Supraspinatus Tendonitis

Article Last Updated: Jun 8, 2006

INTRODUCTION
Background
Supraspinatus tendonitis is often associated with shoulder impingement
syndrome !he common "elief is that impingement of the supraspinatus tendon
leads to supraspinatus tendonitis #inflammation of the supraspinatus$rotator cuff
tendon and$or the contiguous peritendinous soft tissues%, which is a &nown stage
of shoulder impingement syndrome #stage ''% as descri"ed originally "y (eer in
)*+2
!he causes of supraspinatus tendonitis can "e "ro&en down into e,trinsic and
intrinsic factors -,trinsic factors are further "ro&en down into primary
impingement, which is a result of increased su"acromial loading, and secondary
impingement, which is a result of rotator cuff o.erload and muscle im"alance 'n
athletes whose sport in.ol.es stressful repetiti.e o.erhead motions, a
com"ination of causes may "e found
Frequency
United States
Supraspinatus tendonitis is a common cause of shoulder pain in athletes whose
sports in.ol.e throwing and o.erhead motions
Functional Anatomy
!he shoulder consists of 2 "ones #ie, humerus, scapula%, 2 /oints #ie,
glenohumeral, acromiocla.icular%, and 2 articulations #ie, scapulothoracic,
acromiohumeral% Se.eral interconnecting ligaments and layers of muscles /oin
these "ones !he relati.e lac& of "ony sta"ility in the shoulder permits a wide
range of motion Soft tissue structures are the ma/or glenohumeral sta"ili0ers
!he static sta"ili0ers consist of the articular anatomy, glenoid la"rum, /oint
capsule, glenohumeral ligaments, and inherent negati.e pressure in the /oint
!he dynamic sta"ili0ers include the rotator cuff muscles, long head of the "iceps
tendon, scapulothoracic motion, and other shoulder girdle muscles such as the
pectoralis ma/or, latissimus dorsi, and serratus anterior
!he rotator cuff consists of 1 muscles, which control 2 "asic motions: a"duction,
internal rotation, and e,ternal rotation !he supraspinatus muscle is responsi"le
1
for initiating a"duction, the infraspinatus and teres minor for controlling e,ternal
rotation, and the su"scapularis for controlling internal rotation !he rotator cuff
muscles pro.ide dynamic sta"ili0ation to the humeral head on the glenoid fossa,
forming a force couple with the deltoid to allow ele.ation of the arm 't is
responsi"le for 134 of a"duction strength and *04 of e,ternal rotation strength
!he supraspinatus outlet is a space formed "y the acromion, coracoacromial
arch, and acromiocla.icular /oint on the upper rim and the humeral head and
glenoid "elow 't accommodates passage and e,cursion of the supraspinatus
tendon A"normalities of the supraspinatus outlet ha.e "een identified as a cause
of impingement syndrome and rotator cuff tendonitis
'mpingement implies e,trinsic compression of the rotator cuff in the
supraspinatus outlet space 5igliani and associates disco.ered and descri"ed
that .ariations in acromial si0e and shape can contri"ute to impingement 6rom
cada.eric studies, 2 different .ariations in the morphology of the acromion are
descri"ed !ype ' is flat, type '' is cur.ed, and type ''' is anteriorly hoo&ed
Although the cur.ed configuration is the most common #124 pre.alence,
compared with )+4 for flat and 104 for hoo&ed%, the hoo&ed configuration is
associated most strongly with rotator cuff pathology
7ther sites of impingement in the supraspinatus outlet space include the
coracoacromial ligament, where thic&ening can occur, and the undersurface of
the acromiocla.icular /oint, where osteophytes can form 7nly rarely is the medial
coracoid in.ol.ed !hese impingement sites in the supraspinatus outlet are
compressed further when the humerus is placed in the forward fle,ed and
internally rotated position, forcing the greater tu"erosity of the humerus into the
undersurface of the acromion and coracoacromial arch
(onoutlet impingement can also occur !he causes may "e loss of normal
humeral head depression either from a large rotator cuff tear or wea&ness of the
rotator cuff muscles from a 83$86 neural segmental lesion or a suprascapular
mononeuropathy Another way this may occur is with thic&ening or hypertrophy of
the su"acromial "ursa and rotator cuff tendons
Sport Speciic Biomec!anics
7.eruse or repetiti.e microtrauma sustained in the o.erhead position may
contri"ute to impingement and rotator cuff tendonitis Shoulder pain and rotator
cuff tendonitis are common in athletes in.ol.ed in sports re9uiring repetiti.e
o.erhead arm motion #eg, swimming, "ase"all, tennis%
Secondary impingement
Supraspinatus tendonitis is often attri"uted to impingement, which is seldom
mechanical in athletes :otator cuff tendonitis in this population may "e related to
2
su"tle insta"ility and therefore may "e secondary to such factors as eccentric
o.erload, muscle im"alance, and glenohumeral insta"ility or la"ral lesions !his
has led to the concept of secondary impingement, which is defined as rotator cuff
impingement that occurs secondary to a functional decrease in the supraspinatus
outlet space due to underlying insta"ility of the glenohumeral /oint
Secondary impingement may "e the most common cause in young athletes who
use o.erhead motions and who fre9uently place repetiti.e large stresses on the
static and dynamic glenohumeral sta"ili0ers, resulting in microtrauma and
attenuation of the glenohumeral ligamentous structures and leading to su"clinical
glenohumeral insta"ility Such insta"ility places increased stress on the dynamic
sta"ili0ers of the glenohumeral /oint, including the rotator cuff tendon !hese
increased demands may lead to rotator cuff pathology such as partial tearing or
tendonitis, and, as the rotator cuff muscles fatigue, the humeral head translates
anteriorly and superiorly, impinging on the coracoacromial arch, which leads to
rotator cuff inflammation 'n these patients, treatment should "e directed at the
underlying insta"ility
"lenoid impingement
:ecently, the concept of glenoid impingement has "een suggested as an
e,planation for partial;thic&ness rotator cuff tears in throwing athletes, particularly
those tears in.ol.ing the articular surface of the rotator cuff tendon Such tears
might occur in the presence of insta"ility due to increased tensile stresses on the
rotator cuff tendon either from a"normal motion of the glenohumeral /oint or from
increased forces on the rotator cuff necessary to sta"ili0e the shoulder
Arthroscopic studies of these patients ha.e noted impingement "etween the
posterior superior edge of the glenoid and the insertion of the rotator cuff tendon
with the arm placed in the throwing position, a"ducted and e,ternally rotated
Lesions are noted along the area of impingement at the posterior aspect of the
glenoid la"rum and articular surface of the rotator cuff !his concept is "elie.ed
to occur most commonly in throwing athletes and must "e considered when
assessing for impingement and rotator cuff tendonitis
C#INICA#
$istory
Age

