Supraspinatus Tendonitis Treatment & Management

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. An 8-week placebo-controlled study demonstrated a decrease in pain and an improvement in function with use of steroids compared with placebo. Furthermore, the study showed no significant differences between higher (40 mg) and lower (20 mg) doses of triamcinolone acetonide. Therefore, in general, lower doses of steroids should be used initially.^[6] 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.

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.

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 warm-up, 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.