Supraspinatus Tendonitis Clinical Presentation

Note the following:

• 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

Note the following:

• 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%). ^[8]  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. ^[8]  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.