3
o <ounger than 10 years: 't is usually glenohumeral insta"ility !he
cause is acromiocla.icular /oint disease or in/ury
o 7lder than 10 years: 8onsider glenohumeral impingement
syndrome or rotator cuff tendonitis Additionally, consider
degenerati.e /oint disease of the glenohumeral /oint
7ccupation

o La"orers and persons with /o"s that re9uire repetiti.e o.erhead

acti.ity #most at ris&%
o Athletes #eg, swimmers, those participating in throwing sports,
tennis players, .olley"all players%
Athletic acti.ity

o 7nset of symptoms related to specific phases of the athletic e.ent

performed
o =uration and fre9uency of play
o =uration and fre9uency of practice
o Le.el of play #Little League >elementary school?, middle school,
high school, college, professional%
o Actual playing time #starter, "ac&up, "ench player%
o @osition played
Symptom onset

o Sudden onset of sharp pain in the shoulder with tearing sensation ;

Aore suggesti.e of a rotator cuff tear
o Bradual increase in shoulder pain with o.erhead acti.ities ; Aore
suggesti.e of an impingement pro"lem
8hronicity of symptoms
Location of symptoms #ie, pain%

o Usually lateral, superior, anterior shoulderC occasionally referred to

deltoid region
o @osterior shoulder capsule ; Usually consistent with anterior
insta"ility causing posterior tightness
Setting during which symptoms appear #eg, pain during sleep or .arious
sleeping positions, at night, with acti.ity, types of acti.ities, at rest%

Duality of pain #eg, sharp, dull, radiating, thro""ing, "urning, constant,

intermittent, occasional%

Se.erity of pain #ie, on a scale of );)0, with )0 "eing the worst%

Alle.iating factors #eg, change of position, medication, rest%

Aggra.ating factors #eg, change of position, medication, increase in
practice, increase in play, change in athletic gear, change in position
played%
4
Associated manifestations #eg, chest pain, di00iness, a"dominal pain,
shortness of "reath% ; Aay indicate a more ominous pro"lem than
supraspinatus tendonitis
@ro.ocati.e positions

o @ain with humerus in forward fle,ed and internally rotated position ;

Suggesti.e of rotator cuff impingement
o @ain with humerus in a"ducted and e,ternally rotated position ;
Suggesti.e of anterior glenohumeral insta"ility and la,ity
7ther history ; @re.ious or recent trauma, stiffness, num"ness,
paresthesias, clic&ing, catching, wea&ness, crepitus, symptoms of
insta"ility, nec& symptoms
%!ysical
'nspection

o Aen should wear no shirtC women are instructed to wear a tan& top
to the .isit
o Eisuali0e the entire shoulder girdle and scapular area, noting
muscle mass asymmetry$atrophy or "ony asymmetry
Acti.e range of motion:

o !est this if possi"leC if not, then test passi.e range of motion

o !est forward fle,ion !he a.erage range is )30;)80F
o !est a"duction !he a.erage range is )30;)80F
o !est e,ternal rotation !he a.erage range with the arm in adduction
is 20;60F, and the a.erage range with the arm in a"duction is +0;
*0F
o !est internal rotation !he a.erage range is measured "y how high
the patient can reach up his or her "ac& with the ipsilateral thum"
#ie, ipsilateral hip, !)2, L3% !he a.erage range is a"o.e !8
o !est adduction !he a.erage range is 13F
o !est e,tension !he a.erage range is 13F
o (ote that stiffness with e,ternal$internal rotation is "est tested with
the arm in *0F of a"duction Also, for an optimal e.aluation, test
e,ternal and internal rotation in the supine position with the
scapulothoracic articulation sta"ili0ed Aoreo.er, most high;le.el
pitchers ha.e increased e,ternal rotation and decreased internal
rotation in the pitching arm compared with the nonpitching arm
Gowe.er, the o.erall a"solute arc of motion when measured in
degrees is usually e9ual !his may not "e pathologic in the high;
le.el athletic population 6inally, a painful arc of motion may "e
e,perienced with ele.ation a"o.e the shoulder le.el in patients with
impingement #typically 80;)30F%
@alpation
5

o Areas that are palpated include the /oints, "iceps tendons,

supraspinatus and su"scapularis tendons, and anterolateral corner
of the acromion
o !he entire shoulder girdle is palpated #noting tenderness,
deformities, or atrophy% from the acromiocla.icular /oint, cla.icle,
glenohumeral /oint, scapula, scapulothoracic articulation,
anterior$posterior shoulder capsule, supraspinous fossa,
infraspinous fossa, and humerus, especially pro,imally
Aanual muscle testing

o 8oncentrate on the shoulder girdle muscles #especially e,ternal

and internal rotation, a"duction%
o !he supraspinatus may "e isolated "y ha.ing the patient rotate the
upper e,tremity so that the thum"s are away from the floor and
resistance is applied with the arms at 20F of forward fle,ion and *0F
of a"duction
o (ote that pain is felt with tendonitis or partial in/ury to the
supraspinatus tendon with the supraspinatus isolation test, "ut
wea&ness can also "e found accompanying partial; or full;thic&ness
disruption of the supraspinatus tendon Also, wea&ness may "e
found with tendonitis "ecause of muscle inhi"ition from the pain
stimulus
Special tests #impingement signs%

o 6or the (eer test, the e,aminer forcefully ele.ates an internally

rotated arm in the scapular plane, causing the supraspinatus
tendon to "e impinged against the anterior inferior acromion
o 6or the Gaw&ins;Hennedy test, the e,aminer forcefully internally
rotates a *0F forwardly fle,ed arm, causing the supraspinatus
tendon to "e impinged against the coracoacromial ligamentous
arch @ain and a grimacing facial e,pression indicate impingement
of the supraspinatus tendon, and this is a positi.e (eer$Gaw&ins;
Hennedy impingement sign
o 6or the impingement test, the e,aminer in/ects )0 mL of a )4
lidocaine solution into the su"acromial space and then repeats the
tests for the impingement sign -limination or significant reduction
of pain constitutes a positi.e impingement test result
o Iith the drop arm test, the patient places the arm in ma,imum
ele.ation in the scapular plane and then lowers it slowly !he test
can "e repeated following su"acromial in/ection of lidocaine
Sudden dropping of the arm suggests a rotator cuff tear
o Iith the supraspinatus isolation test$empty can test #ie, Jo"e test%,
the supraspinatus may "e isolated "y ha.ing the patient rotate the
upper e,tremity so that the thum"s are pointing to the floor and
resistance is applied with the arms in 20F of forward fle,ion and *0F
6
of a"duction #simulates emptying of a can% !he result is positi.e
when wea&ness is present compared with the unaffected side,
suggesting a disruption of the supraspinatus tendon
!ests for insta"ility

