eMedicine Specialties > Sports Medicine > Shoulder

Supraspinatus Tendonitis: Treatment & Medication

Author: Thomas M DeBerardino, MD, Director, John A Feagin Jr West Point Sports Medicine Fellowship, Orthopedic Surgery Service, Clinical Instructor in Surgery, Keller Army Community Hospital at West Point
Coauthor(s): Wing K Chang, MD, Musculoskeletal Spine Fellow, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center
Contributor Information and Disclosures

Updated: Jun 8, 2006

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The goals of the acute phase are to relieve pain and inflammation, prevent muscle atrophy without exacerbating the pain, reestablish nonpainful range of motion, and normalize the arthrokinematics of the shoulder complex. This includes a period of active rest, eliminating any activity that may cause an increase in symptoms.

Range-of-motion exercises may include pendulum exercises and symptom-limited, active-assisted range-of-motion exercises. Joint mobilization may be included with inferior, anterior, and posterior glides in the scapular plane. Strengthening exercises should be isometric in nature and work on the external rotators, internal rotators, biceps, deltoid, and scapular stabilizers (ie, rhomboids, trapezius, serratus anterior, latissimus dorsi, pectoralis major). Neuromuscular control exercises also may be initiated.

Modalities that also may be used as an adjunct include cryotherapy, transcutaneous electrical nerve stimulation, high-voltage galvanic stimulation, ultrasound, phonophoresis, or iontophoresis.

Patient education regarding activity; pathology; and the avoidance of overhead activity, reaching, and lifting is particularly important for this acute phase. The general guidelines to progress from this phase are decreased pain or symptoms, increased range of motion, painful arc in abduction only, and improved muscular function.

Other Treatment

During the acute to subacute phase, when pain and inflammation predominate, a subacromial injection may be diagnostic and therapeutic as an adjunct to the rehabilitation program. Injecting 10 mL of a 1% lidocaine solution without epinephrine into the subacromial space may relieve the shoulder pain if the pain and inflammation are truly originating from the supraspinatus outlet/subacromial space.

Adding a low-dose, intermediate-acting, injectable corticosteroid may provide a therapeutic effect. Betamethasone, triamcinolone, and methylprednisolone are used commonly. The common dose is 1 mL of any of these available injectable corticosteroids mixed with 9 mL of a 1% lidocaine solution without epinephrine.

• Technique
  
  
  • Have patients sit with their arms hanging by their side to distract the humerus from the acromion.
  • Identify the lateral edge of the acromion.
  • Insert a needle at the midpoint of the acromion, and angle it slightly upward under the acromion to its full length.
  • Slowly withdraw the needle while simultaneously injecting fluid in a bolus (wherever resistance is not present). Continue aspirating before injecting. Sometimes, a swelling caused by the fluid is visible around the edge of the acromion.
  • Occasionally, calcification occurs within the bursa, and hard resistance is encountered. In this case, aspiration and infiltration with a large-bore needle and local anesthetic may be helpful. Failing this, surgical evaluation may be necessary.

• Aftercare
  
  
  • Inform the patient that once the effect of the lidocaine wears off, a local reaction to the corticosteroid may occur in the next 24-72 hours. If this occurs, instruct the patient to apply ice (wrapped in a towel) to the affected shoulder for 20 minutes, remove it for 20 minutes, and then repeat (ie, 20 min on, 20 min off) 3 times in the beginning and at the end of the day.
  • Relief of pain after one injection is usual, but the patient must be advised to maintain correct posture with retraction and depression of the shoulder and to avoid the painful arc of elevation for 1 week.
  • The patient may resume a symptom-limited therapy program in the first week postinjection and then resume the full course thereafter.
     
• Adverse effects in general
  
  
  • Although uncommon with this injection procedure when performed correctly, adverse effects may occur. The clinician and the patient must be educated about them, and the clinician must know how to manage any related complications.
  • Absolute contraindications include documented allergy to any corticosteroid or local anesthetics, overlying skin infection, or cellulitis.
  • Relative contraindications include diabetes, hypertension, immunosuppression, cardiac arrhythmias, and heart blocks.
  • Note that adverse effects of the medications may be minimized when the medication is administered in the recommended dose.
     
