Supraspinatus tendon impingement causes pain with small movements, like changing gears in the car and getting dressed. Not to mention lifting and carrying groceries. You may even struggle to sleep on your shoulder. Supraspinatus tendinitis is inflammation of the supraspinatus tendon. At least that is what we used to think happens to the tendon when you experience sharp pain when lifting your arm sideways. Now we understand tendon pathology differently. Supraspinatus tendonitis or supraspinatus tendinopathy all refer to supraspinatus tendon pain, and can all be used interchangeably. Supraspinatus tendinitis is frustrating, to say the least. Your shoulders connect your arm to your body, and even though you may not lift weights and sculpt your shoulders in the gym, you need a lot of movement and stability from your shoulder joint to move your arms and hands.
What is the supraspinatus tendon?
Wherever muscle attaches to bone, you find tendons. This insertion site of muscle to bone is particularly at risk of injury because of the amount of load transfer that happens at this anchor site, with relatively poor blood supply to the tendon itself.
Rotator cuff muscle group
The supraspinatus muscle is part of the rotator cuff muscle group. The rotator cuff muscles are a family of muscles around the shoulder blade that all merge together to form the shoulder’s cuff, that is crucial to keep the shoulder snuggly and safely within the joint. The supraspinatus is a small muscle shaped like a triangle that sits in the supraspinatus fossa of the shoulder blade or scapula. The triangular muscle belly then forms a long, rope-like tendon that runs through a relatively small space, the subacromial space, and inserts on the greater tubercle of the humerus. The bicep tendon is fairly close to the supraspinatus tendon and injury to one may cause injury to the other.
Bursa
Inbetween tendon and bone the body has a smart way to reduce friction caused by movement. Bursae are found in between two tendons, and tendon and bone. Bursae are fluid filled bags that reduce friction between tissues. Just like a plaster will prevent chafing your heel from a new pair of shoes. Bursae can become overworked too and get inflamed. This increases its size. Any space occupying substance, like inflammation, may cause compression or supraspinatus tendon impingement.
Nerves
A great number of nerves from the brachial plexus travel close to the shoulder joint and supraspinatus tendon. Muscles that cross and move both the shoulder joint and neck, like the trapezius and levator scapulae muscle can become fatigued. This leads to compensatory movement patterns that can cause neck pain and even headaches.
What does the supraspinatus tendon do?
The supraspinatus muscle is the top ‘stabiliser’ of the rotator cuff muscle group of the shoulder. This muscle group has an important role in stabilising the shoulder joint. The supraspinatus muscle:
- stabilises the humeral head in the glenoid, to allow overhead activities or controlled movement of the shoulder and hand.
- externally rotates the humerus, turn the shoulder outwards, and
- initiate abduction, sideways movement, of the humerus.
This tendinous insertion site of muscle to bone is particularly at risk of injury because of the amount of load transfer that happens locally. Were the tendon inserts on the bone a leverage system is created. Contraction of the supraspinatus muscle will transfer load through the tendon and “pull” the humerus into abduction, initiating a sideways movement of the shoulder. We rarely do any of these movements in isolation, a combination of these movements enables you to reach sideways out the window for a parking ticket or put your arm through the sleeve of a jacket. The stability function of the muscle comes into play when you lift something heavy, like a basket of wet laundry.
How does supraspinatus tendinitis happen?
The shoulder joint
The shoulder or glenohumeral joint (GHJ) needs to move in harmony with three other joints to allow full movement. These joints are the:
- Sternoclavicular (SC) joint between the collarbone (clavicle) and breastbone (sternum)
- Acromioclavicular (AC) joint between the collarbone and acromion (part of the shoulder blade)
- The scapula (shoulder blade) also glides on the ribcage to allow free movement of the shoulder joint.
The shoulder is a ball & socket joint. The glenoid, which is part of the shoulder-blade, forms the socket, and the head of the humerus of the upper arm, forms the ball. The socket is very shallow, especially when compared to the hip joint. This allows a lot of movement, but very little stability. Luckily the shoulder joint has help from muscles and ligaments that assist in the stability of the joint.