o !o elicit the sulcus sign, the e,aminer grasps the patientJs el"ow
and applies inferior traction =impling of the s&in su"/acent to the
acromion #the sulcus sign% indicates inferior humeral translation,
which suggests multidirectional insta"ility
o !he apprehension test is performed most effecti.ely with the patient
supine, sta"ili0ing the scapulae !he e,aminer gently "rings the
affected arm into an a"ducted and e,ternally rotated position !he
patientJs apprehension and guarding "y not allowing further motion
"y the e,aminer denotes a positi.e test result, which is consistent
with anterior shoulder insta"ility
o !he relocation test is usually performed in con/unction with the
apprehension test After placing the patient in an apprehensi.e
position, posteriorly directed pressure is applied to the anterior
pro,imal humerus, simulating a relocation of the glenohumeral /oint
that was presuma"ly partially dislocated from the apprehension
test !he adept e,aminer may feel posterior translation of the
humeral head on the glenoid A positi.e test result is when the
patientJs apprehension is relie.ed "y the application of pressure on
the anterior pro,imal humerus, which suggests anterior shoulder
insta"ility
(ote: Any tests completed should compare "oth shoulders in order to
detect "ilateral pathology or ha.e a control for comparison with the
affected shoulder
7ther tests: !hese should "e performed during the shoulder e,amination
to rule out other pathology affecting the "iceps tendon, glenoid la"rum,
cer.ical spine, sternocla.icular /oint, acromiocla.icular /oint, and
scapulothoracic /oint A sur.ey of other /oint range of motion should also
"e performed to assess for generali0ed ligamentous la,ity
(euro.ascular e,amination

o !o complete the shoulder e,amination, a full neurologic

e,amination must "e performed along with an assessment of all
upper e,tremity .ascular pulses
o !he neurologic e,amination should include all neurologic segments
from 83 through !) myotome and dermatome, with the
corresponding stretch refle,es
Causes
-,trinsic causes

7
o @rimary impingement
'ncreased su"acromial loading
!rauma #direct macrotrauma or repetiti.e microtrauma%
7.erhead acti.ity #athletic and nonathletic%
o Secondary impingement
:otator cuff o.erload$soft tissue im"alance
-ccentric muscle o.erload
Blenohumeral la,ity$insta"ility
Long head of the "iceps tendon la,ity$wea&ness
Blenoid la"ral lesions
Auscle im"alance
Scapular dys&inesia
@osterior capsular tightness
!rape0ius paralysis
'ntrinsic causes

o Acromial morphology #ie, hoo&ed acromion, presence of an os

acromiale or osteophyte, calcific deposits in the su"acromial space,
all of which predispose to primary impingement%
o Acromiocla.icular arthrosis #inferior osteophytes%
o 8oracoacromial ligament hypertrophy
o 8oracoid impingement
o Su"acromial "ursal thic&ening and fi"rosis
o @rominent humeral greater tu"erosity
o 'mpaired cuff .ascularity
o Aging #primary%
o 'mpingement #secondary%
o @rimary tendinopathy
o 'ntratendinous
o Articular side partial;thic&ness tears
o 8alcific tendinopathy
DIFF&R&NTIA#S
Acromiocla.icular Joint 'n/ury
5icipital !endonitis
5rachial @le,us 'n/ury
8er.ical =isc 'n/uries
8er.ical =iscogenic @ain Syndrome
8er.ical :adiculopathy
8er.ical Spine Sprain$Strain 'n/uries
8la.icular 'n/uries
8ontusions
8
'nfraspinatus Syndrome
Ayofascial @ain in Athletes
:otator 8uff 'n/ury
Shoulder =islocation
Shoulder 'mpingement Syndrome
Superior La"rum Lesions
SwimmerJs Shoulder
Ot!er %ro'lems to Be Considered
7s Acromiale
(OR)U%
Imaging Studies
Standard radiographic studies are used to rule out
glenohumeral$acromiocla.icular arthritis and 7s Acromiale

o Anteroposterior .iew of the glenohumeral /oint

o 'nternal rotation .iew of the humerus with a 20F upward angulation
to show the acromiocla.icular /oint
o A,illary .iew ; Aost useful to rule out su"tle signs of insta"ility #eg,
glenoid a.ulsion, Gill;Sachs lesion% and to .isuali0e the presence of
an os acromiale
o Stry&er notch .iew ; @otential os acromiale is easily .isuali0ed and
assessed when .iewed through the humeral head
o Supraspinatus outlet .iew ; Aost useful to assess the
supraspinatus outlet space #'f K+ mm, the patient is more at ris& for
impingement syndrome% and helps assess morphology of the
acromion #A hoo&ed acromion is more at ris& for impingement%

A:' is considered the imaging study of choice for shoulder pathology

o Ad.antages
(onin.asi.e
(o radiation
8an detect intrasu"stance tendon degeneration or partial
rotator cuff tears
8an detect inflammation, edema, hemorrhage, and scarring
8an "e used with an intra;articular contrast agent #eg,
gadolinium%, impro.ing its a"ility to detect partial rotator cuff
9
tears

o =isad.antages
7ften cannot accommodate patients with claustropho"ia
7ften cannot accommodate larger patients
8annot accommodate patients with pacema&ers, other metal
implants, or particles
=ependent on 9uality of the A:' machine
=ependent on the s&ill of the technician performing the
imaging and the radiologist interpreting the images
Gigh cost

6or arthrography, dye is in/ected into the glenohumeral /oint and
postin/ection radiographs are ta&en to assess the integrity of the
glenohumeral /oint

o 8an "e used to e.aluate rotator cuff tears #A finding of dye

escaping out of the /oint and into the su"acromial space is
diagnostic of a full;thic&ness rotator cuff tear%
o Ad.antages ; 8an "e used in con/unction with a 8! scan to
e.aluate intra;articular pathology #eg, 5an&art tears% and has a low
cost
o =isad.antages ; Si0e of the tears cannot "e 9uantified, patient is
e,posed to radiation and contrast dye, procedure is in.asi.e