• Adverse effects of injectable corticosteroids
  
  
  • Systemic effects include flushing, menstrual irregularity, impaired glucose tolerance, osteoporosis, psychological disturbance, steroid arthropathy, steroid myopathy, and immunosuppression.
  • Local effects include postinjection flare, which may include local injection site erythema, mild swelling, ecchymoses, and pain.
     
• Adverse effects of local anesthetics
  
  
  • These usually result from an overdose or allergic reactions, which definitely can be minimized by double-checking the dose before administering and inquiring about and checking on the records for medication allergies.
  • Overdose and allergic reactions may be catastrophic and may include cardiac, respiratory, and cerebral compromise.
     
• Adverse reaction to the injection
  
  
  • Aside from the one mentioned, occasionally a patient may have a vasovagal reaction (fainting episode) due to pain, apprehension, or needle phobia.
  • Treatment involves placing the patient supine, elevating the legs, and strongly reassuring him or her that recovery is forth coming shortly. If the patient loses consciousness briefly, protect the airway and give oxygen at 35% concentration.

Recovery Phase

Rehabilitation Program

Physical Therapy

The initial goals of this phase are to normalize range of motion and shoulder arthrokinematics, perform symptom-free activities of daily living, and improve neuromuscular control and muscle strength. Range-of-motion exercises are progressed to active exercises in all planes and self-stretches, concentrating on the joint capsule, especially posteriorly.

Strengthening includes isotonic resistance exercises with the supraspinatus, internal rotators, external rotators, prone extension, horizontal abduction, forward flexion to 90°, upright abduction to 90°, shoulder shrugs, rows, push-ups, press-ups, and pull-downs to strengthen the scapular stabilizers.

Other important goals include maintaining joint motion and neuromuscular re-education. Upper extremity ergometry exercises, trunk exercises, and general cardiovascular conditioning for endurance are also recommended. Therapies may be continued if necessary. Guidelines to advance are full, nonpainful range of motion when manual muscle testing of strength is 70% of the contralateral side.

The final goal of this phase is to progress to the point at which the athlete is again throwing and includes improving strength, power, endurance, and sports-specific neuromuscular control. Emphasis is placed on high-speed, high-energy strengthening exercises and eccentric exercises in diagonal patterns. Continue isotonic strengthening with increased resistance in all planes, allowing resistance in the throwing position, 90° of abduction, and 90° of external and internal rotation. Initiate plyometrics, sports-specific exercises, proprioceptive neuromuscular facilitation, and isokinetic exercises.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The goal of this phase is to maintain a high level of training and prevent reoccurrence. Emphasis is placed on longer and more intense workouts, proper arthrokinematics of the shoulder, and analysis and modification of techniques and mechanics that may reexacerbate symptoms. Make refinements in intensity and coordination.

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 warmup, strengthening techniques, and warning signs of early impingement.

Surgical Intervention

In general, conservative measures are continued for at least 3-6 months or longer if the patient is improving, which is usually the case in 60-90% of patients. If the patient remains significantly disabled and has no improvement after 3 months of conservative treatment, the clinician must perform a more extensive diagnostic workup, reconsider other etiologies, or refer the patient for surgical evaluation.

Appropriate surgical referrals are patients with rotator cuff tendonitis refractory to 3-6 months of appropriate conservative treatment. Surgery may be particularly beneficial in patients with full, unrestricted passive range of motion; a positive response to injection of lidocaine into the subacromial space; or a type III acromion with a large subacromial spur and in those in whom changes are noted in the rotator cuff tendon after MRI.