Scapulohumeral rhythm
Harmonious movement of all of these joints allows you to reach overhead. If one joint is stuck it will affect the movement of the others, like one member of an orchestra that plays out of time. More strain will then be placed on the other musicians, or in our case, the other joints. Let’s say the shoulder blade isn’t moving optimally on the ribcage. This may be due to weakness of certain muscles and will limit the lift from the acromioclavicular joint when you elevate your arm. Now the head of the humerus hits the roof of the acromion and pinches the poor supraspinatus tendon in between the bone surface, ouch! Supraspinatus tendon impingement most definitely cause significant tendon pain.
Overload
When the load is higher than the tendon junction can tolerate small tears occur. Excessive load in a once off traumatic event, like lifting a too heavy weight during your training. Or small tears accumulate over a longer period of time from repetitive overuse, like perfecting your tennis serve.
Once there are small tears in the tendon inflammation forms around the injured area to aid its recovery. Inflammation is the body’s way of getting all the healing agents where they are needed. Once healing has taken place, inflammation should settle. Repetitive injury sustains this inflammatory reaction which then initiates the tendinopathy continuum, explained later. Insufficient rest or poor movement patterns worsen the problem.
If you get caught in this cycle of exercising or doing an aggravating activity, experience shoulder pain, rest, less pain, go back to participating, you unconsciously create new compensatory movement patterns to adapt. This is the body’s way of avoiding pain. These “new” movements contribute and sustain your supraspinatus tendinitis.
Causes of supraspinatus tendinitis
Supraspinatus tendonitis refers to the changes in the tendon tissue. Tendon thickening lead supraspinatus tendon impingement. Because the supraspinatus tendon needs to move through a relatively small space, the subacromial space, thickening causes the tendon to be pinched within this small space. It’s like trying to get the thread through the small eye of a needle, the more you lick and twist the thread, the more it frays until you can’t get it through at all. A vicious cycle is created because a thicker supraspinatus tendon will impinge on movement and each time it pinches the thicker it becomes.
Different factors can cause or worsen a supraspinatus tendon impingement and lead to supraspinatus tendonitis. You may be more prone to develop an impingement because of the shape of your acromion. This is known as an intrinsic primary impingement, at no fault of your own. Repetitive trauma, overload and failure to rest will cause extrinsic primary impingement, where you are to a degree responsible for your injury. Both situations describe impingement caused by the shoulder joint’s shape.
Secondary intrinsic impingement is caused by structural changes in the tissues, where secondary extrinsic impingement is caused by issues further away and compensatory movement patterns. The table below classifies the different supraspinatus impingement types.
| Types of supraspinatus tendon impingement | Primary supraspinatus tendon impingement (mechanical decreased subacromial space) | Secondary supraspinatus tendon impingement (functional decreased subacromial space) |
|---|---|---|
| Intrinsic (cause is from inside the shoulder joint) |
| |
| Extrinsic cause (cause is from outside of the shoulder joint) |
|
|
Symptoms of supraspinatus tendinitis
How bad is my supraspinatus tendinitis?
Supraspinatus tendinopathy is an umbrella term used to cover any and all types of the pathology of the supraspinatus tendon. The pain experienced may come and go and fluctuate in intensity, as your tendon transitions through the different phases of supraspinatus tendinopathy. The three different stages are:
Phase 1
Reactive supraspinatus tendinopathy is the first phase and happens when the tendon responds to acute compressive or tensile overload. The cells adapt and cause the tendon to thicken by producing more protein, while the collagen integrity is maintained. This is like an “organised peaceful protest” within the tissue. Tendon thickening is not necessarily a bad thing, it shows that the body can alter as demand changes. You will feel acute pain when the tendon is pressurised by movement, like a sharp sudden pain when you lift your arm. This phase is of short duration and the potential of the supraspinatus tendon to heal completely is high.
Phase 2
Supraspinatus tendon disrepair happens when the tendon is not offloaded and allowed adequate rest to complete the healing process. The increase in protein production persists and leads to collagen separation and disorganisation. The “peaceful protest” escalates to a “strike”. Vascularization and neural growth, where capillaries and nerve ending are formed within the tissue take place. The pain may become more constant and intense because of this. This phase tends to happen with repeat supraspinatus injuries. Your shoulder will feel less flexible now.
Phase 3
Degenerative supraspinatus tendinopathy is the final phase in the tendon continuum and unfortunately has a poor prognosis as the changes within the tendon are now irreversible. Let’s say the “strike” took a wrong turn and there were fatalities. Cell death has been found in this phase and grossly thickened tendon, where most fibres are disappeared and only a small amount are normal. This happens when you neglect your supraspinatus tendonitis for a long time. The pain will follow even the smallest of exertion and felt chronic.
