A supraspinatus tear is a tear or rupture of the tendon of the supraspinatus muscle. The supraspinatus is part of the rotator cuff of the shoulder. Most of the time it is accompanied with another rotator cuff muscle tear.
This can occur in due to a trauma or repeated micro-trauma and present as a partial or full thickness tear. Most of the time the tear occurs in the tendon or as an avulsion from the greater tuberosity.
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| Supraspinatus Tear |
Clinical Relevant Anatomy
The shoulder joint is made up of three bones: the humerus, scapula and clavicle. The head of humerus and glenoid of the scapula form a ball-and-socket joint.
The supraspinatus muscle is located on the back of the shoulder, forming part of the rotator cuff. The rotator cuff consists of Supraspinatus, Infraspinatus, Subscapularis and teres minor.
The rotator cuff covers the head of the humerus and keeps it into place. These muscles help to lift and rotate the arm.
Epidemiology/Etiology
The etiology of supraspinatus tears is multifactorial, consisting of age-related degeneration, microtrauma and macrotrauma. The incidence increases with the age to about 50% during the 80s, mostly affecting the dominant arm.
Injury and degeneration are the two main causes of rotator cuff tears. Rotator cuff tears are associated with older patients, a history of trauma and mostly affect the dominant arm. The most common risk factors for a tear consist of a history of trauma, dominant arm and age.
Mechanism of Injury
Acute tear: Can occur with other shoulder injuries (e.g. clavicle fracture of shoulder dislocation)
- Fall on your outstretched arm
- Heavy lifting something too heavy
- Degenerative: Wear and tear of the tendon slowly over time
- Increases with the age
- More common in the dominant arm
When you have a degenerative tear in one shoulder, you have a greater risk for a tear in the opposite shoulder, even if you have no pain in the opposite shoulder.
Risk Factors
- > 40 years old
- Male > Female
- Smoking
- Genetics
- Hypercholesterolemia
- Body mass index
- Height
- Repetitive stress/lifting
- History of trauma
- Lack of blood supply
- Bony spurs
- Overhead activities and other people who do overhead work: Tennis players, Baseball pitchers, Painters, Carpenters, Plumbers.
- Traumatic injury e.g. fall (more common cause in younger individuals)
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| Supraspinatus Tear |
Characteristics/Clinical presentation
Supraspinatus tears normally present as partial or full-thickness tears. It can be asymptomatic or symptomatic.
Partial thickness:
- Incomplete disruption of muscle fibers
- Can progress to complete tear - Increasing pain is normally the first sign of progression of a tear
Full thickness:
- Complete disruption of muscle fibers
- Large tears (1-1,5cm) have a high rate of progression
- If progression is suspected in conservatively managed cases - further investigation is warranted
- Smaller tears (<1cm) progress slower
Signs and Symptoms
- Pain
- Pain/worsening pain (in cases where tears are progressing): Most common symptom
- Pain when lifting and lowering your arm or with specific movement
- Pain at rest
- Pain at night, predominantly when you lie on the affected shoulder
- Traumatic tears: Sudden, intense pain often accompanied by a snapping sensation and immediate weakness in the upper arm
- Located anterolaterally and superiorly
- Referred to the level of the deltoid insertion with full-thickness tears
- Repetitive strain tear: Starts off mild and only when lifting your arm; over time the pain can become more noticeable at rest
- Aggravated in overhead or forward-flexed position
- Limited range of motion
- Reduced forward elevation, external rotation and abduction
- Struggle with activities like reaching behind back, combing hair and overhead activities
- Stiffenss
- Muscle weakness
- Weakness when rotating or lifting your arm
- Crepitus, Clicking, and Instability
Differential Diagnosis
- Acromioclavicular joint injury
- Brachial plexus injury
- Bicipital tendinopathy
- Cervical radiculopathy
- Cervical spine sprain
- Cervical strain injuries
- Cervical disc injuries
- Cervical nerve root injury
- Cervical Spondylosis
- Cervical discogenic pain syndrome
- Clavicular fracture
- Sternoclavicular joint disorders
- Infraspinatus syndrome
- Contusions
- Rotator cuff tear
- Shoulder dislocation
- Myofascial pain
- Shoulder impingement syndrome
- Superior labrum lesions
- Shoulder subluxation
- Angina pectoris
- Myocardial infarction
- Subacromial impingement
- Osteoarthritis
- Rheumatoid arthritis
- Subscapular nerve entrapment
- Shoulder instability
- Anterior instability
- Posterior instability
Diagnostic Procedures
Physical Examination
Muscle power
- Test supraspinatus by resisting abduction at 90° and internal rotation
- Scapular movement may be affected
- Palpation:
- Forearm behind back to palpate rotator cuff just anterior and below the acromion
- Muscle atrophy present
- Tenderness
Special tests
Drop-arm test: Active shoulder abduction to 90°, then return
Positive: Dropping the arm down with pain indicates a positive test
Jobe/supraspinatus/empty can test: Resist shoulder abduction and internal rotation
Positive: Pain/weakness
Full can test: Resisted shoulder abduction in external rotation
Positive: Pain/weakness
Subacromial grind test: Patient standing and examiner standing facing the patient, the examiner grasps the patient's flexed elbow.
