking,
• acceleration,
• deceleration and
• follow through phase
Shoulder injuries
• Injuries to the shoulder are most common baseball pitching
and more particularly in the late cocking and deceleration
phase. Following is the list of potential shoulder injuries in
different phases of pitching.
• Windup - No injuries are common.
• Cocking - Anterior subluxation, internal impingement, glenoid
labrum lesions, subacromial impingement.
• Acceleration - Shoulder instability, labral tears, overuse
tendinitis, tendon ruptures.
• Deceleration - Labral tears at the attachment of long head of
biceps, subluxation of the long head of biceps by tearing off a
transverse ligament, lesions of the rotator cuff.
• Follow Through - Tear of the superior aspect of glenoid labrum
at the origin of the biceps tendon, subacromial impingement
Racquet sports include tennis, racquetball, and
badminton.
• Serving the ball requires a tremendous amount of
energy and force, and it accounts for 65% of the
swings taken in tennis.
• Studies show that tennis players are at an increased
risk of rotator cuff tears due to overuse of the shoulder.
Baseball
• Just like tennis players are at an increased risk of
developing rotator cuff injuries due to repetitive
swings, so are baseball players.
• Any player who throws is at risk for a shoulder injury,
but studies show that pitchers are most likely to injury
their rotator cuff due to the repetitive throwing motion.
Swimming
• Swimming is touted as a low-impact sport that’s easy on joints.
The repetitive overhead motion can increase risk of rotator cuff
tears, rotator cuff tendonitis, swimmer’s shoulder, and cartilage
tears.
Volleyball
• Just like tennis and baseball demand a lot from shoulders, so does
volleyball. Serving, spiking, and blocking can lead to both
overuse injuries and acute injuries.
Trauma
• While most rotator cuff injuries result from overuse in older
individuals and overhead athletes, tears may also occur during a
fall or trauma.
• Collision sports such as ice hockey, football, rugby might put an
athlete at risk.
Causes
• The supraspinatus tendon muscle unit sees its greatest stress forces during shoulder
abduction. It acts to depress the humeral head during abduction and forward flexion
positions. This depression keeps the humeral head centered on the glenoid and
functions to allow for the deltoid to maintain its mechanical advantage, and thereby
its power.
• Supraspinatus tendonitis develops when there is repetitive friction on the tendon or
it is repeatedly squashed or “impinged” in the subacromial space. This leads to
inflammation and gradual degeneration of the tendon. In time, tears may also
develop in the supraspinatus tendon leading to a partial or complete rotator cuff
tear.
Common causes of painful arc syndrome include:
• Repetitive Overhead Activities: activities where your arm is frequently raised,
such as sports e.g. tennis and swimming, and gardening e.g. hedge trimming or
pruning
• Heavy Work: Repetitive heavy lifting overhead e.g. builders and labourers
• Posture: spending long periods slouched forwards reduces the subacromial space
• Injury: e.g. fall on to an outstretched hand
• Participate in overhead sports (handball, volleyball, tennis, baseball)
• Age: The subacromial space tends to narrow with age due to wear and tear
• Primary Shoulder Impingement: Bone spurs or
abnormal acromion position/shape reduce the
subacromial space
• Secondary Shoulder Impingement: Dynamic shoulder
instability – weakness in the rotator cuff muscles leads
to poor control and thus friction
• Supraspinatus Tendonitis may develop in isolation but it
is often associated with other shoulder problems such as:
• Subacromial bursitis
• Shoulder impingement syndrome
• Biceps tendonitis
• Rotator cuff tears
Pathophysiology
• There are multiple proposed etiologies for rotator cuff
tendonitis.
• Traditionally, Neer's hypothesis of a predictable
breakdown in three stages is still commonly used.
• He proposed a predictable breakdown in three stages:
edema and hemorrhage, fibrosis and tendonitis, and
eventual tendon rupture.
• He reported that overhead activities and heavy labor might
predispose a patient to this pathway.