Chronic supraspinatus tendinitis left untreated increase the risk of tendon rupture. Tendon strains are classified as grade I, II or III. Grade I injury involves a few microscopic tears of the tendon, approximately 20 % of the total tissue. A grade III strain or rupture is where 80% of the fibres are torn. This leads to disability because of weakness. The leverage system is compromised and the muscle cannot exert force on the joint to enable movement. Everything in between is classified as a grade II injury. Repetitive grade I or II strains lead to chronic supraspinatus tendonitis, tendon weakening and the “perfect storm” to sustain a complete tendon rupture.
Diagnosis of supraspinatus tendinitis
We are trained to test tendons, ligament integrity, muscle length, strength and endurance. You can trust us to make the correct diagnosis of your supraspinatus tendon pain and the factors that are contributing to your unique case.
Our physiotherapists are able to accurately diagnose your Supraspinatus tendinitis without expensive scans. We know and understand the anatomy of the shoulder. We consider the the intricacy of the biomechanics of carrying, throwing and pushing.
Different factors will contribute to each patient’s Supraspinatus tendon pain. Therefore we look at the bigger picture. We look at what is important to you and what you would like to achieve with your training. During your physiotherapy evaluation, we will be able to determine how bad your Supraspinatus tendonitis is by stretching and stressing the tendon as well as different joints and muscles in the area. We also test muscle strength and length, range of movement and can measure swelling in the area. This is why our physiotherapists are the best at diagnosing this type of problem.
X-rays
X-ray imaging of the shoulder joint will show only the bone. It will give us valuable information about the acromion joint space, especially if we suspect that you have an intrinsic supraspinatus tendon impingement caused by bony factors, like an osteophyte or particular acromion shape. X-rays will not visualise the supraspinatus tendon.
Sonar
On a diagnostic ultrasound, we will be able to see the bone and supraspinatus muscle and tendon insertion. Your sonographer may ask you to do certain movements so that the structures that are contributing to your supraspinatus tendinopathy can be seen. Any problem in the supraspinatus muscle belly, like microtears and inflammation, will also be visible on sonar. This is the most valuable scan for confirming a supraspinatus tendinitis diagnosis.
MRI
Both the bone and soft tissue structures are visible on MRI, which enables the exclusion of any sinister pathology. If your injury was traumatic or you had previous surgery, this will be valuable, but it is not necessary to diagnose supraspinatus tendon impingement. An MRI can only be ordered by a specialist, if your physiotherapist deems it necessary we will definitely refer you to consult with an orthopaedic surgeon.
Why is my shoulder pain not going away?
As described the causes of supraspinatus tendinitis can be internal or external, primary or secondary. Therefore it is very important to get the correct diagnosis. It may be easy to relieve the symptoms, but in the long run, the pain will keep coming back if you do not address the cause of the problem. If every single time you lift your arm up, the supraspinatus tendon impingement occurs against the acromion, the pain will become constant. A muscular imbalance may cause this. You need to retrain the way your shoulder moves. This requires dedication and patience, as muscles take between 4 – 6 weeks to change.
If your supraspinatus tendinitis is caused by internal differences, like thickening of the coracoacromial ligament or osteophytes, we will refer you to an orthopaedic surgeon for further imaging and management of your supraspinatus tendon pain.
A big problem we see with supraspinatus tendinitis these days
Impatience! You may get quick symptomatic relief from a cortisone injection or other oral medications, but to get to the bottom of the problem and prevent a recurrence, you need to put in the time and effort to make the necessary changes in your movement patterns and tissues. This takes patience and hard work, we will guide you every step of the way to deal with and heal your supraspinatus tendon impingement.
Recurrence of supraspinatus tendon pain means that the cause was never addressed. Rest alone or avoiding specific exercises in the gym is not the answer. Addressing the interplay between the shoulder blade and shoulder joint’s movement is key. Facilitating the needed stability to allow controlled movement, especially if you are loading the joint, be it with weights or upside down in a handstand, is key. We can assist you to load responsibly while the supraspinatus tendon heals.