The shoulder is passively abducted in the scapular plane to 90°. The examiner's other hand is placed over the patient's shoulder overlying the anterior acromion and greater tuberosity. The examiner passively internally and externally rotates the shoulder detecting the presence of palpable crepitus.
Positive: Palpable crepitus.
Special Investigations
X-rays
- Excluding sclerosis and osteophyte formation on the acromion
- X-rays measures the size of the subacromial space
- Supraspinatus tear as seen in radiographics
MRI
MRI Scan shows partial or full tears in the tendons of the rotator cuff, inflammation to weak structures and cracks in the capsule
CT Scan
CT scan is able to localize tendon when patient positioned with forearm behind the back
Ultrasound
Ultrasound helps in localising tendon
Outcome Measures
- Rotator Cuff Quality of Life (RC-QOL) scale
- Western Ontario Rotator Cuff (WORC) index
- Disabilities of the Arm, Shoulder and Hand (DASH)[1]
Medical Management
- Conservative Management
- Older (>70 years) patients with a chronic tear
- Patients with irreparable tears with irreversible changes
- Patients of any age with small (<1 cm) full-thickness tears
- As a result of the slow rate of progression of these tears
- Patients without a full-thickness tear
Management includes:
NSAID's:
Ibuprofen
Corticosteroid injections:
Eliminate pain for a period of time, making physiotherapy management easier
Tendon tissue can be weakened by these injections (which would have an adverse effect on the outcome of a possible surgery)
Surgical Management
Failed conservative management
Larger symptomatic full-thickness tears (1-1,5cm) as a result of the high rate of progression. Should be considered for earlier surgical repair in younger patients if the tear is repairable and the muscle degeneration is limited
- Acute large tears (>1 cm-1.5 cm) or
- Young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes
- Complete tear with significant pain and dysfuction after 6 months of treatment
- Repeated dislocations
- Rotator cuff repair
Mostly done arthroscopically. Severity (partial vs full-thickness) will determine the approach.
Partial repair: The tendon and surrounding bone will be smoothed to avoid further damage and therefore allowing the tendon to heal mostly on its own[16]
Complete tear: Tear in middle of tendon: Suture the two parts of the tendon back together. Tear close or on its point of attachment on the head of the humerus: Attach the tendon back to its original place by an anchor (sometimes two).
This anchor actually consists of a small screw that is bored into the head of the humerus with on the back surgical wires which hold the tendon in place.
Physiotherapy Management
Physiotherapy management depends on the extend of the tear, and plays in important role in both conservative management as well as post-surgical rehabilitation. More details can also be obtained from the rotator cuff page.
- Improve pain together with NSAID’s (2-6 weeks)
- Cryotherapy (only in first 48 hours)
- Massage
- Improve circulation (to control inflammation and speed up the healing process)
- Improve range of motion:
- Stretching (careful with timing, as stretching of acute injury may aggravate the tear
- Crossover arm stretch: 12 seconds, 5 times a day; 5-6days/week
- Kristian Berg. Prescriptive stretching; Human Kinetics
- Door stretch: 5 x 30 seconds (5 second rest in between)
- Passive/Active range of motion
- Pendulum exercises: Forward and back, side-to-side, circular motion. 2 sets of 10 a day, 5-6days/week
- Symptom limited active-assisted range of motion exercises
- Kristian Berg. Prescriptive stretching; Human Kinetics
Increase strength
- Rotator cuff (especially supraspinatus) strengthening to improve muscle control and strength – 13,19
- Prone Horizontal Abduction progress by using theraband
- Prone Row with External Rotation
- Regain function of affected upper limb (up to 3 months)
- Home exercise programme
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