=iagnostic arthroscopy

o Ainimally in.asi.e, .isual, surgical procedure to assess shoulder

pathology
o 8an .isuali0e and assess most shoulder pathology
o Aay afford the patient and physician a chance to diagnose and
treat the pathology with one procedure
o =isad.antage ; Aay miss capsular;sided, partial;thic&ness tears

(ote: A wor&up for other, more systemic processes may "e included as
clinically indicated
TR&AT*&NT
Acute %!ase
Re!a'ilitation %rogram
%!ysical T!erapy
10
!he goals of the acute phase are to relie.e pain and inflammation, pre.ent
muscle atrophy without e,acer"ating the pain, reesta"lish nonpainful range of
motion, and normali0e the arthro&inematics of the shoulder comple, !his
includes a period of acti.e rest, eliminating any acti.ity that may cause an
increase in symptoms
:ange;of;motion e,ercises may include pendulum e,ercises and symptom;
limited, acti.e;assisted range;of;motion e,ercises Joint mo"ili0ation may "e
included with inferior, anterior, and posterior glides in the scapular plane
Strengthening e,ercises should "e isometric in nature and wor& on the e,ternal
rotators, internal rotators, "iceps, deltoid, and scapular sta"ili0ers #ie, rhom"oids,
trape0ius, serratus anterior, latissimus dorsi, pectoralis ma/or% (euromuscular
control e,ercises also may "e initiated
Aodalities that also may "e used as an ad/unct include cryotherapy,
transcutaneous electrical ner.e stimulation, high;.oltage gal.anic stimulation,
ultrasound, phonophoresis, or iontophoresis
@atient education regarding acti.ityC pathologyC and the a.oidance of o.erhead
acti.ity, reaching, and lifting is particularly important for this acute phase !he
general guidelines to progress from this phase are decreased pain or symptoms,
increased range of motion, painful arc in a"duction only, and impro.ed muscular
function
Ot!er Treatment
=uring the acute to su"acute phase, when pain and inflammation predominate, a
su"acromial in/ection may "e diagnostic and therapeutic as an ad/unct to the
reha"ilitation program 'n/ecting )0 mL of a )4 lidocaine solution without
epinephrine into the su"acromial space may relie.e the shoulder pain if the pain
and inflammation are truly originating from the supraspinatus outlet$su"acromial
space
Adding a low;dose, intermediate;acting, in/ecta"le corticosteroid may pro.ide a
therapeutic effect 5etamethasone, triamcinolone, and methylprednisolone are
used commonly !he common dose is ) mL of any of these a.aila"le in/ecta"le
corticosteroids mi,ed with * mL of a )4 lidocaine solution without epinephrine
!echni9ue
o Ga.e patients sit with their arms hanging "y their side to distract the
humerus from the acromion
o 'dentify the lateral edge of the acromion
o 'nsert a needle at the midpoint of the acromion, and angle it slightly
upward under the acromion to its full length
11
o Slowly withdraw the needle while simultaneously in/ecting fluid in a
"olus #where.er resistance is not present% 8ontinue aspirating
"efore in/ecting Sometimes, a swelling caused "y the fluid is .isi"le
around the edge of the acromion
o 7ccasionally, calcification occurs within the "ursa, and hard
resistance is encountered 'n this case, aspiration and infiltration
with a large;"ore needle and local anesthetic may "e helpful
6ailing this, surgical e.aluation may "e necessary
Aftercare
o 'nform the patient that once the effect of the lidocaine wears off, a
local reaction to the corticosteroid may occur in the ne,t 21;+2
hours 'f this occurs, instruct the patient to apply ice #wrapped in a
towel% to the affected shoulder for 20 minutes, remo.e it for 20
minutes, and then repeat #ie, 20 min on, 20 min off% 2 times in the
"eginning and at the end of the day
o :elief of pain after one in/ection is usual, "ut the patient must "e
ad.ised to maintain correct posture with retraction and depression
of the shoulder and to a.oid the painful arc of ele.ation for ) wee&
o !he patient may resume a symptom;limited therapy program in the
first wee& postin/ection and then resume the full course thereafter

Ad.erse effects in general
o Although uncommon with this in/ection procedure when performed
correctly, ad.erse effects may occur !he clinician and the patient
must "e educated a"out them, and the clinician must &now how to
manage any related complications
o A"solute contraindications include documented allergy to any
corticosteroid or local anesthetics, o.erlying s&in infection, or
cellulitis
o :elati.e contraindications include dia"etes, hypertension,
immunosuppression, cardiac arrhythmias, and heart "loc&s
o (ote that ad.erse effects of the medications may "e minimi0ed
when the medication is administered in the recommended dose

Ad.erse effects of in/ecta"le corticosteroids
o Systemic effects include flushing, menstrual irregularity, impaired
glucose tolerance, osteoporosis, psychological distur"ance, steroid
arthropathy, steroid myopathy, and immunosuppression
o Local effects include postin/ection flare, which may include local
in/ection site erythema, mild swelling, ecchymoses, and pain

Ad.erse effects of local anesthetics
o !hese usually result from an o.erdose or allergic reactions, which
definitely can "e minimi0ed "y dou"le;chec&ing the dose "efore
12
administering and in9uiring a"out and chec&ing on the records for
medication allergies
o 7.erdose and allergic reactions may "e catastrophic and may
include cardiac, respiratory, and cere"ral compromise

