Physical Therapy Management Of Supraspinatus Tendinitis

Summary of the Condition

Inflammation of the tendon of the supraspinatus muscle leads to supraspinatus tendinitis. This is the most common cause of shoulder pain⁸. Patients with Supraspinatus Tendinitis present with shoulder pain with movement and pain at night. They will also show weakness in the shoulder and arm. There is also possibility of tenderness and swelling in the upper front part of the shoulder and in some severe cases, difficulty to raise the arm to shoulder level⁴. Positive Neer’s, Hawkins-Kennedy, and Empty Can Test indicate Supraspinatus Tendinitis². The problems that patient with Supraspinatus Tendinitis presents are:

• Pain and inflammation
• Decreased ROM
• Decreased Strength
• Decreased Functional Activity

Guide to Physical Therapy Practice

According to the Guide to Physical Therapy Practice there are three different practice patterns for Supraspinatus Tendinitis:

• Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction¹.
• Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation¹.
• Pattern 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery¹.

Prognosis for practice pattern 4D are 2 weeks to 6 months and during this period patient will demonstrate optimal joint mobility, muscle performance, and range of motion and the highest level of functioning. Recommended visits do achieve patient goals range from 3 to 36¹.

Prognosis for practice pattern 4E are 2 to 4 months and during this period patient will demonstrate optimal joint mobility, muscle performance, and range of motion and the highest level of functioning. Recommended visits do achieve patient goals range from 6 to 24¹.

Prognosis for practice pattern 4I are 1 to 8 months and during this period patient will demonstrate optimal joint mobility, muscle performance, and range of motion and the highest level of functioning. Recommended visits do achieve patient goals range from 6 to 70¹.

Relieving Pain and Inflammation

Patients with Supraspinatus Tendinitis present with shoulder pain with movement and pain at night. There is also possibility of tenderness and swelling in the upper front part of the shoulder and in some severe cases, difficulty to raise the arm to shoulder level⁴. Patients also present with painful arc between 60⁰ and 120⁰ of shoulder abduction.

NSAIDs (non-steroidal anti-inflammatory drugs) are often prescribed for the management of inflammation.

Ice packs can help reduce pain and inflammation and should be applied to painful area for 15 min at the time6.

Manual therapy also has been proven to decrease pain in patients with supraspinatus tendinitis⁷. Manual therapy to decrease pain includes scapular and glenohumeral joint mobilizations and deep friction massage.

Increasing Strength

Patients with Supraspinatus Tendinitis show weakness in the shoulder and arm. The impingement syndrome is the most common cause of supraspinatus tendinitis. Weakness and dysfunction of the rotator cuff muscles leads to elevation of the humeral head during arm abduction which causes compression of the tissues under the acromion process. Edema and hemorrhage of the supraspinatus tendon occur which can eventually lead to the tendon degeneration and rupture⁵.
The muscles that should be strengthen to correct biomechanics of the shoulder that cause supraspinatus tendinitis are external and internal rotators, deltoid, and scapular stabilizers (rhomboids, trapezius, serratus anterior, latissimus dorsi)³.

Proprioceptive neuromuscular facilitation (PNF) exercises should also be performed to increase strength³. PNF patterns will increase strength in rotator cuff muscles and increase the stability of the shoulder. Four different patterns that should be performed are as follows:
• D1 Flexion pattern: shoulder flexion, elbow flexion, forearm supination, wrist flexion, and finger flexion.
• D1 Extension pattern: shoulder extension, elbow extension, forearm pronation, wrist and finger extension.
• D2 Flexion pattern: shoulder flexion, elbow extension, forearm supination, wrist extension, and finger extension.
• D2 Extension pattern: shoulder extension, elbow flexion, forearm pronation, wrist and finger flexion.

Increasing ROM

ROM exercises may include pendulum exercises and active assisted ROM exercises. ROM exercises are then progressed to active exercises in all planes and self-stretches concentrating mainly on posterior joint capsule. Some of the stretching exercises are represented on the picture below.

ROM of the shoulder can also be increased with joint mobilizations. Joint mobilizations should include inferior, anterior, and posterior glides³.

Functional Activities

It is very important for patient to achieve normal shoulder arthrokinematics. Once the patient reaches full ROM and 70% strength compared to uninvolved side. Patients should return to their regular activity level, ADLs, and their occupation. In the case of nonathletes, the aim should be returning them to their previous activity level, whether it is activities of daily living or activities specific to their occupations. Treatment should include activities more specific to the patient’s daily activities (ie, activities related to daily living, household activities, occupational and job-specific activities, and recreational activities). As the patient advances, he or she should be educated on techniques to prevent repeat injury, observing proper shoulder biomechanics, activity modification, and continuing a consistent home exercise program of stretching and strengthening³.
If the patient is an athlete, treatment should also focus on sport specific exercises, plyometric exercises, PNF, and isokinetic exercises². It is important to get athletes back to their sport.

Home Exercise

Home exercise program has to be patient specific and it will depend on patient’s level of injury, previous functional ability, and patient’s current strength and ROM. This will determine which exercises patient is going to do, which resistance they are going to use, and how many repetitions they are going to do. Make sure that patient has only few exercises to do for home exercise program because that way they are more likely to do them on a regular basis.

