Supraspinatus Tendonitis

Upper Limb

Overview

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

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade D
A+ABCDLimited value: little effect on the diagnosis on its own
limited standalone value.

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

58%/67%

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.

Sources

No accuracy study

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.

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.

Sources

No accuracy study

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.

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. A 2013 JAMA review of the examination for rotator cuff disease (Hermans et al.; 28 studies, all in patients seen by specialists) found the painful arc the most useful pain-provocation test: a positive arc made rotator cuff disease more likely (likelihood ratio 3.7) and a normal arc made it less likely (0.36). The review reports likelihood ratios rather than one sensitivity and specificity pair, so no figure is shown.

Sources

No accuracy study

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.

Sources

No accuracy study

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.

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.

Sources

No accuracy study

Speed's Test

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.

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.

Sources

⚠ 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

Exercise is the first-line treatment, and most add-ons may not beat exercise alone. Manual therapy can be added for a small, mostly short-term drop in pain; the evidence is low quality.

Region

Upper and mid thoracic spine

Technique

Articulation, thoracic
Grade B
Moderate evidence: supported by at least one good study
Reviews found thoracic mobilisation reduced pain and disability in shoulder impingement. Thrust manipulation (HVLA) did not show the same effect.

Rationale

Gentle, rhythmic mobilisation of a stiff upper back. Reviews found it reduced shoulder pain and disability in impingement.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of restricted thoracic segments within their passive range, with no thrust. The patient is seated, side-lying or prone. For neck problems the upper thoracic segments (T1–T6) are the usual focus.

Evidence in Supraspinatus Tendonitis

A 2026 meta-analysis of 12 studies found thoracic Maitland mobilisation improved pain and disability in subacromial impingement more than control, while thrust (HVLA) techniques showed no significant effect. A 2025 meta-analysis of 10 trials found thoracic manual therapy reduced pain and disability, including versus placebo. An earlier 2018 review found a single session was no better than placebo straight after treatment.

Region

Glenohumeral joint (Spencer sequence)

Technique

Articulation, shoulder (Spencer technique)
Grade C
Limited evidence: indirect or low-quality support only
Manual therapy eased pain a little more than placebo or exercise alone, with low-quality evidence. The best placebo-controlled trial found no clinically important difference.

Rationale

Graded mobilisation of the shoulder through its range. Adds a small, short-term pain benefit to exercise.

How it's done, cautions & evidence

How it's done

Patient side-lying, affected shoulder up. Stabilise the shoulder girdle with one hand and support the arm at the forearm and wrist with the other. Work through seven stages: extension, flexion, circumduction with compression, circumduction with traction, abduction (then adduction with external rotation), internal rotation, and traction in abduction. At each barrier use slow rhythmic oscillations, then a gentle isometric contraction to reach the new barrier.

Cautions

Its isometric step is a muscle energy technique, so do not use it with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in Supraspinatus Tendonitis

A 2015 meta-analysis of 21 trials found manual therapy cut pain by about 1 point out of 10 versus placebo or when added to exercise; its effect on function was unclear. A 2017 meta-analysis found it beat placebo and, added to exercise, helped only at the shortest follow-up (very low quality). A 2016 Cochrane review found the one high-quality trial of manual therapy plus exercise versus placebo showed no clinically important difference. These trials tested shoulder mobilisation in general, not the Spencer sequence.

Region

Rotator cuff, deltoid and periscapular muscles

Technique

Soft tissue, shoulder and periscapular muscles
Grade C
Limited evidence: indirect or low-quality support only
Massage helped pain, function and range in the short term versus no treatment (low-quality evidence). Added to exercise, it gave no extra benefit in a trial.

Rationale

Eases tension in the rotator cuff and shoulder blade muscles. Short-term help; it adds little to exercise.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the muscles around the shoulder: the rotator cuff, deltoid and the muscles around the shoulder blade. In trials it was given alongside shoulder exercise.

Evidence in Supraspinatus Tendonitis

A 2014 meta-analysis found low-quality evidence that soft tissue massage improved pain, function and range of motion in non-specific shoulder pain in the short term, versus no treatment. A 2015 trial of 80 patients found adding massage to exercise gave no extra benefit; at 12 weeks exercise alone did slightly better for pain. A 2025 review found trigger point manual therapy matched other passive treatments for pain in rotator cuff related shoulder pain, with slightly better function.

Region

Upper and mid thoracic spine

Technique

Muscle energy, thoracic
Grade C
Limited evidence: indirect or low-quality support only
Thoracic MET beat placebo for pain and disability in shoulder impingement, up to 1 year. This is one trial of 75 patients.

Rationale

Low-force, patient-powered upper-back technique. Beat placebo for pain and disability in one impingement trial.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Supraspinatus Tendonitis

A 2022 placebo-controlled trial of 75 patients aged 40 or over with shoulder impingement, run in an osteopathic practice, found 4 weekly sessions of MET to the thoracic spine improved pain and disability more than placebo at discharge, 6 and 12 months. MET plus soft tissue massage improved disability but not pain.

Rehabilitation Exercises

Pendulum Circles (Codman's Pendulum)

Range of MotionBeginner

Supine Passive Shoulder Abduction with Gravity Reduction

Range of MotionBeginner

Cross-body Shoulder Stretch (Horizontal Adduction Stretch)

StretchingBeginner

Sleeper Stretch (Internal Rotation)

StretchingIntermediate

Prone Shoulder Abduction (Y-position) with Neutral Rotation

StrengtheningBeginner

Prone External Rotation with Elbow Flexed (90/90 position)

StrengtheningIntermediate

Quadruped Shoulder Stabilization (Rhythmic Stabilization)

StrengtheningIntermediate

Serratus Anterior Activation (Quadruped Scapular Protraction)

StrengtheningBeginner

Scapular Retraction and Stabilization (Prone Squeeze)

PosturalBeginner

Upper Crossed Syndrome Correction (Thoracic Extension with Shoulder Blade Squeeze)

PosturalIntermediate

Single-arm Proprioceptive Training (Wobble Board or Unstable Surface)

BalanceAdvanced

Stationary Cycling with Postural Support

CardiovascularBeginner

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