• Surgical evaluation
  
  
  • Initially, perform the examination with the patient under anesthesia (general anesthesia vs regional block) and include diagnostic arthroscopy.
  • Evaluate shoulder range of motion and stability.
  • In patients with limited motion, manipulation of the shoulder is performed and diagnostic arthroscopy also may be performed, but arthroscopic subacromial decompression is generally not performed in patients with significant preoperative stiffness because of the increased risk of postoperative adhesive capsulitis.
  • Document any instability.
  • Perform an arthroscopic evaluation.
  • Particular attention is directed to the rotator cuff, especially the supraspinatus tendon near its insertion onto the greater tuberosity.
  • Visualize the subscapularis tendon.
  • Assess for labral pathology or changes suggesting glenohumeral instability.
  • A partial tearing of the supraspinatus tendon along its articular surface is a common finding in symptomatic throwing athletes. The fragmented and torn tissue is debrided, leaving all intact rotator cuff tendon. This allows a more accurate determination of the size and thickness of the tear on the articular side of the rotator cuff and may help reduce symptoms of catching and pain.
  • Following glenohumeral arthroscopy, the bursal side of the rotator cuff is evaluated using arthroscopy.
  • The bursal surface of the rotator cuff is assessed for evidence of fraying and for the amount of clearance between the anterior inferior acromion and the supraspinatus tendon.
  • Also note any signs of fraying or wear changes on the undersurface of the coracoacromial ligament.
  • If no evidence of rotator cuff disruption is noted and the coracoacromial ligament is smooth, with adequate space between the anterior inferior acromion and rotator cuff, then the diagnosis of subacromial impingement is unlikely. In this case, subacromial decompression is not performed.
  • In case of a small partial-thickness rotator cuff tear on the articular surface, without evidence of impingement, only perform glenohumeral debridement of this tear.
  • If the patient has changes suggestive of impingement syndrome, arthroscopic subacromial decompression (acromioplasty, ie, resection of the anterior inferior portion of the acromion) is also performed.
  • If, following subacromial decompression, a rotator cuff repair is necessary, it may be continued under arthroscopic assistance or it may require conversion of the rotator cuff repair to an open procedure.
     
• Postoperative care
  
  
  • A postoperative radiograph (supraspinatus outlet view) is obtained to document the adequacy of the subacromial decompression. The appearance on this radiographic view should be of a type I acromial arch without any residual spurring.
  • Following subacromial decompression, the patient is placed in a sling but is encouraged to remove the sling when comfortable and begin active and passive range-of-motion exercises. When pain has decreased significantly and range of motion has returned toward normal, a program of strengthening, similar to the previously mentioned conservative management, is instituted. Patients cannot begin sports-specific activities until they have full, active range of motion in the operated shoulder and normal strength, generally a period of approximately 3-4 months.
     
• Surgical outcome
  
  
  • Subacromial decompression results generally are poor in young, high-performance athletes with injuries from overhead motions.
  • Results generally are good for properly selected middle-aged patients with evidence of impingement in history and physical examination findings and at the time of arthroscopy.
  • General consensus in the literature is that arthroscopic subacromial decompression results in a good return to the previous level of function in approximately 85-90% of patients.

Medication

During the acute to subacute phases of shoulder impingement syndrome, a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) is appropriate as an adjunct to the therapy program and other treatment modalities because of their analgesic and anti-inflammatory effects. Choices in this drug classification are extensive; only selected examples are discussed. Patient responses to different NSAIDs may vary. For information on the full array of NSAIDs, their dose, and their schedule, refer to the latest edition of the Physician's Desk Reference.

NSAIDs mechanism of action

The major mechanism of action of NSAIDs is inhibition of the synthesis of prostaglandin (PG), specifically PGE2, via blocking cyclooxygenase (COX), which is the enzyme that converts arachidonic acid into PG. PGs lower the threshold to noxious stimuli by sensitizing the nociceptors to the actions of other noxious endogenous substances (eg, bradykinin, histamine, substance P, serotonin). In soft tissue, PGE2 causes pain and inflammation. In the GI tract, it is cytoprotective and increases the secretion of mucus and bicarbonates and decreases the secretion of gastric acids and digestive enzymes. In the renal system, PGE2 enhances renal salt and water excretion by acting as a vasodilator of small arterial blood vessels.