Ad.erse reaction to the in/ection
o Aside from the one mentioned, occasionally a patient may ha.e a
.aso.agal reaction #fainting episode% due to pain, apprehension, or
needle pho"ia
o !reatment in.ol.es placing the patient supine, ele.ating the legs,
and strongly reassuring him or her that reco.ery is forth coming
shortly 'f the patient loses consciousness "riefly, protect the airway
and gi.e o,ygen at 234 concentration
Reco+ery %!ase
Re!a'ilitation %rogram
%!ysical T!erapy
!he initial goals of this phase are to normali0e range of motion and shoulder
arthro&inematics, perform symptom;free acti.ities of daily li.ing, and impro.e
neuromuscular control and muscle strength :ange;of;motion e,ercises are
progressed to acti.e e,ercises in all planes and self;stretches, concentrating on
the /oint capsule, especially posteriorly
Strengthening includes isotonic resistance e,ercises with the supraspinatus,
internal rotators, e,ternal rotators, prone e,tension, hori0ontal a"duction, forward
fle,ion to *0F, upright a"duction to *0F, shoulder shrugs, rows, push;ups, press;
ups, and pull;downs to strengthen the scapular sta"ili0ers
7ther important goals include maintaining /oint motion and neuromuscular re;
education Upper e,tremity ergometry e,ercises, trun& e,ercises, and general
cardio.ascular conditioning for endurance are also recommended !herapies
may "e continued if necessary Buidelines to ad.ance are full, nonpainful range
of motion when manual muscle testing of strength is +04 of the contralateral
side
!he final goal of this phase is to progress to the point at which the athlete is
again throwing and includes impro.ing strength, power, endurance, and sports;
specific neuromuscular control -mphasis is placed on high;speed, high;energy
strengthening e,ercises and eccentric e,ercises in diagonal patterns 8ontinue
isotonic strengthening with increased resistance in all planes, allowing resistance
in the throwing position, *0F of a"duction, and *0F of e,ternal and internal
rotation 'nitiate plyometrics, sports;specific e,ercises, propriocepti.e
neuromuscular facilitation, and iso&inetic e,ercises
13
*aintenance %!ase
Re!a'ilitation %rogram
%!ysical T!erapy
!he goal of this phase is to maintain a high le.el of training and pre.ent
reoccurrence -mphasis is placed on longer and more intense wor&outs, proper
arthro&inematics of the shoulder, and analysis and modification of techni9ues
and mechanics that may ree,acer"ate symptoms Aa&e refinements in intensity
and coordination
@atient education is again reemphasi0ed, maintaining proper mechanics,
strength, and fle,i"ility, and ha.ing a good understanding of the pathology !he
patient should also show an understanding of a home e,ercise program with the
proper warmup, strengthening techni9ues, and warning signs of early
impingement
Surgical Inter+ention
'n general, conser.ati.e measures are continued for at least 2;6 months or
longer if the patient is impro.ing, which is usually the case in 60;*04 of patients
'f the patient remains significantly disa"led and has no impro.ement after 2
months of conser.ati.e treatment, the clinician must perform a more e,tensi.e
diagnostic wor&up, reconsider other etiologies, or refer the patient for surgical
e.aluation
Appropriate surgical referrals are patients with rotator cuff tendonitis refractory to
2;6 months of appropriate conser.ati.e treatment Surgery may "e particularly
"eneficial in patients with full, unrestricted passi.e range of motionC a positi.e
response to in/ection of lidocaine into the su"acromial spaceC or a type '''
acromion with a large su"acromial spur and in those in whom changes are noted
in the rotator cuff tendon after A:'
Surgical e.aluation
o 'nitially, perform the e,amination with the patient under anesthesia
#general anesthesia .s regional "loc&% and include diagnostic
arthroscopy
o -.aluate shoulder range of motion and sta"ility
o 'n patients with limited motion, manipulation of the shoulder is
performed and diagnostic arthroscopy also may "e performed, "ut
arthroscopic su"acromial decompression is generally not
performed in patients with significant preoperati.e stiffness
"ecause of the increased ris& of postoperati.e adhesi.e capsulitis
o =ocument any insta"ility
14
o @erform an arthroscopic e.aluation
o @articular attention is directed to the rotator cuff, especially the
supraspinatus tendon near its insertion onto the greater tu"erosity
o Eisuali0e the su"scapularis tendon
o Assess for la"ral pathology or changes suggesting glenohumeral
insta"ility
o A partial tearing of the supraspinatus tendon along its articular
surface is a common finding in symptomatic throwing athletes !he
fragmented and torn tissue is de"rided, lea.ing all intact rotator cuff
tendon !his allows a more accurate determination of the si0e and
thic&ness of the tear on the articular side of the rotator cuff and may
help reduce symptoms of catching and pain
o 6ollowing glenohumeral arthroscopy, the "ursal side of the rotator
cuff is e.aluated using arthroscopy
o !he "ursal surface of the rotator cuff is assessed for e.idence of
fraying and for the amount of clearance "etween the anterior
inferior acromion and the supraspinatus tendon
o Also note any signs of fraying or wear changes on the undersurface
of the coracoacromial ligament
o 'f no e.idence of rotator cuff disruption is noted and the
coracoacromial ligament is smooth, with ade9uate space "etween
the anterior inferior acromion and rotator cuff, then the diagnosis of
su"acromial impingement is unli&ely 'n this case, su"acromial
decompression is not performed
o 'n case of a small partial;thic&ness rotator cuff tear on the articular
surface, without e.idence of impingement, only perform
glenohumeral de"ridement of this tear
o 'f the patient has changes suggesti.e of impingement syndrome,
arthroscopic su"acromial decompression #acromioplasty, ie,
resection of the anterior inferior portion of the acromion% is also
performed
o 'f, following su"acromial decompression, a rotator cuff repair is
necessary, it may "e continued under arthroscopic assistance or it
may re9uire con.ersion of the rotator cuff repair to an open
procedure

@ostoperati.e care
o A postoperati.e radiograph #supraspinatus outlet .iew% is o"tained
to document the ade9uacy of the su"acromial decompression !he
appearance on this radiographic .iew should "e of a type ' acromial
arch without any residual spurring
o 6ollowing su"acromial decompression, the patient is placed in a
sling "ut is encouraged to remo.e the sling when comforta"le and
"egin acti.e and passi.e range;of;motion e,ercises Ihen pain
has decreased significantly and range of motion has returned
toward normal, a program of strengthening, similar to the pre.iously
15
mentioned conser.ati.e management, is instituted @atients cannot
"egin sports;specific acti.ities until they ha.e full, acti.e range of
motion in the operated shoulder and normal strength, generally a
period of appro,imately 2;1 months