Strengthening exercises that can be given to the patient for home exercise program are (http://www.physioroom.com/experts/asktheexperts/answers/qa_mb_20050225.php):
Side lying External Rotation

Prone Horizontal Abduction

Prone Elevation in the plane of the Scapula

Prone Row with External Rotation



External and Internal Rotation with surgical tubing

Horizontal Abduction with Thera-tubing

Rows with Thera-tubing

Standing Elevation in the plane of the Scapula

Stretching exercises should be done by repeating the exercise 3 times and holding the stretch each time for 30 seconds.
Examples of the stretches for home exercise program are (http://www.shoulder-pain-management.com/shoulderrotatorcuffexercises.html):

Pendulum Swings
Stand and lean over with arm hanging. Begin swinging the arm in small circles and gradually enlarge the size of the circles. Repeat 10 times.

Rotator Cuff Stretch I
Stand or sit.
Bend elbow at 90-degree angle, keeping elbows close to body, lower arms are pointed forward and parallel to floor, thumbs pointed up.
Move hands away from body until stretch is felt in shoulder.
Hold stretch for 30 seconds. Rest and repeat.

Rotator Cuff stretch II
Stand in front of doorframe bend elbow at 90-degree angle and place palm against doorframe. Move forward to stretch rotator cuff.

Rotator Cuff Stretch III
Sit or stand. Hands on waist, thumbs facing frontward. Bend at hips until body is resting on lap if sitting or parallel to floor if standing. Let arms hang toward floor to stretch the shoulder joint. Hold stretch for 20 seconds.

Back of shoulder stretch
Reach arm right across chest, use left hand to grasp arm just above elbow and gently pull arm farther across body until you feel a stretch in the back of the shoulder.
Hold stretch for 30 seconds. Rest and repeat.
Repeat on other side.

Overhead Stretch
Place hands on edge of counter top.
Bend upper body at hips at 90-degree angle.
Reach and stretch shoulders.

Towel Stretch - Internal Rotation
Place right hand behind back.
With the left hand, dangle a towel behind the back.
Grasp the towel with the right hand.
Gently pull the right hand upward by raising the left arm to stretch the right shoulder.
Towel should be in vertical position.
Hold for 30 seconds. Repeat on other side.

Towel Stretch - External Rotation
Place right hand behind back.
With the left hand, dangle a towel behind the back.
Grasp the towel with the right hand.
Pull right hand downward to stretch the left shoulder.
Towel should be in vertical position.
Hold for 30 seconds. Repeat on other side.

Modality Use

Modalities used in treatment of Supraspinatus Tendinitis are cryotherapy, ultrasound, electric stimulation, and acupuncture.

Cryotherapy reduces blood flow and swelling to the injury site. Cryotherapy has effects on the muscle tendon by decreasing capillary blood flow, preservation of deep tendon oxygen saturation, and facilitated venous capillary outflow⁶. Cryotherapy also has an analgesic effect.

Ultrasound is also used to treat pain and enhance healing of the muscle tendon. This treatment results in heating of the tissue. However studies show no conclusive evidence in effectiveness of this type of treatment⁶.

Electric stimulation is used to treat pain in patients. The studies that tested effect of electric stimulation on patient pain levels are inconclusive and results are not clear due to the very hard way of producing placebo effect on patients in control group.

Acupuncture is one of the treatments used in patients with supraspinatus tendinitis and studies show that acupuncture has no beneficial effects in comparison to placebo TENS⁵.

All of the modalities in treatment of patients with supraspinatus tendinitis are used in combination with strengthening exercises, stretching exercises, and manual therapy.

Special Instructions

Patients should be educated regarding activity, pathology, and avoidance of overhead activity, reaching, and lifting. Patients should also be educated on how to prevent reoccurrence of supraspinatus tendinitis and importance of home exercise program³.

References

1. American Physical Therapy Association. Guide to physical therapist practice. second edition. american physical therapy association. Phys Ther. 2001;81(1):9-746.
2. Chang W. Shoulder impingement syndrome. Physical Medicine and Rehabilitation Clinics of North America. 15 (2004) 493–510.
3. DeBerardino T. Supraspinatus Tendinitis Treatment & Management. Medscape Reference. http://www.emedicine.medscape.com/article/93095-treatment
4. McLaughlin E. Supraspinatus Tendinitis: Rotator Cuff Tendinitis. Medicine on Line. http://www.medicineonline.com/articles/s/2/supraspinatus-tendinitis/rotator-cuff-tendinitis.html
5. Razavi M, Jansen G. Effects of Acupuncture and Placebo TENS in Addition to Exercise in Treatment of Rotator Cuff Tendinitis. Clinical Rehabilitation. 2004; 18:872-877.
6. Rees J, Maffulli N, Cook J. Management of Tendinopathy. The American Journal of Sports Medicine. 2009; 37:1855-1866.
7. Senbursa G, Baltaci G, Atay A. The effectiveness of manual therapy in supraspinatus tendinopathy. ACTA Orthopaedica et Traumatologica Turcica. 2011;45(3):162-167.
8. Starr M, Kang H. Recognition and management of common forms tendinitis and bursitis. The Canadian Journal of CME. 2001; 155-163.