Supraspinatus Tendonitis
Upper LimbOverview
Supraspinatus tendonitis is inflammation of the supraspinatus tendon, commonly resulting from repetitive overhead activities, postural dysfunction, or rotator cuff impingement. It presents with pain in the anterolateral shoulder, particularly with abduction and overhead movements. This condition is a frequent cause of shoulder dysfunction and can progress to rotator cuff tears if left untreated.
Pathophysiology
The supraspinatus originates from the supraspinous fossa of the scapula and passes through the narrow subacromial space before inserting on the greater tubercle of the humerus. Repetitive microtrauma, poor scapular biomechanics, humeral head superior migration, or direct subacromial impingement causes inflammatory changes within the tendon. Degenerative changes, calcification, and reduced vascularity at the critical zone (the area of poorest blood supply 10-15mm proximal to the insertion) contribute to chronicity. Associated subacromial bursitis often accompanies this condition.
Patient Education
Supraspinatus tendonitis typically improves with activity modification, postural correction, scapular stabilization exercises, and gradual progressive loading rather than complete rest.
Typical Presentation
Site
Anterolateral shoulder, may radiate to lateral arm and deltoid region
Quality
Dull ache, sharp pain with specific movements, mechanical 'catching' sensation
Intensity
Mild to moderate (typically 4-7/10), variable depending on activity level
Aggravating
Overhead activities, abduction 60-120 degrees (painful arc), reaching across body, sleep on affected side, sustained postures with rounded shoulders
Relieving
Rest from provocative activities, ice application, arm support in sling, postural correction, gentle pendulum movements
Associated
Scapular dyskinesis, reduced shoulder abduction strength, restricted internal rotation, subacromial impingement signs, possible night pain, muscle guarding in upper trapezius and levator scapulae
Orthopaedic Tests
Hawkins-Kennedy Impingement Test
Procedure
Patient seated or standing. Raise the arm to 90° of forward flexion with the elbow bent to 90°, support the elbow, then turn the forearm down to internally rotate the shoulder.
Positive Finding
Reproduction of the familiar anterolateral shoulder pain.
Sensitivity / Specificity
Reference: Gismervik SØ et al., BMC Musculoskelet Disord 2017; PMID 28122541
Interpretation
Compresses the cuff and bursa under the coracoacromial arch. A positive test supports a subacromial pain source but does not identify which structure; combine it with the painful arc and resisted external rotation. The Hawkins–Kennedy test pools at 58% sensitivity / 67% specificity for subacromial impingement (Gismervik 2017) — the highest-ranked single impingement test, but only moderately discriminative.
Empty Can Test (Jobe's Test)
Procedure
Patient standing. Arms elevated to 90° in the scapular plane (about 30° forward of the side), elbows straight, thumbs pointing down. Apply a downward force at the forearms while the patient resists; compare sides.
Positive Finding
Weakness compared with the other side, or reproduction of the familiar lateral shoulder pain.
Related reference: Itoi E et al., Am J Sports Med 1999; PMID 9934421
Interpretation
Loads supraspinatus. Weakness points more towards a tear; pain alone is common with tendinopathy and bursitis. The full-can position (thumbs up) tests the same muscle and is often less painful. Use it with the history and other cuff tests. Itoi (1999, Am J Sports Med — not JSES) compared the empty-can and full-can tests by diagnostic accuracy (~70–75%), not a sensitivity/specificity pair.
Painful Arc Test
Procedure
Ask the patient to raise the arm slowly out to the side as far as possible and lower it again. Note where in the movement pain appears and disappears.
Positive Finding
Pain in the middle of the range (roughly 60–120° of elevation) that eases above and below it.
Related reference: Park HB et al., J Bone Joint Surg Am 2005; PMID 15995110
Interpretation
A mid-range painful arc fits a subacromial source (rotator cuff tendon or bursa). It does not separate tendinopathy from bursitis or a tear. Pain only at the top of the range points more to the acromioclavicular joint. Park (2005) reported the painful arc at ~74% sensitivity, but a matched specificity varied by severity; shown Not verified pending a single confirmed pair.
Supraspinatus Tendon Palpation
Procedure
Patient seated with the hand behind the back (shoulder extended and internally rotated), which brings the supraspinatus insertion forward. Palpate just below the anterolateral corner of the acromion and compare sides.
Positive Finding
Tenderness over the tendon insertion that reproduces the familiar pain.
Interpretation
Supports local tendon irritation, but the bursa overlies the tendon and cannot be separated by palpation. Use it with the loading tests rather than alone.
Infraspinatus Test (Resisted External Rotation)
Procedure
Patient seated, arm at the side, elbow bent to 90°, forearm pointing forward and slightly internally rotated. Ask the patient to push outwards against your hand; compare sides.