Surgical outcome
o Su"acromial decompression results generally are poor in young,
high;performance athletes with in/uries from o.erhead motions
o :esults generally are good for properly selected middle;aged
patients with e.idence of impingement in history and physical
e,amination findings and at the time of arthroscopy
o Beneral consensus in the literature is that arthroscopic su"acromial
decompression results in a good return to the pre.ious le.el of
function in appro,imately 83;*04 of patients
*&DICATION
=uring the acute to su"acute phases of shoulder impingement syndrome, a short
course of nonsteroidal anti;inflammatory drugs #(SA'=s% is appropriate as an
ad/unct to the therapy program and other treatment modalities "ecause of their
analgesic and anti;inflammatory effects 8hoices in this drug classification are
e,tensi.eC only selected e,amples are discussed @atient responses to different
(SA'=s may .ary 6or information on the full array of (SA'=s, their dose, and
their schedule, refer to the latest edition of the Physician's Desk Reference
NSAIDs mec!anism o action
!he ma/or mechanism of action of (SA'=s is inhi"ition of the synthesis of
prostaglandin #@B%, specifically @B-2, .ia "loc&ing cycloo,ygenase #87L%,
which is the en0yme that con.erts arachidonic acid into @B @Bs lower the
threshold to no,ious stimuli "y sensiti0ing the nociceptors to the actions of other
no,ious endogenous su"stances #eg, "rady&inin, histamine, su"stance @,
serotonin% 'n soft tissue, @B-2 causes pain and inflammation 'n the B' tract, it
is cytoprotecti.e and increases the secretion of mucus and "icar"onates and
decreases the secretion of gastric acids and digesti.e en0ymes 'n the renal
system, @B-2 enhances renal salt and water e,cretion "y acting as a .asodilator
of small arterial "lood .essels
!he 87L pathway is su"di.ided into 87L;), which is responsi"le for @B-2
production in the B' tract and &idneys, and 87L;2, which is responsi"le for
inflammatory @B synthesis during soft tissue in/ury (SA'=s ser.e as competiti.e
inhi"itors of 87L acti.ity and either selecti.ely inhi"it the 87L;2 en0ymes or
nonselecti.ely inhi"it "oth the 87L;) and the 87L;2 en0ymes, ma&ing the
nonselecti.e (SA'=s a higher ris& for potential ulcerogenic and other ad.erse
effects
16
Ad+erse drug reactions
All (SA'=s ha.e similar ad.erse drug reactions !he first is hepatoto,icity !he
li.er function profile should "e monitored periodically, especially in high;ris&
indi.iduals !he second is renal to,icity !he renal function profile should "e
monitored periodically, especially in high;ris& indi.iduals !he third is B' to,icity
Symptoms may include nausea, diarrhea, acid reflu,, and perium"ilical cramping
8onsider administering (SA'=s in con/unction with B' protecti.e medications
#eg, misoprostol, omepra0ole, G2 "loc&ers%, and instruct patients to ta&e (SA'=s
with food 'f B' symptoms persist for more than 2 wee&s or if patients ha.e
e.idence of complications #eg, iron deficiency anemia, B' "leeding, une,plained
weight loss, dysphagia%, an endoscopic e.aluation is indicated !he fourth is
aplastic anemia Aonitor the complete "lood count, especially platelets,
periodically for );2 months !he fifth is anaphyla,is 'n9uire a"out and chec&
medical records for a history of allergic reactions
Drug Category, Nonsteroidal anti-inflammatory drugs
Aost widely used drugs in the world, e,hi"iting anti;inflammatory, antipyretic, and
analgesic acti.ities !hey are primarily used for treating inflammatory conditions
that are musculos&eletal in origin (umerous drugs are a.aila"le in this category,
and they all ha.e similar drug profiles
Drug Name '"uprofen #'"uprin, Ad.il, Aotrin%
Description
Arylpropionic acid prototypical (SA'=
that has the ad.antage of causing less
epigastric pain, B' occult "lood loss, and
less hepatoto,icity Aostly indicated for
rheumatoid arthritis and osteoarthritis for
mild to moderate pain 8ompared with
other a.aila"le (SA'=s, it has a short
half;life
Adult Dose
100;800 mg @7 tid$9idC not to e,ceed
2200 mg$d
%ediatric Dose
K6 months: (ot esta"lished
M6 months
K20 &g: Up to 100 mg$d @7 in di.ided
doses
20;20 &g: Up to 600 mg$d @7 in di.ided
doses
20;10 &g: Up to 800 mg$d @7 in di.ided
doses
Contraindications =ocumented hypersensiti.ityC peptic
ulcer disease, recent B' "leeding or
perforation, renal insufficiency, or high
17
ris& of "leeding
Interactions
8oadministration with aspirin increases
ris& of inducing serious (SA'=;related
ad.erse effectsC pro"enecid may
increase concentrations and, possi"ly,
to,icityC may decrease effect of
hydrala0ine, captopril, and "eta;"loc&ersC
may decrease diuretic effects of
furosemide and thia0idesC may increase
@! when ta&ing anticoagulants #instruct
patients to watch for signs of "leeding%C
may increase ris& of methotre,ate
to,icityC phenytoin le.els may "e
increased when administered
concurrently
%regnancy
5 ; Usually safe "ut "enefits must
outweigh the ris&s
%recautions
8ategory = in third trimester of
pregnancyC caution in congesti.e heart
failure, hypertension, and decreased
renal and hepatic functionC caution in
anticoagulation a"normalities or during
anticoagulant therapy
Drug Name
=iclofenac sodium$diclofenac potassium
#Eoltaren, 8ataflam%
Description
8hemical composition is heteroaryl
acetic acid with a short half;life =elayed;
release enteric;coated form is diclofenac
sodium, and immediate;release form is
diclofenac potassium 5oth are primarily
indicated for rheumatoid arthritis,
osteoarthritis, and an&ylosing spondylitis
=iclofenac can cause hepatoto,icityC
hence, monitor li.er en0ymes in the first
8 w& of treatment =iclofenac has a
relati.ely low ris& for "leeding B' ulcers
Adult Dose )00;200 mg$d @7 di.ided doses tid$9id
%ediatric Dose
(ot esta"lishedC 23 mg @7 "id$tid
suggested if M6 mo
Contraindications =ocumented hypersensiti.ityC do not
administer into 8(S or to patients with
peptic ulcer disease, recent B' "leeding
or perforation, renal insufficiency, or high
18
ris& of "leeding
Interactions
8oadministration with aspirin increases
ris& of inducing serious (SA'=;related
ad.erse effectsC pro"enecid may
increase concentrations and, possi"ly,
to,icityC may decrease effect of
hydrala0ine, captopril, and "eta;"loc&ersC
may decrease diuretic effects of
furosemide and thia0idesC may increase
@! when ta&ing anticoagulants #instruct
patients to watch for signs of "leeding%C
may increase ris& of methotre,ate