The COX pathway is subdivided into COX-1, which is responsible for PGE2 production in the GI tract and kidneys, and COX-2, which is responsible for inflammatory PG synthesis during soft tissue injury. NSAIDs serve as competitive inhibitors of COX activity and either selectively inhibit the COX-2 enzymes or nonselectively inhibit both the COX-1 and the COX-2 enzymes, making the nonselective NSAIDs a higher risk for potential ulcerogenic and other adverse effects.

Adverse drug reactions

All NSAIDs have similar adverse drug reactions. The first is hepatotoxicity. The liver function profile should be monitored periodically, especially in high-risk individuals. The second is renal toxicity. The renal function profile should be monitored periodically, especially in high-risk individuals. The third is GI toxicity. Symptoms may include nausea, diarrhea, acid reflux, and periumbilical cramping. Consider administering NSAIDs in conjunction with GI protective medications (eg, misoprostol, omeprazole, H2 blockers), and instruct patients to take NSAIDs with food. If GI symptoms persist for more than 2 weeks or if patients have evidence of complications (eg, iron deficiency anemia, GI bleeding, unexplained weight loss, dysphagia), an endoscopic evaluation is indicated. The fourth is aplastic anemia. Monitor the complete blood count, especially platelets, periodically for 1-2 months. The fifth is anaphylaxis. Inquire about and check medical records for a history of allergic reactions.

Nonsteroidal anti-inflammatory drugs

Most widely used drugs in the world, exhibiting anti-inflammatory, antipyretic, and analgesic activities. They are primarily used for treating inflammatory conditions that are musculoskeletal in origin. Numerous drugs are available in this category, and they all have similar drug profiles.

Ibuprofen (Ibuprin, Advil, Motrin)

Arylpropionic acid prototypical NSAID that has the advantage of causing less epigastric pain, GI occult blood loss, and less hepatotoxicity. Mostly indicated for rheumatoid arthritis and osteoarthritis for mild to moderate pain. Compared with other available NSAIDs, it has a short half-life.

Diclofenac sodium/diclofenac potassium (Voltaren, Cataflam)

Chemical composition is heteroaryl acetic acid with a short half-life. Delayed-release enteric-coated form is diclofenac sodium, and immediate-release form is diclofenac potassium. Both are primarily indicated for rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. Diclofenac can cause hepatotoxicity; hence, monitor liver enzymes in the first 8 wk of treatment. Diclofenac has a relatively low risk for bleeding GI ulcers.

Etodolac (Lodine, Lodine XL)

Indole NSAID with an intermediate half-life, indicated for rheumatoid arthritis and osteoarthritis. Short-acting form is approved for analgesic use, comparable to aspirin/acetaminophen with codeine. Etodolac has a lower risk of producing GI complications and, as a result, is especially well tolerated in elderly patients.

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Probably the most potent of the arylpropionic acids, with a long half-life. Indicated for rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, juvenile arthritis, acute gout, and mild to moderate pain. Available in a controlled-release form, which is also used for acute pain, and an enteric-coated form, which is not used for acute pain.

Oxaprozin (Daypro)

An arylpropionic acid with a 40-50 h half-life and can be given once daily. Used for relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of COX, which results in a decrease in PG synthesis.

Nabumetone (Relafen)

Alkanone NSAID with a long (24 h) half-life and can be given once daily. Has a lower risk of producing GI complications and is indicated for rheumatoid arthritis and osteoarthritis.

Piroxicam (Feldene)

Enolic acid, piroxicam with long half-life (50 h) that can be given once daily. Indicated for use in rheumatoid arthritis and osteoarthritis. Has high GI toxicity (greater than aspirin).

Celecoxib (Celebrex)

Selective COX-2 inhibitor NSAID. Approved by FDA on December 31, 1998 and indicated for use in osteoarthritis and rheumatoid arthritis and for moderate to severe pain. Potentially presents less GI complications and platelet aggregation problems than the nonselective COX-inhibitor NSAIDs. Renal complications are comparable. Has a sulfonamide chain and is primarily dependent on cytochrome P-450 enzymes (a hepatic enzyme) for metabolism.

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