Positive Finding
Weakness or pain on resisted external rotation compared with the other side.
Related reference: Park HB et al., J Bone Joint Surg Am 2005; PMID 15995110
Interpretation
Tests infraspinatus. Weakness suggests infraspinatus involvement or a larger cuff tear; normal strength with painful elevation points more to supraspinatus or the bursa. Park (2005) reported the infraspinatus strength test as highly specific (~90%) for rotator cuff disease; sensitivity is lower and a single confirmed pair is not shown.
Speed's Test (Biceps Loading Test I)
Procedure
Patient standing, shoulder flexed to 90°, elbow straight, forearm supinated. Apply a downward force at the forearm while the patient resists.
Positive Finding
Pain in the bicipital groove or front of the shoulder.
Related reference: Bennett WF, Arthroscopy 1998; PMID 9848587
Interpretation
Primarily loads the long head of biceps. Anterior pain is common with any subacromial problem, so a positive test does not isolate the biceps tendon. Use it to look for coexisting biceps involvement. Speed's test accuracy is inconsistent across studies (e.g. Bennett 1998: 90% sensitivity, 14% specificity); no reliable pair is shown.
⚠ Red Flags
- •Acute severe pain with trauma suggesting acute rupture
- •Progressive neurological deficit or numbness in arm/hand
- •Signs of infection (fever, lymphadenopathy, systemic illness)
- •Unilateral shoulder swelling with constitutional symptoms suggesting systemic disease
- •History of malignancy with shoulder pain
- •Inability to maintain arm position (complete rotator cuff tear)
- •Severe night pain unresponsive to conservative management
⚡ Yellow Flags
- •Fear-avoidance behavior limiting shoulder use
- •Catastrophic thinking about condition progression
- •High stress or anxiety exacerbating muscle tension
- •Work-related dissatisfaction or job insecurity
- •Poor self-efficacy regarding recovery
- •Delayed presentation (>12 weeks) with minimal improvement
- •Dependence on passive treatments without active participation
Osteopathic Techniques
Region
Subacromial space and rotator cuff
Technique
Rationale
Direct soft tissue techniques to the supraspinatus, infraspinatus, and subscapularis muscles reduce muscular guarding, improve local circulation, and address trigger points contributing to referred pain patterns
Region
Glenohumeral joint and shoulder capsule
Technique
Rationale
Gentle mobilization of the glenohumeral joint in pain-free ranges promotes synovial fluid nutrition, reduces capsular restriction, and restores accessory motion necessary for pain-free function
Region
Scapulothoracic articulation
Technique
Rationale
Muscle energy techniques address scapular dyskinesis by normalizing tone in serratus anterior, lower trapezius, and other scapulohumeral muscles, improving scapular mechanics and reducing subacromial impingement
Region
Rotator cuff and supraspinatus
Technique
Rationale
Functional technique positions the shoulder in ease and allows release of protective patterns and neuromuscular tension without aggressive stretching
Region
Lymphatic drainage of shoulder region
Technique
Rationale
Lymphatic drainage techniques reduce inflammatory exudate around the subacromial space and promote tissue healing through improved vascular return
Rehabilitation Exercises
Pendulum Circles (Codman's Pendulum)
Supine Passive Shoulder Abduction with Gravity Reduction
Cross-body Shoulder Stretch (Horizontal Adduction Stretch)
Sleeper Stretch (Internal Rotation)
Prone Shoulder Abduction (Y-position) with Neutral Rotation
Prone External Rotation with Elbow Flexed (90/90 position)
Quadruped Shoulder Stabilization (Rhythmic Stabilization)
Serratus Anterior Activation (Quadruped Scapular Protraction)
Scapular Retraction and Stabilization (Prone Squeeze)
Upper Crossed Syndrome Correction (Thoracic Extension with Shoulder Blade Squeeze)
Single-arm Proprioceptive Training (Wobble Board or Unstable Surface)
Stationary Cycling with Postural Support
Referral Criteria
- •Failure to improve after 6-8 weeks of conservative treatment
- •Suspected complete rotator cuff tear (positive drop-arm test, inability to initiate abduction)
- •Signs of glenohumeral instability requiring specialist assessment
- •Persistent night pain significantly affecting sleep quality
- •Evidence of calcific tendonitis on imaging requiring specific intervention
- •Acute traumatic onset with severe pain and functional loss
- •Suspected glenohumeral osteoarthritis or advanced degenerative changes
- •Neurological symptoms suggesting cervical radiculopathy or neural compromise
- •Systemic disease features (rheumatoid arthritis, polymyalgia rheumatica) requiring rheumatology input