to,icityC phenytoin le.els may "e
increased when administered
concurrently
%regnancy
5 ; Usually safe "ut "enefits must
outweigh the ris&s
%recautions
8ategory = in third trimester of
pregnancyC acute renal insufficiency,
hyper&alemia, hyponatremia, interstitial
nephritis, and renal papillary necrosis
may occurC increases ris& of acute renal
failure in patients with pree,isting renal
disease or compromised renal perfusionC
low I58 counts occur rarely and usually
return to normal in ongoing therapyC
discontinuation of therapy may "e
necessary if persistent leu&openia,
granulocytopenia, or throm"ocytopenia
occurs
Drug Name -todolac #Lodine, Lodine LL%
Description
'ndole (SA'= with an intermediate half;
life, indicated for rheumatoid arthritis and
osteoarthritis Short;acting form is
appro.ed for analgesic use, compara"le
to aspirin$acetaminophen with codeine
-todolac has a lower ris& of producing B'
complications and, as a result, is
especially well tolerated in elderly
patients
Adult Dose 600;)200 mg$d @7 di.ided doses "id$9idC
not to e,ceed )200 mg or 20 mg$&g for
patients K60 &g
-,tended;release form: 100;)000 mg @7
19
9d
%ediatric Dose
K)1 years: (ot esta"lished
M)1 years: Administer as in adults
Contraindications
=ocumented hypersensiti.ityC do not
administer into 8(S or to patients with
peptic ulcer disease, recent B' "leeding
or perforation, renal insufficiency, or high
ris& of "leeding
Interactions
8oadministration with aspirin increases
ris& of inducing serious (SA'=;related
ad.erse effectsC pro"enecid may
increase concentrations and, possi"ly,
to,icityC may decrease effect of
hydrala0ine, captopril, and "eta;"loc&ersC
may decrease diuretic effects of
furosemide and thia0idesC may increase
@! when ta&ing anticoagulants #instruct
patients to watch for signs of "leeding%C
may increase ris& of methotre,ate
to,icityC phenytoin le.els may "e
increased when administered
concurrently
%regnancy
8 ; Safety for use during pregnancy has
not "een esta"lished
%recautions
8ategory = in third trimester of
pregnancyC acute renal insufficiency,
hyper&alemia, hyponatremia, interstitial
nephritis, and renal papillary necrosis
may occurC increases ris& of acute renal
failure in patients with pree,isting renal
disease or compromised renal perfusionC
low I58 counts occur rarely and usually
return to normal in ongoing therapyC
discontinuation of therapy may "e
necessary if persistent leu&openia,
granulocytopenia, or throm"ocytopenia
occurs
Drug Name
(apro,en #Ale.e, Anapro,, (aprelan,
(aprosyn%
Description @ro"a"ly the most potent of the
arylpropionic acids, with a long half;life
'ndicated for rheumatoid arthritis,
osteoarthritis, an&ylosing spondylitis,
20
/u.enile arthritis, acute gout, and mild to
moderate pain A.aila"le in a controlled;
release form, which is also used for
acute pain, and an enteric;coated form,
which is not used for acute pain
Adult Dose
230;300 mg @7 "idC not to e,ceed )000
mg$d
%ediatric Dose
(ot esta"lishedC )0 mg$&g$d @7 di.ided
"id suggested if M6 mo
Contraindications
=ocumented hypersensiti.ityC do not
administer into 8(S or to patients with
peptic ulcer disease, recent B' "leeding
or perforation, renal insufficiency, or high
ris& of "leeding
Interactions
8oadministration with aspirin increases
ris& of inducing serious (SA'=;related
ad.erse effectsC pro"enecid may
increase concentrations and, possi"ly,
to,icityC may decrease effect of
hydrala0ine, captopril, and "eta;"loc&ersC
may decrease diuretic effects of
furosemide and thia0idesC may increase
@! when ta&ing anticoagulants #instruct
patients to watch for signs of "leeding%C
may increase ris& of methotre,ate
to,icityC phenytoin le.els may "e
increased when administered
concurrently
%regnancy
5 ; Usually safe "ut "enefits must
outweigh the ris&s
%recautions
8ategory = in third trimester of
pregnancyC acute renal insufficiency,
interstitial nephritis, hyper&alemia,
hyponatremia, and renal papillary
necrosis may occurC patients with
pree,isting renal disease or
compromised renal perfusion ris& acute
renal failureC leu&openia occurs rarely, is
transient, and usually returns to normal
during therapyC persistent leu&openia,
granulocytopenia, or throm"ocytopenia
warrants further e.aluation and may
re9uire discontinuation of drug
21
Drug Name 7,apro0in #=aypro%
Description
An arylpropionic acid with a 10;30 h half;
life and can "e gi.en once daily Used for
relief of mild to moderate painC inhi"its
inflammatory reactions and pain "y
decreasing acti.ity of 87L, which results
in a decrease in @B synthesis
Adult Dose
600;)200 mg @7 9dC not to e,ceed )800
mg$d
%ediatric Dose
K)1 years: (ot esta"lished
M)1 years: Administer as in adults
Contraindications
=ocumented hypersensiti.ityC do not
administer into 8(S or to patients with
peptic ulcer disease, recent B' "leeding
or perforation, renal insufficiency, or high
ris& of "leeding
Interactions
8oadministration with aspirin increases
ris& of inducing serious (SA'=;related
ad.erse effectsC pro"enecid may
increase concentrations and, possi"ly,
to,icityC may decrease effect of
hydrala0ine, captopril, and "eta;"loc&ersC
may decrease diuretic effects of
furosemide and thia0idesC may increase
@! when ta&ing anticoagulants #instruct
patients to watch for signs of "leeding%C
may increase ris& of methotre,ate
to,icityC phenytoin le.els may "e
increased when administered
concurrently
%regnancy
8 ; Safety for use during pregnancy has
not "een esta"lished
%recautions 8ategory = in third trimester of
pregnancyC acute renal insufficiency,
interstitial nephritis, hyper&alemia,
hyponatremia, and renal papillary
necrosis may occurC patients with
pree,isting renal disease or
compromised renal perfusion ris& acute
renal failureC leu&openia occurs rarely, is
transient, and usually returns to normal
during therapyC persistent leu&openia,
granulocytopenia, or throm"ocytopenia
warrants further e.aluation and may
22
re9uire discontinuation of drug
Drug Name (a"umetone #:elafen%
Description
Al&anone (SA'= with a long #21 h% half;
life and can "e gi.en once daily Gas a
lower ris& of producing B' complications
and is indicated for rheumatoid arthritis
and osteoarthritis
Adult Dose
)000 mg$d @7C not to e,ceed 2000 mg$d
in );2 di.ided doses
%ediatric Dose
K)1 years: (ot esta"lished
M)1 years: Administer as in adults
Contraindications
=ocumented hypersensiti.ityC do not
administer into 8(S or to patients with
peptic ulcer disease, recent B' "leeding
