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. This mechanism is multifactorial.
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| Supraspinatus Tendinopathy |
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.
The anterior margin of the supraspinatus is defined by the posterior edge of the rotator interval that separates the supraspinatus from the rolled superior border of the subscapularis.
The posterior margin of the supraspinatus is marked by the extension of the raphe between supraspinatus and infraspinatus around the scapular spine.
The anterior portion of the supraspinatus is composed of a long and thick tendinous component whereas the posterior portion has been shown to be short and thin.
An anatomic dissection study of the supraspinatus footprint found that the mean anterior to posterior dimension of the supraspinatus tendon was 25 mm, with a mean medial to lateral thickness of the footprint of 12 mm - the mean distance from the cartilage to the supraspinatus footprint was 1.5 mm at mid tendon.
The supraspinatus and infraspinatus tendons fuse 1.5 cm proximal to their insertions. Collagen is the major matrix protein of supraspinatus tendons, consisting of > 95% type I collagen, with lesser amounts of other collagens including collagen type III.
The causes of supraspinatus tendinopathy can be primary impingement, which is a result of increased subacromial loading, and secondary impingement, which is a result of rotator cuff overload and muscle imbalance. The table below gives a view on the different extrinsic and intrinsic factors.
An anatomic dissection study of the supraspinatus footprint found that the mean anterior to posterior dimension of the supraspinatus tendon was 25 mm, with a mean medial to lateral thickness of the footprint of 12 mm - the mean distance from the cartilage to the supraspinatus footprint was 1.5 mm at mid tendon.
The supraspinatus and infraspinatus tendons fuse 1.5 cm proximal to their insertions. Collagen is the major matrix protein of supraspinatus tendons, consisting of > 95% type I collagen, with lesser amounts of other collagens including collagen type III.
Epidemiology/Etiology
The mean age of onset of this complication is in the sixth decade (age 50 to 59), and it is more frequent in diabetic patients[5]. It is also a common cause of shoulder pain in athletes whose sports involve throwing and overhead motions.The causes of supraspinatus tendinopathy can be primary impingement, which is a result of increased subacromial loading, and secondary impingement, which is a result of rotator cuff overload and muscle imbalance. The table below gives a view on the different extrinsic and intrinsic factors.
Characteristics/Clinical presentation
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.
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.
Patient had a former shoulder trauma.
The shoulder may be warm and there may be fullness anterolaterally. Further, there is a painful arc between 70° and 120° of abduction.
Supraspinatus tendinopathy is usually consistent with anterior instability causing posterior tightness. The problems that patient with Supraspinatus Tendinopathy complain of are: pain, inflammation, decreased ROM, strength, and functional activity.
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.
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.
Patient had a former shoulder trauma.
The shoulder may be warm and there may be fullness anterolaterally. Further, there is a painful arc between 70° and 120° of abduction.
Supraspinatus tendinopathy is usually consistent with anterior instability causing posterior tightness. The problems that patient with Supraspinatus Tendinopathy complain of are: pain, inflammation, decreased ROM, strength, and functional activity.
Differential Diagnosis
In general, the causes of an acute painful shoulder can be classified into different categories, according to the prevailing patho-anatomy. These include:- Acromioclavicular Joint Injury
- Bicipital Tendinopathy
- Brachial Plexus Injury
- Cervical Disc Injuries
- Cervical Discogenic Pain Syndrome
- Cervical Radiculopathy
- Cervical Spine Sprain/Strain Injuries
- Clavicular Injuries
- Contusions
- Infraspinatus Syndrome
- Infective causes like acute pyogenic arthritis and osteomyelitis
- Inflammatory causes like gouty arthritis, adhesive capsulitis or frozen shoulder and calcific tendinopathy
- Myofascial Pain in Athletes
- Neoplastic causes like tumor metastasis
- Shoulder Dislocation
- Subacromial impingement
- Superior Labrum Lesions
- Swimmer's Shoulder
- Traumatic fractures and dislocations
Fluid intensity filling an incomplete gap in the tendon on fat suppressed T2-weighted sequences changes are seen on MRI for partial-thickness tears. On MRI, an area of high signal intensity on all pulse sequences outlines complete disruption of the tendon.
Testings
- Neer’s sign
- Hawkin’s sign
- Supraspinatus challenge test = “The Empty Can” sign = Job ‘s test
- Drop arm test
- Impingement test
Medical Management
The treatment used to manage a supraspinatus tendinopathy depends on the etiology of the pathology. At first a conservative treatment is preferred. This treatment involves physical therapy, 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.
NSAIDs may be the first choice for mild to moderate symptoms, if there are no contraindications to these agents. A short term use (7-14 days) of NSAIDs is useful to relieve the pain associated with a tendinitis. However, there is little evidence supporting a long term course of NSAIDs.
Moderate to severe symptoms may require a local subacromial corticosteroid injection. For more information about corticosteroid injections.
The major indications for surgery are ongoing pain, loss of function, failure to respond to conservative therapy for 3 months or evidence of an acute tear in a younger patient.
NSAIDs may be the first choice for mild to moderate symptoms, if there are no contraindications to these agents. A short term use (7-14 days) of NSAIDs is useful to relieve the pain associated with a tendinitis. However, there is little evidence supporting a long term course of NSAIDs.