• Smith et al. showed lower blood supply in pathologic
supraspinatus tendons when compared to their healthy
counterparts, suggesting that there may be a significant
vascular component to tendon breakdown as well.
Clinical features
• Patients present with progressive subdeltoid aching that is
aggravated by abduction, elevation, or sustained overhead activity.
They feel also tenderness and a burning sensation in their shoulder.
• The pain may radiate to the lateral upper arm or may be located in
the top and front of the shoulder. It typically becomes worse with
overhead activity. Initially, the pain is felt during activities only, but
eventually may occur at rest.
One has to think of supraspinatus tendinopathy when the patient
says:
• Pain increases with reaching.
• Pain is felt after frequent repetitive activity at, or above shoulder.
• Patient feels weakness of resisted abduction and forward flexion,
especially with pushing and overhead movements.
• Patient has difficulty sleeping at night due to pain, especially when
lying on the affected shoulder, and with an inability to sleep.
• Patient has difficulties with simple movements, such as brushing hair,
putting on a shirt or jacket, or reaching the arm above shoulder height.
• Patient has a limited range of motion in the shoulder.
• There is a painful arc between 70° and 120° of abduction. This is the
classic symptom of supraspinatus tendonitis, hence the name “Painful Arc
Syndrome”
• Full PROM: Whilst pain may limit active shoulder
movement, passive movement (where the arm is
moved by someone else so your muscles are
completely relaxed) is typically full or nearly full
with pure supraspinatus tendonitis as long as there
are no other shoulder impingement problems.
So supraspinatus tendinitis is usually consistent
with anterior instability causing posterior tightness.
The problems that patient with Supraspinatus
Tendinitis complain off, are pain, inflammation,
decreased ROM, strength, and functional activity
History and Physical
• Pain is the most common reason for presentation
in rotator cuff injury, and pain lateral or anterior
are the most common sites of pain in all comers.
• For example, anterior pain may be indicative of
proximal biceps tendon pathologies, while
anterolateral or straight lateral pain may be
indicative of subacromial impingement or rotator
cuff dysfunction and posterior shoulder pain may
include, but not be limited to, degenerative
conditions of the shoulder and/or referred pain
from the neck.
• To examine the shoulder, first inspect the shoulder, as well as
the scapula, for any obvious asymmetry.
• Evaluate for scapular winging or dyskinesia. There may or
may not be wasting about the scapula if rotator cuff
pathology is present.
• To perform a focused examination of the supraspinatus, ask the
patient to forward flex the arm. Pain at liftoff or pain at 90 to
120 degrees of active elevation may indicate rotator cuff
pathology.
• Furthermore, pain during active slow de-elevation of the arm
may indicate cuff pathology.
• Care is necessary to rule out adhesive capsulitis as out as a
diagnosis. In this scenario, the clinician should evaluate both
active and passive (supine) range of motion. In isolated
supraspinatus tendinitis (or rotator cuff syndrome/dysfunction),
passive ROM should be full in all planes
• The neurovascular exam should be normal in
patients with isolated rotator cuff dysfunction or
tendonitis.
• Decreased pulsed with overhead arm
positioning, radicular or dermatomal sensory
abnormalities, or focal weakness outside of the
shoulder should raise the examiner to look for
alternate diagnoses including cervical
radiculopathy, thoracic outlet syndrome, brachial
plexopathy, or peripheral nerve compression.
 Physical test
• Full Can Test
Purpose
• The Full Can Test is used to assess the function
of Supraspinatus muscle and tendon of the shoulder
complex.
Technique
• The patient can be seated or standing for this test, holding
their arm in 90° of elevation in scapular plane with full
external rotation of the glenohumeral joint. In this position,
the patient's thumb should be pointing up. The therapist
should stabilize the shoulder while applying a downward
force to the arm whilst the patient tries to resist this motion.
This test is considered positive if the patient experiences
pain or weakness with resistance to the shoulder complex.
Empty Can Test or Job’s Test.
Purpose
• The Empty Can Test is used to assess the supraspinatus
muscle and supraspinatus tendon.
