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composition and has been categorised into four transition zones (34). The first zone is proper tendon,
made up of largely type I collagen and small amounts of decorin. The second zone is fibrocartilage
and consists of largely types II and III collagen, with small amounts of types I, IX and X collagen.
The third zone is mineralised fibrocartilage and consists of type II collagen, with significant amounts
of type X collagen and aggrecan. The fourth zone is bone and is largely type I collagen with a high
mineral content. This effective bone-tendon attachment is achieved through a functional grading in
mineral content and collagen fibre orientation. The supraspinatus enthesis is a highly specialised in
homogeneous structure that is subjected to both tensile and compressive forces (33).
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[1]. It is also a common cause of shoulder pain in athletes whose sports
involve throwing and overhead motions[2].
The causes of supraspinatus tendinitis 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[4]. Figure 1 gives a view on the different extrinsic and intrinsic factors
Differential Diagnosis[1]
In general, the causes of an acute painful shoulder can be classified into different categories,
according to the prevailing pathoanatomy. These include (10):
Figure 3: The neck, shoulder and chest wall have to be examined, so that other causes of shoulder
pain should be excluded.
(Caroline, Adebajo, Hay & Carr, 2005)
The shoulders are inspected for symmetry, localized swelling and muscle atrophy. There may be
tenderness below the acromion and over the greater tuberosity. Internal rotation of the shoulder can
facilitate palpation of the supraspinatus insertion on the greater tuberosity. The most important clinical
maneuvers are as follows[1]:
Painful arc[4] (see figure 2)
Testings:
Neers sign (http://www.physio-pedia.com/Neers_Test)
Hawkins sign (http://www.physio-pedia.com/Hawkins_/_Kennedy_Test)
Supraspinatus challenge test = The Empty Beer Can sign = Job s test (http://www.physiopedia.com/Empty_Can_Test)
Drop arm test (http://www.physio-pedia.com/Drop_Arm_Test)
Impingement tes
Neer's test
Hawkin's sign
If sonografy is done, the standard method for sonographic evaluation of the supraspinatus tendon
requires the arm behind the back (Crass position) or hand on the back pocket (modified Crass
position) (23). Crass et al. (24) described scanning the shoulder in extension and internal rotation,
achieved by placing the patients hand behind the back.
Figure 4
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 physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), ice treatments and resting. (41) Corticoid injections can also be used
additional to physical therapy(42). A surgical intervention can be a solution if there is no improvement
after 3-6 months of conservative treatment. (47)
NSAIDs may be the first choice for mild to moderate symptoms, if there are no contraindications to
these agents[2]. 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. (40)
Moderate to severe symptoms may require a local subacromial corticosteroid injection. For more
information about corticosteroid injections, see http://www.physiopedia.com/Therapeutic_Corticosteroid_Injection
The major indications for surgery are ongoing pain, loss of function[1], failure to respond to
conservative therapy for 3 months or evidence of an acute tear in a younger patient.(44) Surgical
approaches include calcium deposit resection, with or without subacromial decompression, bursal
resectionA and acromioplastyB, using either arthroscopic or open methods. Its 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. [1] 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. (44)
ABursal resection: Removement of the subacromial bursa.
BAcromioplasty: 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.
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. (45)
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.(45) Gentle range-of-
motion exercises, such as Codmans classic pendulum exercises, maintain range of motion and
prevent development of adhesive capsulitis[2][1]. (Figure 6)[1][4]. 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 (Figure 7). (45) Strengthening exercises should work on the external rotators,
internal rotators, biceps, deltoid, and scapular stabilizers [4].
Strengthening these muscles will keep the shoulder joint more stable and prevent further injuries.
Eccentric exercises will also be more effective than concentric exercises.(46)
I.E.:
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(47)
Scapular protraction and retraction(47)
Joint mobilization may be included with inferior, anterior, and posterior glides in the scapular plane [1].
Stretching exercises should be done by repeating the exercise 3 times and holding the stretch each
time for 30 seconds.
Examples of the stretches for home exercise program are (Figure 7):
Neuromuscular control exercises also may be initiated [2]. 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 [5], transcutaneous
electrical nerve stimulation and ultrasound[6]. Intensive ultrasound therapy has been shown to increase
calcium resorption, but this requires frequent treatment that may not always be practical [6].
Massage of the supraspinatus muscle combined with joint movement; therapy technique.
a, Starting position. b, End position.
Patient's starting position: lying on the left side, arm abducted.
Therapist's starting position: standing, in front of the patient (Fig. Zahnd and Miihlemann 1998).
The therapist applies friction in a direction perpendicular to the normal orientation of the tendon,
using the thumb both as fulcrum and to maintain pressure. The thumb and fingers of the opposite hand
support and gather the skin over the shoulder to avoid friction between the massaging finger and skin.
This is the most valuable treatment in the management of supraspinatus tendinitis and is a key
component of the treatment program. A similar technique is used for the other tendons of the rotator
cuff.
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 (a).
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 (b).
Patients suffering from non-calicfying supraspinatus tendinopathy may benefit from low energy
extracorporeal shock wave therapy, at least in short-term[3].
At the end of the therapy you should initiate plyometric and sports-specific exercises.
Patient education is again reemphasized, 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 [2][4].
Key Research
Starr M, Kang H. Recognition and management of common forms tendinitis and bursitis. The
Canadian Journal of CME. 2001; 155-163.
Clinical Bottom Line
Supraspinatus tendinitis is a common source of shoulder pain in athletes that participate in overhead
sports (handball, volleyball, tennis, baseball). This tendinitis is in most cases caused by an
impingement of the supraspinatus tendon on the acromion as it passes between the acromion and the
humeral head. Pain, and a decrease in range of motion, strength and functionality are the main
complaints that accompany this injury and should be addressed in the physical therapy. There is
enough evidence to prove that physical applications such as ultrasound , cryotherapy, hyperthermia,
transcutaneous electrical nerve stimulation and extracorporeal shock wave therapy have a beneficial
effect on the recovery of supraspinatus tendinitis. But we have to remember that it is very important to
use these methods as an adjunct to physical therapy (increasing ROM, strength training of the rotator
cuff muscles and other shoulder stabilizers).