Supraspinatus Tendonitis Clinical Presentation

  • Author: Thomas M DeBerardino, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: May 23, 2016
 

History

See the list below:

  • Age
    • Younger than 40 years: It is usually glenohumeral instability. The cause is acromioclavicular joint disease or injury.
    • Older than 40 years: Consider glenohumeral impingement syndrome or rotator cuff tendonitis. Additionally, consider degenerative joint disease of the glenohumeral joint.
  • Occupation
    • Laborers and persons with jobs that require repetitive overhead activity (most at risk).
    • Athletes (eg, swimmers, those participating in throwing sports, tennis players, volleyball players)
  • Athletic activity
  • Onset of symptoms related to specific phases of the athletic event performed
  • Duration and frequency of play
  • Duration and frequency of practice
  • Level of play (Little League [elementary school], middle school, high school, college, professional)
  • Actual playing time (starter, backup, bench player)
  • Position played
  • Symptom onset
    • Sudden onset of sharp pain in the shoulder with tearing sensation - More suggestive of a rotator cuff tear
    • Gradual increase in shoulder pain with overhead activities - More suggestive of an impingement problem
  • Chronicity of symptoms
  • Location of symptoms (ie, pain)
    • Usually lateral, superior, anterior shoulder; occasionally referred to deltoid region
    • Posterior shoulder capsule - Usually consistent with anterior instability causing posterior tightness
  • Setting during which symptoms appear (eg, pain during sleep or various sleeping positions, at night, with activity, types of activities, at rest)
  • Quality of pain (eg, sharp, dull, radiating, throbbing, burning, constant, intermittent, occasional)
  • Severity of pain (ie, on a scale of 1-10, with 10 being the worst)
  • Alleviating factors (eg, change of position, medication, rest)
  • Aggravating factors (eg, change of position, medication, increase in practice, increase in play, change in athletic gear, change in position played)
  • Associated manifestations (eg, chest pain, dizziness, abdominal pain, shortness of breath) - May indicate a more ominous problem than supraspinatus tendonitis
  • Provocative positions
    • Pain with humerus in forward flexed and internally rotated position - Suggestive of rotator cuff impingement
    • Pain with humerus in abducted and externally rotated position - Suggestive of anterior glenohumeral instability and laxity
  • Other history - Previous or recent trauma, stiffness, numbness, paresthesias, clicking, catching, weakness, crepitus, symptoms of instability, neck symptoms
Next

Physical

See the list below:

  • Inspection
    • Men should wear no shirt; women are instructed to wear a tank top to the visit.
    • Visualize the entire shoulder girdle and scapular area, noting muscle mass asymmetry/atrophy or bony asymmetry.
  • Active range of motion:
    • Test this if possible; if not, then test passive range of motion.
    • Test forward flexion. The average range is 150-180°.
    • Test abduction. The average range is 150-180°.
    • Test external rotation. The average range with the arm in adduction is 30-60°, and the average range with the arm in abduction is 70-90°.
    • Test internal rotation. The average range is measured by how high the patient can reach up his or her back with the ipsilateral thumb (ie, ipsilateral hip, T12, L5). The average range is above T8.
    • Test adduction. The average range is 45°.
    • Test extension. The average range is 45°.
    • Note that stiffness with external/internal rotation is best tested with the arm in 90° of abduction. Also, for an optimal evaluation, test external and internal rotation in the supine position with the scapulothoracic articulation stabilized. Moreover, most high-level pitchers have increased external rotation and decreased internal rotation in the pitching arm compared with the nonpitching arm. However, the overall absolute arc of motion when measured in degrees is usually equal. This may not be pathologic in the high-level athletic population. Finally, a painful arc of motion may be experienced with elevation above the shoulder level in patients with impingement (typically 80-150°).
  • Palpation
    • Areas that are palpated include the joints, biceps tendons, supraspinatus and subscapularis tendons, and anterolateral corner of the acromion.
    • The entire shoulder girdle is palpated (noting tenderness, deformities, or atrophy) from the acromioclavicular joint, clavicle, glenohumeral joint, scapula, scapulothoracic articulation, anterior/posterior shoulder capsule, supraspinous fossa, infraspinous fossa, and humerus, especially proximally.
  • Manual muscle testing
    • Concentrate on the shoulder girdle muscles (especially external and internal rotation, abduction).
    • The supraspinatus may be isolated by having the patient rotate the upper extremity so that the thumbs are away from the floor and resistance is applied with the arms at 30° of forward flexion and 90° of abduction.
    • Note that pain is felt with tendonitis or partial injury to the supraspinatus tendon with the supraspinatus isolation test, but weakness can also be found accompanying partial- or full-thickness disruption of the supraspinatus tendon. Also, weakness may be found with tendonitis because of muscle inhibition from the pain stimulus.
  • Special tests (impingement signs)
    • For the Neer test, the examiner forcefully elevates an internally rotated arm in the scapular plane, causing the supraspinatus tendon to be impinged against the anterior inferior acromion.
    • For the Hawkins-Kennedy test, the examiner forcefully internally rotates a 90° forwardly flexed arm, causing the supraspinatus tendon to be impinged against the coracoacromial ligamentous arch. Pain and a grimacing facial expression indicate impingement of the supraspinatus tendon, and this is a positive Neer/Hawkins-Kennedy impingement sign.
    • For the impingement test, the examiner injects 10 mL of a 1% lidocaine solution into the subacromial space and then repeats the tests for the impingement sign. Elimination or significant reduction of pain constitutes a positive impingement test result.
    • With the drop arm test, the patient places the arm in maximum elevation in the scapular plane and then lowers it slowly. The test can be repeated following subacromial injection of lidocaine. Sudden dropping of the arm suggests a rotator cuff tear.
    • With the supraspinatus isolation test/empty can test (ie, Jobe test), the supraspinatus may be isolated by having the patient rotate the upper extremity so that the thumbs are pointing to the floor and resistance is applied with the arms in 30° of forward flexion and 90° of abduction (simulates emptying of a can). The result is positive when weakness is present compared with the unaffected side, suggesting a disruption of the supraspinatus tendon.
  • Tests for instability
    • To elicit the sulcus sign, the examiner grasps the patient's elbow and applies inferior traction. Dimpling of the skin subjacent to the acromion (the sulcus sign) indicates inferior humeral translation, which suggests multidirectional instability.
    • The apprehension test is performed most effectively with the patient supine, stabilizing the scapulae. The examiner gently brings the affected arm into an abducted and externally rotated position. The patient's apprehension and guarding by not allowing further motion by the examiner denotes a positive test result, which is consistent with anterior shoulder instability.
    • The relocation test is usually performed in conjunction with the apprehension test. After placing the patient in an apprehensive position, posteriorly directed pressure is applied to the anterior proximal humerus, simulating a relocation of the glenohumeral joint that was presumably partially dislocated from the apprehension test. The adept examiner may feel posterior translation of the humeral head on the glenoid. A positive test result is when the patient's apprehension is relieved by the application of pressure on the anterior proximal humerus, which suggests anterior shoulder instability.
  • Note: Any tests completed should compare both shoulders in order to detect bilateral pathology or have a control for comparison with the affected shoulder.
  • Other tests: These should be performed during the shoulder examination to rule out other pathology affecting the biceps tendon, glenoid labrum, cervical spine, sternoclavicular joint, acromioclavicular joint, and scapulothoracic joint. A survey of other joint range of motion should also be performed to assess for generalized ligamentous laxity.
  • Neurovascular examination
    • To complete the shoulder examination, a full neurologic examination must be performed along with an assessment of all upper extremity vascular pulses.
    • The neurologic examination should include all neurologic segments from C5 through T1 myotome and dermatome, with the corresponding stretch reflexes.
    • Lewis et al demonstrated the presence of neovascularity in individuals with a clinical diagnosis of rotator cuff tendinopathy and, to a lesser extent, in asymptomatic shoulders. Twenty patients (mean age, 50.2 y; range 32-69 y) with a clinical diagnosis of unilateral rotator cuff tendinopathy received a clinical examination then underwent bilateral grey scale and color Doppler ultrasound assessment.Neovascularity was found in the symptomatic shoulder in 13 of 20 patients (35%) as well as in the asymptomatic shoulder in 5 of the 20 patients (25%).[5] Of 6 other patients who withdrew from the study before entering the trial, 1 withdrew due to cessation of symptoms and did not have neovascularity in either shoulder; 5 withdrew due to bilateral symptoms, of whom 2 had signs of bilateral neovascularity, 1 had unilateral neovascularity, and the remaining 2 did not have neovascularity in either shoulder.[5] No association was identified between the presence of neovascularity and pain, duration of symptoms, and neovascularity and shoulder function. The investigators noted more research is needed to evaluate the relevance of their findings.
Previous
Next

Causes

See the list below:

  • Extrinsic causes
    • Primary impingement
      • Increased subacromial loading
      • Trauma (direct macrotrauma or repetitive microtrauma)
      • Overhead activity (athletic and nonathletic)
    • Secondary impingement
      • Rotator cuff overload/soft tissue imbalance
      • Eccentric muscle overload
      • Glenohumeral laxity/instability
      • Long head of the biceps tendon laxity/weakness
      • Glenoid labral lesions
      • Muscle imbalance
      • Scapular dyskinesia
      • Posterior capsular tightness
      • Trapezius paralysis
  • Intrinsic causes
    • Acromial morphology (ie, hooked acromion, presence of an os acromiale or osteophyte, calcific deposits in the subacromial space, all of which predispose to primary impingement)
    • Acromioclavicular arthrosis (inferior osteophytes)
    • Coracoacromial ligament hypertrophy
    • Coracoid impingement
    • Subacromial bursal thickening and fibrosis
    • Prominent humeral greater tuberosity
    • Impaired cuff vascularity
    • Aging (primary)
    • Impingement (secondary)
    • Primary tendinopathy
    • Intratendinous
    • Articular side partial-thickness tears
    • Calcific tendinopathy
Previous
 
 
Contributor Information and Disclosures
Author

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Research Director, BRIO of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician; Adjunct Associate Professor, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Coauthor(s)

Wing K Chang, MD Physician, Peachtree Orthopaedic Clinic

Wing K Chang, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American College of Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

References
  1. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972 Jan. 54(1):41-50. [Medline].

  2. Fu FH, Stone DA, eds. Sports Injuries: Mechanisms, Prevention, Treatment. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1994. 895-923.

  3. Miller MD, Cooper DE, Warner JJ, eds. Review of Sports Medicine and Arthroscopy. Philadelphia, Pa: WB Saunders Co; 1995. 113-64.

  4. Millar NL, Wei AQ, Molloy TJ, Bonar F, Murrell GA. Cytokines and apoptosis in supraspinatus tendinopathy. J Bone Joint Surg Br. 2009 Mar. 91(3):417-24. [Medline].

  5. Lewis JS, Raza SA, Pilcher J, Heron C, Poloniecki JD. The prevalence of neovascularity in patients clinically diagnosed with rotator cuff tendinopathy. BMC Musculoskelet Disord. 2009 Dec 21. 10:163. [Medline]. [Full Text].

  6. Seo JB, Yoo JS, Ryu JW. Sonoelastography findings of supraspinatus tendon in rotator cuff tendinopathy without tear: comparison with magnetic resonance images and conventional ultrasonography. J Ultrasound. 2015 Jun. 18 (2):143-9. [Medline].

  7. Lee SU, Joo SY, Kim SK, Lee SH, Park SR, Jeong C. Real-time sonoelastography in the diagnosis of rotator cuff tendinopathy. J Shoulder Elbow Surg. 2016 May. 25 (5):723-9. [Medline].

  8. Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM R. 2013 Mar. 5(3):169-75. [Medline].

  9. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014 Apr 29. 4:CD010071. [Medline].

  10. Andrews JR, Harrelson GL, Wilk KE, Lampert R, eds. Physical Rehabilitation of the Injured Athlete. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1998. 478-553.

  11. Bigliani LU, Morrison DS, April EW. The morphology of the acromion its relationship to rotator cuff tears. J Orthop Trans. 1986. 10:228.

  12. Brotzman SB, ed. Clinical Orthopaedic Rehabilitation. London, England: Mosby; 1995. 92-8.

  13. Chae J, Jedlicka L. Subacromial corticosteroid injection for poststroke shoulder pain: an exploratory prospective case series. Arch Phys Med Rehabil. 2009 Mar. 90(3):501-6. [Medline].

  14. Cumpston M, Johnston RV, Wengier L, Buchbinder R. Topical glyceryl trinitrate for rotator cuff disease. Cochrane Database Syst Rev. 2009 Jul 8. CD006355. [Medline].

  15. Denaro V, Ruzzini L, Longo UG, et al. Effect of dihydrotestosterone on cultured human tenocytes from intact supraspinatus tendon. Knee Surg Sports Traumatol Arthrosc. 2010 Jul. 18(7):971-6. [Medline].

  16. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980 May-Jun. 8(3):151-8. [Medline].

  17. Hong JY, Yoon SH, Moon do J, Kwack KS, Joen B, Lee HY. Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial. Arch Phys Med Rehabil. 2011 Dec. 92(12):1951-60. [Medline].

  18. Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009 Sep. 37(9):1855-67. [Medline].

  19. Schmitt J, Haake M, Tosch A, Hildebrand R, Deike B, Griss P. Low-energy extracorporeal shock-wave treatment (ESWT) for tendinitis of the supraspinatus. A prospective, randomised study. J Bone Joint Surg Br. 2001 Aug. 83(6):873-6. [Medline].

  20. Valen PA, Foxworth J. Evidence supporting the use of physical modalities in the treatment of upper extremity musculoskeletal conditions. Curr Opin Rheumatol. 2010 Mar. 22(2):194-204. [Medline].

Previous
Next
 
 
Medscape Consult
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.