The supraspinatus tendon , is the tendon of the supraspinatus muscle, runs below the roof of the shoulder in the subacromial space and is part of the rotator cuff. The rotator cuff is made up of the tendons of four muscles that closely surround the joint of the humerus. Of these muscles and tendons, the supraspinatus tendon is the one that is exposed to the greatest efforts, so it is often related to the pain that patients experience in rotator cuff tendinitis.
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- 1 Function
- 2 Tendon
- 1 Degenerative process of tendons
- 2 Tendon healing process
- 3 Supraspinatus tendinitis
- 4 Clinical picture
- 5 Causes
- 1 symptoms
- 6 Other exams
- 7 Painful shoulder: Treatment
- 8 Functional rehabilitation proposal for total rupture of the supraspinatus tendon
- 1 Objectives
- 9 Traction
- 10 Glenohumeral joint
- 11 Recovery of range of motion
- 12 Active joint and muscle rehabilitation
- 13 Source
The function of the supraspinatus tendon is to raise the arm outward by pulling the muscle (abduction); the arm needs the strength of the supraspinatus muscle to perform this movement, especially from an angle of 60º. When the arm is raised laterally, the supraspinatus tendon slides underneath a ligament that joins the coracoid process and the roof of the shoulder (acromion) called the coracoacromial ligament. As the arm continues to be raised, the tendon is placed between the large humerus bulge (tuberculum majus), the mentioned ligament and the roof of the shoulder.
The tendon is a dense connective tissue structure that originates from the middle blastodermal sheet (mesoderm) and is made up of type I collagen fibers, longitudinally arranged, parallel to the axis and of various diameters. Transverse fibers and some elastic fibers are also observed.
The fibers are arranged in bundles surrounded by a conjunctive covering, among them are elongated fibroblastic cells with a round nucleus, a cytoplasm with a developed Golgi apparatus and a cell membrane in contact with collagen fibers. These cells called tendinosites are capable of making intercellular matrix, especially collagen. The irrigation is rich and occurs through capillaries that come from the muscle, bone or loose connective tissue that surrounds it. When you do not penetrate, they execute nutrition from a distance. For its part, the wealth of Golgi neurotendinous corpuscles lodged between the collagen fibers produces an important proprioceptive influence. The architectural arrangement of a tendon varies depending on whether it belongs to a long or short muscle. In the first case, the fibers take a spiral shape when they are at rest, while in the case of the short muscle it is in parallel, an arrangement that also acquires the long muscle tendon when it contracts and pulls. The spiral allows the contraction to pull smoothly and gradually. In wide muscles as in the case of fascia the disposition is in lattice.
As for its coverage, the tendon is enveloped by a sheath made up of a synovial plate that has two sheets: an internal one, the epitheon, which is attached to the tendon through loose tissue and an external one, peritenon, which is attached to neighboring structures , the latter presents in the middle a fold, mesothenon, through which the nutrient vessels pass.
Degenerative process of the tendons
The degenerative process has a certain order of progression practically unavoidable and that we differentiate in degrees:
- Tendinosis: formerly known as tendinitis and described as inflammatory processes that are now ruled out because studies have shown that there is no inflammatory sign (except in acute processes that would no longer fall into the category of degeneration), showing whether a process of change in the collagen and hence the change in conceptualization.
To know the origin of tendinosis we have to refer to repeated polytraumatisms added to aging of the tissue itself over time.
- Calcifications: Hematomas caused by partial tears or congestion in the subacromial slide can trigger the appearance of calcium deposits with a clear tendency to chronification and predisposing to total ruptures.
In people older than forty years we can affirm that there is no rupture of the supraspinatus tendon without having previously suffered problems in the serous pouch.
- Rupture: As we have previously explained, it is accepted that ruptures in young people are due to high intensity traumatic agents and in older people to the degenerative process mainly of collagen.
Tendon healing process
In order to recover, the injured tendon requires a dense fibrous union of the separated ends as well as extensibility and flexibility, demanding abundant collagen synthesis and giving rise to the risk of increased production and the consequent fibrosis that would make sliding difficult. The progression consists of the following stages:
The supraspinatus muscle runs through the top of the shoulder and inserts into the upper area of the humeral head. Its main function is to separate the arm from the body. This muscle is part of the so-called rotator cuff of the shoulder along with the infraspinatus, minor round and subscapularis. It has a characteristic that causes it to be injured very frequently, and that is that it runs through a strait formed by the acromion above, the humeral head below and the coracoacromial ligaments.
Supraspinatus pathology usually occurs by separating the arm 90º, a situation in which the tuberosity of the head of the humerus compresses the rotator cuff against the acromion, causing acute pain.
Other pathological entities that frequently present are its irritation, inflammation and degeneration, including rupture due to narrowing of that subacromial space. In addition, breaks can occur in an area of the tendon that is less vascularized and whose collagen is of “lower quality” than that of the rest of the tendon. It is also common to find tendinitis or tendinosis that present associated calcifications and tendinitis of the long portion of the biceps due to the close relationship between both tendons.