Faulty diagnosis and management of supraspinatus tendonitis can lead to long term supraspinatus tendon pain. A cortisone injection, followed by 2 weeks in a sling, is not optimal. Think about how you would feel after 2 weeks in bed, stiff and creaking. The same is true for your shoulder! Unnecessary immobilisation leads to muscular weakness and restricted movement. This can cause non-optimal movement patterns when you finally take off the sling. Poor biomechanics can cause further load or subacromial space narrowing that can further lead to supraspinatus tendon pain. Long term use of shoulder slings is not recommended as this deconditions the muscles and may lead to dependence, stiffness, weakness and instability.
Do not avoid movement. If you are participating in an exercise class set up, continue to do it, just let your instructor know about your supraspinatus tendon pain. Pilates and yoga is a good low load option to maintain shoulder mobility, while you get to the root of the problem. You need to find the balance between doing too little and doing too much, tipping the scales in any direction can aggravate your supraspinatus tendon pain.
Supraspinatus tendinitis treatment
Everybody’s lives are different and what you need your shoulder to do may be completely different from what your neighbour needs their shoulder to do. So whether you are doing pull ups or handstands, or just want to do your hair in the mornings, we will set specific goals to get you there. We are experts at identifying the contributing factors to supraspinatus tendon pain, be it poor shoulder control or weakness that is causing overload or faulty exercise technique, we will get to the bottom of the problem so that you can go on without fear of recurrence of your shoulder tendon pain.
1st Phase: Protection & initial Healing
Rest
Rest from activities that are worsening your pain. Give it time to heal. Don’t continuously test your supraspinatus tendon pain.
Avoid anti-inflammatory mendication
The use of anti-inflammatory medication should be avoided, especially during the first 48 hours after injury. Inflammation is the body’s way of getting all the supplies needed for healing at the site of injury. If you hamper this process you can delay healing taking place.
Compression and ice
Strapping or taping can relieve your pain by supporting the shoulder joint and limiting movement. Ice can aid in relieving your pain by limiting inflammation.
Information & Load
It is important to understand what is going on in your body to make informed decisions. We are happy to answer all your questions. It is important to avoid movement and activities that aggravate your symptoms, but not moving at all is equally harmful. You need to find the sweet spot between the two to fast track the healing process without causing unnecessary delays.
2nd Phase: Establish pain free range of movement
During your examination, it will be clear what you are able to do, and what you should avoid. We identify factors that contribute to your pain, specific to your case. There is a pain free range of movement that is safe to move in, and our exercises will be targeted between these boundaries, i.e usually 0 – 60 degrees of forward and sideways shoulder movement. On completion of this phase, you should be able to lift your arm to shoulder level, like moving the steering wheel in the car. As your rehabilitation progress, we aim to gain a larger pain free range of movement, to ultimately reach overhead to wash your hair or hang laundry.
3rd Phase: Tendon tissue healing
All tissue heal by means of scar tissue. It is like having a scab on the inside. We monitor the progress of the fibrous tissue formation of the “scar” around your supraspinatus tendon. On a cellular level, we are able to accelerate tissue healing by using electrotherapy, like Laser and Ultrasound, and specific exercises that increase circulation without the risk of overloading the supraspinatus tendon.
4th Phase: Tendon Stress & ability to heal
During each treatment session, we check that you are achieving the targets to ensure that the supraspinatus tendon can handle tensile, elastic and compression forces. That you are able to push through the arm, like pushing a trolley and pull through the arm, like changing gears. We teach you to do isometric muscle contractions. These are muscle contractions without movement, like imaginary movements that keep the surrounding muscles active without compromising your injury site, by increasing circulation while maintaining strength. You can expect to be pressing into a wall in all directions during this phase. It is pain free to do and can relieve pain too.
5th Phase: Shoulder stability
Any contributing muscle imbalance and postural problems that influence your shoulder joint will be addressed with exercise. Weight bearing exercises in kneeling or plank will be introduced to increase shoulder stability under load. Our physiotherapist guides you to reengage in safe increments, and adjust where necessary. We’ll follow your progress and adapt where needed.
On completion of this phase, you should be able to identify correct shoulder blade placement for exercise and maintain this position.
6th Phase: Muscle Strength & Full Range of Movement
The most important component of rehabilitation is to regain full range of movement of the muscle fibres. The scar tissue that forms within the supraspinatus tendon must be able to lengthen and move in the same orientation as the supraspinatus muscle. We use massage, stretches and neurodynamic mobilizations to achieve full range of movement.
On completion of this phase you should be able to lift your arms overhead without any pain to reach the shelf or wave.