Moderate to severe symptoms may require a local subacromial corticosteroid injection. For more information about corticosteroid injections.
The major indications for surgery are ongoing pain, loss of function, failure to respond to conservative therapy for 3 months or evidence of an acute tear in a younger patient.
Surgical approaches include calcium deposit resection, with or without subacromial decompression, bursal resectionA and acromioplastyB, using either arthroscopic or open methods.
It’s also possible to split off the coraco-acromial ligament to enlarge the space between acromion and humerus. This can cause instability, but we can compensate it with some training of the rotator cuff. With physical therapy it takes patients up to 4 months to recover. The goal of a surgery is to obtain pain relief, increased range of motion and increased power.
Acromioplasty: Generally, it implies removal of a small piece of the surface of the acromion that is in contact with a tendon causing, by friction, damage to the latter tissue.
Acromioplasty: Generally, it implies removal of a small piece of the surface of the acromion that is in contact with a tendon causing, by friction, damage to the latter tissue.
Physical Therapy Management
The main goal in the acute phase (initial phase) is to alleviate pain, inflammation, prevent aggravation of pain, reduce muscle wasting and normalize the arthrokinematics of the shoulder girdle.A period of rest should be considered in order to avoid further aggravation and shoulder discomfort.
Passive modalities should be considered in order to avoid painful aggravation. Modalities such as ultrasound, cryotherapy and electrical muscle stimulation can provide temperory relief in acute phase.
Passive modalities should be considered in order to avoid painful aggravation. Modalities such as ultrasound, cryotherapy and electrical muscle stimulation 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 tendinopathy consists of different progressive exercises. There are three phases of treatment: Immobilization, passive/assisted range of motion, progressive resistance exercises.
Early management includes avoidance of repetitive movements that aggravate the pain. Patients should be informed about pain provoking postures and movements. Cryotherapy, soft tissue techniques and wearing a sling/taping are some other techniques to relieve pain.
The management of a supraspinatus tendinopathy consists of different progressive exercises. There are three phases of treatment: Immobilization, passive/assisted range of motion, progressive resistance exercises.
Early management includes avoidance of repetitive movements that aggravate the pain. Patients should be informed about pain provoking postures and movements. 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. Active-assisted mobilisations can be done by the patient himself/herself by using an exercise bar.
We can also use a rope and pulley, this way the unaffected arm is able to pull the affected one into anteversion.
Strengthening exercises should work on the external rotators, internal rotators, biceps, deltoid, and scapular stabilizers.
Strengthening these muscles will keep the shoulder joint more stable and prevent further injuries. Eccentric exercises will also be more effective than concentric exercises.
Stretching exercises should be done by repeating the exercise 3 times and holding the stretch each time for 30 seconds.
Neuromuscular control exercises also may be initiated[26]. PNF patterns will increase strength in rotator cuff muscles and increase the stability of the shoulder. We can use four different patterns.
Modalities that also may be used as an adjunct include cryotherapy, hyperthermia[43], transcutaneous electrical nerve stimulation and ultrasound. Intensive ultrasound therapy has been shown to increase calcium resorption, but this requires frequent treatment that may not always be practical[44]
Movement: pressure into the supraspinous fossa, active adduction of the right glenohumeral joint, then releasing the pressure into the supraspinous fossa, and back to the starting position.
At the end of the therapy you should initiate plyometric and sports-specific exercises.
Patient education is again reemphasised, maintaining proper mechanics, strength, and flexibility, and having a good understanding of the pathology. The patient should also show an understanding of a home exercise program with the proper warm-up and strengthening techniques.
Strengthening these muscles will keep the shoulder joint more stable and prevent further injuries. Eccentric exercises will also be more effective than concentric exercises.
- Sidelying external rotation with dumbbell against gravity
- Prone horizontal abduction with dumbbell against gravity
- Prone anteflexion in the plane of the scapula
- Prone row with external rotation
- External rotation with Thera-tubing (standing position)
- Horizontal abduction with Thera-tubing (standing position)
- Rows with Thera-tubing (standing position)
- Elevation in the plane of the scapula (standing position)
- Scapula settings
Stretching exercises should be done by repeating the exercise 3 times and holding the stretch each time for 30 seconds.
Neuromuscular control exercises also may be initiated[26]. PNF patterns will increase strength in rotator cuff muscles and increase the stability of the shoulder. We can use four different patterns.
Modalities that also may be used as an adjunct include cryotherapy, hyperthermia[43], transcutaneous electrical nerve stimulation and ultrasound. Intensive ultrasound therapy has been shown to increase calcium resorption, but this requires frequent treatment that may not always be practical[44]
Self-exercise
Patient's starting position: sitting, arm abducted to a position before symptoms appear, contact with three finger tips of the left hand in the supraspinous fossa.Movement: pressure into the supraspinous fossa, active adduction of the right glenohumeral joint, then releasing the pressure into the supraspinous fossa, and back to the starting position.
At the end of the therapy you should initiate plyometric and sports-specific exercises.
Patient education is again reemphasised, maintaining proper mechanics, strength, and flexibility, and having a good understanding of the pathology. The patient should also show an understanding of a home exercise program with the proper warm-up and strengthening techniques.
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