It manifests itself with pain in the lateral and upper face of the shoulder, radiating towards the arm and neck quite frequently, functional impotence, especially with the separation and elevation of the arm and internal rotation.
This tendinopathy is characteristic in people whose work gesture is a repetitive movement of the arm above the head and very frequently due to direct trauma to the side of the shoulder.
Night pain when leaning on the injured side is frequent in most cases. To diagnose it, a simple radiography is necessary to demonstrate the narrowing of the subacromial space and ultrasound and Magnetic Resonance as definitive techniques for the correct diagnosis of the pathology.
Treatment consists of the rest of tendinitis or tendinosis in the application of anti-inflammatory measures (ice, pharmacological treatment …), relative rest, and physical treatment (cyriax, massage, electrotherapy, etc …) as well as strengthening exercises. of the muscles that make up the rotated cuff. These treatments are not always effective and usually take a long time.
As a treatment for this pathology in our center we use a therapeutic protocol that includes very novel and decisive techniques with which we are obtaining a very high percentage of cure in this very rebellious pathology.
The clinical picture that characterizes these lesions is included within what is called subacromial impingement syndrome. The common belief is that compression of the supraspinatus tendon causes supraspinatus tendinitis (inflammation of the supraspinatus / rotator cuff tendon and / or contiguous peritendinous soft tissues), which is a known stage of shoulder impingement syndrome (phase II) , originally described by Neer in 1972. The processes that characterize a subacromial impingement syndrome generally affect other structures, in addition to the supraspinatus tendon.
The causes of supraspinatus tendinitis can be divided into extrinsic and intrinsic factors. Extrinsic factors are broken down into primary clamping, which is the result of increased subacromial loading, and secondary clamping, which is the result of rotator cuff muscle overload and imbalance. In athletes whose stressful sports involve repetitive overhead movements, a combination of causes can be found.
Supraspinatus tendinitis is also known as painful arch syndrome. Tendonitis and partial ruptures in the supraspinatus tendon cause a ‘painful arch’, so called because pain is felt when separating the arm from the body in an arc of 60º-120º because in that section the tendon rubs against the acromion. There may be other causes of a painful arch. Arthritis of the acromio-clavicular joint can also cause pain, but that is typically at the end of the arch, when the arm is nearly vertical.
The typical symptoms of painful shoulder (compression syndrome) are shoulder pain, which appear when making certain movements, in certain positions and at night. Impingement can also occur in the hip joint and cause pain in this area. Rotator cuff tendinitis limits the mobility of the arm, which can hardly be lifted or is only lifted with pain because the soft tissues are trapped. Many other everyday actions, such as putting on a shirt, or body hygiene, can only be done with pain.
Symptoms of impingement syndrome often appear when raising the arm from the side (abduction) and are manifested in certain areas of movement, doctors speak of the so-called painful arc. If patients only hold the arm upright, the pain will go away most of the time. Pains due to impingement syndrome can radiate into the shoulder and cause unpleasant symptoms there as well.
Night pain occurs when the patient rests on the sick side or turns unconsciously to it during sleep. In general, the diagnosis of the painful shoulder is made attending to the clinic and by means of a physical examination. The shoulder pain that accompanies the impingement syndrome are one of the most frequent pain in the day to day of traumatologists, which is why they are very familiar with the clinical picture.
Normally, the doctor performs an anamnesis before performing the exam. The most frequently asked questions are the following:
- In what situations does the shoulder hurt?
- Does it hurt constantly or only when performing certain movements or in certain positions?
- Do the pains also appear at night?
- Is there restricted mobility or strength?
- Since when do you feel the pain?
- Are there any known shoulder injuries, for example after a fall or crash?
- Are there risk factors for shoulder injury or wear (such as sports or work-related)?
It is also important to use scanning maneuvers and special methods to examine the patient. The clinical function tests that the doctor uses to make sure of the diagnosis are:
- Jobe’s test (supraspinatus test)
- Neer clamp test (Neer test)
- Hawkins test
- Test to check for a painful arc (English: painful arc)
- Brudzinski’s maneuver
- Lasègue maneuver
-The Jobe test, for example, is carried out as follows: the patient, standing or sitting in an upright position, places both arms horizontally (90 °), bends them about 30 ° at this level and rotates the hands of such that the thumbs face the ground (like shaking a can). From this position, the doctor tries to press down the affected person’s arms against the resistance that the patient makes. If the patient has little resistance, it is an inflammation of the synovial bag under the roof of the shoulder, or an irritated or broken tendon. All of these states can accompany a clamping syndrome.
-The typical picture of the painful arch of a compression, irritation, or inflammation of the humerus joint often serves as a guideline for diagnosing rotator cuff tendinitis.
-The Lasègue maneuver consists of holding both hands behind the back with the thumbs facing upwards, like tying an apron. In the Brudzinski maneuver, the doctor asks the patient to place both hands on the nape of the neck (thumbs facing down). Both maneuvers can cause pain.