7th Phase: Concentric Muscle Strength
Shortening of the muscle during a contraction involves strength and power exercises that will be progressed gradually as healing takes place. This will be tested frequently to determine if you can progress from short lever (bent arm) to long lever (straight arm) exercises. Our physiotherapist will guide and monitor your shoulder’s ability to maintain stability under load.
On completion of this phase, you should be able to do a weighted shoulder press pain free.
8th Phase: Eccentric Muscle Strength
Muscle contraction works in two directions:
- Concentric contraction is when the muscle shortens, and
- Eccentric contraction is when the muscle lengthens.
Concentric contraction enables powerful lifting from the shoulder, while eccentric contraction enables you to control the descend of a heavy object. Its common to feel some pain when we start contracting the muscles – this is due to breaking down abnormal fibrous tissue adhesions. On completion of this phase, you should be able to control returning shoulder movements with weights or resistance bands.
9th Phase: Return to activity
The shoulder muscles must be tested under high load and speed to ensure that the muscles will be able to keep up with the demand of your life. During this phase our physiotherapist will guide you to return to normal activities, this includes challenging your muscle past its ‘normal’ boundaries to determine how it reacts to different forces. Ultimately we prepare you to return to hobbies, painting, walking the dogs of weight training.
10th Phase: Sport Specific Training
This is the final stage of rehabilitation that can last anything from 2-4 weeks. Our Physio will still commence with myofascial release, trigger point release and electrotherapy modalities where needed, but functional rehabilitation is most important during this phase.
Depending on your sport, our physiotherapist will tailor specific exercises that will help strengthen the muscles pertaining to your sport. A successful outcome is when you have gained knowledge throughout the rehabilitation program and can participate at full power and speed, not to mention the benefits of minimizing your chance of future injury.
Healing time for supraspinatus tendinitis
There is no quick fix, do not be fooled with promises that a single injection, manipulation or machine will make your pain go away. An uncomplicated, meaning no other structural contributing factors are present, of the first incident of supraspinatus tendinitis, may take as little as 4-6 weeks to recover with adequate treatment. Ongoing, chronic pain and mismanagement of supraspinatus tendinitis may take 6 months to a year to rehabilitate.
Other medical treatment of supraspinatus tendinitis
Your GP can prescribe oral medication, like analgesics, anti inflammatories or muscle relaxants, to decrease your pain. This is for short term management as all medication has side effects, be it minor or major ones. When your pain is under control it is a great time to begin your rehabilitation.
A subacromial cortisone injection may be considered for chronic supraspinatus tendinitis when followed up with rehabilitation. This can be done by an orthopaedic surgeon in the consultation room.
Chiropractic manipulation may give you pain relief, but it cannot change the joint space in the long run. You need to follow up treatment with rehabilitation.
Biokinetic rehabilitation programs are great to maintain the changes you gain in the treatment room.
Surgery for supraspinatus tendinitis
Surgical intervention will only be considered for the following reasons:
- complete rupture of the supraspinatus tendon
- severe loss of function that impacts the quality of life
- three months of conservative treatment fails to improve movement and function
Surgery is not the “quick fix” that most people expect. Rehabilitation after surgery can take up to four months. Regaining movement, strength and endurance is hard work. Your surgeon can decide to do an arthroscopic, keyhole, or open procedure. Decompression of the subacromial space, bursal resection and calcium deposit resection is usually done, all in one go. This is a very traumatic experience in the tissues. The aim is to increases the subacromial space to allow restriction-free movement of the supraspinatus tendon. This procedure can cause instability, so a strengthening program is of utmost importance.
What else could the pain be?
ACJ dislocation or clavicle fracture can happen with a fall directly onto the side of the shoulder. Immediate severe pain, bruising or a step may be visible.
- Bicep tendinitis
The bicep tendon is in close proximity to the supraspinatus tendon and may present together. Symptoms are very similar, with increased pain when reaching behind the back.
Injury to the neck discs may refer pain to the shoulder. Headaches and neck pain may also be present.
Rotator cuff tears or rupture usually occur with a traumatic injury and sound of the tendon tearing. Extreme weakness or an inability to move the arm may be present.
- Glenoid labrum injury
Traumatic or repetitive injuries that cause clicking or grinding on a specific movement can be a labrum injury.
Trauma (whiplash) or traction may cause injury to the brachial plexus that causes pins & needles into the shoulder and down the arm.
