Supraspinatus Tendonitis Treatment & Management
- Author: Thomas M DeBerardino, MD; Chief Editor: Sherwin SW Ho, MD more...
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.
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.
Other Treatment (Injection, manipulation, etc.)
Subacromial injection of platelet rich plasma (PRP) was reviewed in a retrospective trial. The authors concluded that most patients reported a moderate (>50%) improvement in symptoms of pain; 85% were satisfied with the ultrasound-guided PRP injection. Further studies are needed as a recent Cochrane review concluded that there is currently insufficient evidence to recommend the use of platelet-rich therapies (PRT) to treat musculoskeletal soft tissue injuries.
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.
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.
- 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.
- 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.
- 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.
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