If it is suspected that there may be a painful shoulder (compression syndrome), further examinations may be necessary to make sure of the diagnosis. Thus, for example, the doctor palpates the insertions of the tendons, joints and trigger points. Trigger points are stimulus points that can cause pain when touched. This examines the shoulder area for possible muscle shortening and checks the mobility of the joints. If necessary, a neurological examination is then performed, for example to check for a pinched nerve.
There are imaging procedures that allow more conclusions to be drawn about the state of the humerus joint and the space under the roof of the shoulder, such as:
- NMR (nuclear magnetic resonance)
- Radioscopic recognition
Ultrasounds allow us to assess, above all, the state of the muscles, tendons and ligaments, as well as possible joint tears (accumulations of pathological fluid in the joints). NMR (nuclear magnetic resonance) examination can also be very illuminating. Also, the doctor can inject a local anesthetic under the roof of the shoulder. If the discomfort improves, it is an indication that there is a subacromial impingement. Finally, the doctor uses the results of the anamnesis, clinical tests and complementary examinations (ultrasound and MRI, for example).
If the tests do not clearly indicate what causes the shoulder pain, an intra-articular visual examination (arthroscopy) may provide clarity. With this laparoscopic intervention (minimally invasive) the doctor obtains a direct impression of the structures of the humerus joint. If necessary, it can also give medical treatment, for example, by leveling the oppressive bone nodules or inflamed tissue or suturing a ruptured tendon.
Painful shoulder: Treatment
Rotator cuff tendinitis requires personalized treatment in most cases. The type of treatment depends, among others, on the cause, extent and duration of the pain. The patient’s profession is also important, as some people depend more than others on the humerus joint being healthy and pain-free (painters, for example).
Most of the time, the treatment of the painful shoulder is not surgical at first. Conservative treatment includes medications and physical therapy. Despite intensive treatment, it often takes weeks to months for patients to stop complaining and the impingement syndrome has improved considerably. Therefore, you must have a little patience.
The treatment has three objectives. These are as follows:
- Restoring joint function
- Recover all the strength of the muscles
- Eliminate pain
If conservative treatment fails to improve shoulder pain and its function is restricted, the doctor should be consulted if an operation is indicated and if it is a guarantee of improvement. Regardless of whether the treatment is conservative or surgical, there is something that can be applied in most cases: You can help to alleviate or completely get rid of your shoulder pain yourself.
Functional rehabilitation proposal for total rupture of the supraspinatus tendon
- Decrease pain.
- Eliminate defense contractures and muscle spasms.
- Combat the rise of the humeral head trumpeting for dynamic re-centering.
- Keep ranges of motion at the highest possible angle.
- Encourage muscle work with an emphasis on stabilizing muscles, synergists and strength couplings.
== Techniques and procedures Masotherapy ==
The work should focus on the areas of defensive contractures that are activated in the face of pain, initiating a vicious circle that must be eliminated so that it does not interfere with rehabilitation.
With deep pressure techniques with sliding, friction and kneading on muscle areas such as trapezius, deltoids, pectorals, sternocleidomastid, interscapular and cervicodorsal. Due to the compensations that potentially exist, the contralateral shoulder and the lumbosacral zone must also be taken into account. A variant to consider is the Ciriax deep transverse massage that is used in painful tendon areas such as the rest of the challenging cuff, the coracoid insertion of the pectoralis minor and the distal deltoid insertion. It is also important to mention the myofascial normotension techniques but without direct contact on the shoulder stump but through reflex techniques at distances in the brachial fascia (deltoid extension), the axillary, pectoral,
On the cervicodorsal spine: Performed manually with the patient in the supine position, with one hand depressing the chin and the other in the occipital area, traction is executed, to which slight rotational and lateral movements can be added.
Useful to achieve the descent of the humeral head, it is practiced with the patient in the supine position with the limb to work outside the stretcher. Fixation of the scapula is automatic because it is supported and therefore the therapist’s hands take the distal area of the arm and wrist. From there bring the joint into a functional position and gradually and painlessly pull.
Range of motion recovery
Passive mobilization: this type of mobility is not usually too restricted, but if present, work must be done to regain full range. Entirely developed by the therapist. The progression in the postures must be respected, starting in decubitus, passing through the sitting position, ending in wide angles when standing. Pendular exercises: considered according to the author as passive, self-assisted or active activity, its importance lies in the automatic combination of these three conditions. It has analgesic, muscle-relaxing and range-of-motion recovery characteristics. According to the different research works, they must be carried out starting from an opening that goes from 60º to 90º with the patient in the prone position or standing with high support. Isometry: basic muscle strengthening exercise that is extremely useful to maintain and recover contractile activity. In the case of supraspinatus rupture, its importance lies in the contraction of the internal and external rotators that are practiced against the wall and with an opening of 30º to work on the scapular plane.
Active joint and muscle rehabilitation
To depress and re-center the head of the humerus and inhibit the ascending component of the deltoid. Internal rotation: for work specifically for humeral descent. The movement is carried out with the patient sitting with the elbow close to the body and starting from a neutral position, the exercise is carried out bringing the hand to the abdomen. The resistance will be given manually, with thera-bands or mechanical type tensioners.