Technique
• The patient can be seated or standing for this test.
• The patient's arm should be elevated to 90 degrees in the
scapular plane, with the elbow extended, full internal
rotation, and pronation of the forearm. This results in a
thumbs-down position. The therapist should stabilize the
shoulder while applying a downwardly directed force to the
arm, the patient tries to resist this motion. This test is
considered positive if the patient experiences pain or
weakness with resistance.
Drop Arm Test
The Drop Arm Test is a test for rotator cuff tears, specifically of the
supraspinatus tendon.
Starting Position
• This test can be performed with the patient in standing or sitting. The
examiner supports the patient’s arm to be tested and abducts it to 90
degrees. Alternatively, the examiner may abduct the arm to above 90
degrees, possibly even to full abduction. Another variation is to have the
patient actively abduct their arm to the starting position.
Test Movement
• The patient is asked to actively lower their arm from abduction to their
side in a slow and controlled manner.
Positive Test
• A positive test is determined by the patient’s inability to smoothly
control the lowering of their arm or the inability to hold the arm in 90
degrees of abduction. In a positive test that starts above 90 degrees of
abduction, the patient will tend to have difficulty controlling the
movement around 90 degrees of abduction
Differential Diagnosis of Supraspinatus Tendinities
Acromioclavicular Joint Injury
Bicipital Tendonitis
Brachial Plexus Injury
Cervical Radiculopathy
Cervical Spine Sprain/Strain Injuries
Clavicular Injuries
osteoarthritic glenohumeral joint
Infraspinatus Syndrome
Infective causes like acute pyogenic arthritis and osteomyelitis
Adhesive capsulitis or frozen shoulder and calcific tendonitis
Myofascial Pain in Athletes
Neoplastic causes like tumor metastasis
Shoulder Dislocation
Subacromial impingement
Superior Labrum Lesions
Swimmer’s Shoulder
Traumatic fractures and dislocation
Medical Management
• The treatment used to manage a supraspinatus
tendonitis depends on the etiology of the pathology.
• At first a conservative treatment is preferred. This
treatment involves physiotherapy, nonsteroidal anti-
inflammatory drugs (NSAIDs), ice treatments and
resting.
• Corticoid injections can also be used additional to
physical therapy.
• A surgical intervention can be a solution if there is
no improvement after 3-6 months of conservative
treatment.
Physiotherapy Management
• The main goal in the acute phase (initial phase) is to
alleviate pain, inflammation, prevent aggravation of
pain, reduce muscle wasting
• Electrotherapy modalities should be considered in
order to avoid painful aggravation. Modalities such as
SWD,IFT, TENS, ultrasound and cryotherapy can
provide temperory relief in acute phase.
• Strengthening exercises such as isometric exercises
should be considered in order to work out the shoulder
girdle musculatures. Proper home exercise programs
should also be taught in conjuction with proper
ergonomics.
• The management of a supraspinatus tendonitis consists
of different progressive exercises.
• There are three phases of treatment: Immobilization,
passive/assisted range of motion, progressive
resistance exercises of Supraspinatus Muscle.
• Cryotherapy, soft tissue techniques and wearing a
sling/taping are some other techniques to relieve pain.
• Gentle range-of-motion exercises, such as Codman’s
classic pendulum exercises, maintain range of motion
and prevent development of adhesive capsulitis.
• Once pain has been reduced, joint mobilisations,
massages, muscle stretches, active-assisted and active
exercises are needed to improve the ROM again.
• Deep friction massage (DFM), also known as cross friction
massage, is a specific connective tissue massage that was
developed by James Cyriax. The purpose of DFM is to: maintain
the mobility within the soft tissue structures of ligament, tendon,
and muscle, and prevent adherent scars from forming.

• Active-assisted mobilisations can be done by the patient

himself/herself by using an exercise bar.
• Strengthening these muscles will keep the shoulder joint more
stable and prevent further injuries. Eccentric exercises will also be
more effective than concentric exercises.