or perforation, renal insufficiency, or high
ris& of "leeding
Interactions
8oadministration with aspirin increases
ris& of inducing serious (SA'=;related
ad.erse effectsC pro"enecid may
increase concentrations and, possi"ly,
to,icityC may decrease effect of
hydrala0ine, captopril, and "eta;"loc&ersC
may decrease diuretic effects of
furosemide and thia0idesC may increase
@! when ta&ing anticoagulants #instruct
patients to watch for signs of "leeding%C
may increase ris& of methotre,ate
to,icityC phenytoin le.els may "e
increased when administered
concurrently
%regnancy
8 ; Safety for use during pregnancy has
not "een esta"lished
%recautions 8ategory = in third trimester of
pregnancyC acute renal insufficiency,
interstitial nephritis, hyper&alemia,
hyponatremia, and renal papillary
necrosis may occurC patients with
pree,isting renal disease or
compromised renal perfusion ris& acute
renal failureC leu&openia occurs rarely, is
transient, and usually returns to normal
during therapyC persistent leu&openia,
granulocytopenia, or throm"ocytopenia
23
warrants further e.aluation and may
re9uire discontinuation of drug
Drug Name @iro,icam #6eldene%
Description
-nolic acid, piro,icam with long half;life
#30 h% that can "e gi.en once daily
'ndicated for use in rheumatoid arthritis
and osteoarthritis Gas high B' to,icity
#greater than aspirin%
Adult Dose )0;20 mg @7 9d$"id
%ediatric Dose
K)1 years: (ot esta"lished
M)1 years: Administer as in adults
Contraindications
=ocumented hypersensiti.ityC do not
administer into 8(S or to patients with
peptic ulcer disease, recent B' "leeding
or perforation, renal insufficiency, or high
ris& of "leeding
Interactions
8oadministration with aspirin increases
ris& of inducing serious (SA'=;related
ad.erse effectsC pro"enecid may
increase concentrations and, possi"ly,
to,icityC may decrease effect of
hydrala0ine, captopril, and "eta;"loc&ersC
may decrease diuretic effects of
furosemide and thia0idesC may increase
@! when ta&ing anticoagulants #instruct
patients to watch for signs of "leeding%C
may increase ris& of methotre,ate
to,icityC phenytoin le.els may "e
increased when administered
concurrently
%regnancy
8 ; Safety for use during pregnancy has
not "een esta"lished
%recautions 8ategory = in third trimester of
pregnancyC acute renal insufficiency,
interstitial nephritis, hyper&alemia,
hyponatremia, and renal papillary
necrosis may occurC patients with
pree,isting renal disease or
compromised renal perfusion ris& acute
renal failureC leu&openia occurs rarely, is
transient, and usually returns to normal
during therapyC persistent leu&openia,
granulocytopenia, or throm"ocytopenia
24
warrants further e.aluation and may
re9uire discontinuation of drug
Drug Name 8eleco,i" #8ele"re,%
Description
Selecti.e 87L;2 inhi"itor (SA'=
Appro.ed "y 6=A on =ecem"er 2), )**8
and indicated for use in osteoarthritis and
rheumatoid arthritis and for moderate to
se.ere pain @otentially presents less B'
complications and platelet aggregation
pro"lems than the nonselecti.e 87L;
inhi"itor (SA'=s :enal complications
are compara"le Gas a sulfonamide
chain and is primarily dependent on
cytochrome @;130 en0ymes #a hepatic
en0yme% for meta"olism
Adult Dose
)00;200 mg @7 "idC not to e,ceed 600
mg$d
%ediatric Dose
K)8 years: (ot esta"lished
M)8 years: Administer as in adults
Contraindications =ocumented hypersensiti.ity
Interactions
8oadministration with flucona0ole may
cause increase in celeco,i" plasma
concentrations "ecause of inhi"ition of
celeco,i" meta"olismC coadministration
with rifampin may decrease celeco,i"
plasma concentrations
%regnancy
5 ; Usually safe "ut "enefits must
outweigh the ris&s
%recautions
Aay cause fluid retention and peripheral
edemaC caution in compromised cardiac
function, hypertension, and conditions
predisposing to fluid retentionC caution in
se.ere heart failure and hyponatremia
"ecause may deteriorate circulatory
hemodynamicsC may mas& usual signs of
infectionC caution in the presence of
e,isting controlled infectionsC e.aluate
symptoms and signs suggesting li.er
dysfunction or in a"normal li.er la"
results
25
FO##O(-U%
Return to %lay
:eturn to play is restricted until full, painless range of motion is restoredC "oth
rest; and acti.ity;related pain are eliminatedC and pro.ocati.e impingement signs
are negati.e 'so&inetic strength testing must "e *04 compared with the
contralateral side :esumption of acti.ities is completed gradually, first during
practice, to "uild up endurance, wor& on modified techni9ue$mechanics, and
simulate a game situation @atients must "e free of symptoms !o pre.ent
recurrence, the patient should continue fle,i"ility and strengthening e,ercises
after returning to sports acti.ities
Complications
'f rotator cuff tendonitis is not diagnosed and treated promptly and correctly, it
can progress to rotator cuff degeneration and e.entual tear 7ther complications
may include progression to adhesi.e capsulitis, cuff tear arthropathy, and refle,
sympathetic dystrophy 7ther complications may result from surgery, in/ections,
physical therapy, or medications
%re+ention
@rimary pre.ention should "e considered an integral part of the treatment of
rotator cuff tendonitis -ducating patients at ris& can circum.ent the de.elopment
of rotator cuff tendonitis Athletes, particularly those in.ol.ed in throwing and
sports in.ol.ing o.erhead actions, and la"orers with repetiti.e shoulder stress
should "e instructed in proper warmup techni9ues, specific strengthening
techni9ues, and warning signs of early impingement
%rognosis
'n general, the prognosis is good for rotator cuff tendonitis that is promptly and
correctly diagnosed and treated 7f patients, 60;*04 impro.e and are free of
symptoms with conser.ati.e treatment Surgical outcomes are also .ery
promising for patients in whom a full trial of conser.ati.e therapy fails
&ducation
@atient education may impro.e the outcome "ecause the patient is educated
regarding a.oidance of pro.ocati.e acti.ities, pathology, and proper shoulder
arthro&inematics -ducation should also stress proper warmup techni9ues,
specific strengthening techni9ues, and warning signs of early impingement A
proper home e,ercise program should "e formulated and encouraged to pre.ent
recurrence of symptoms
26
6or e,cellent patient education resources, .isit eAedicineJs 5rea&s, 6ractures,
and =islocations 8enter and Sports 'n/ury 8enter Also, see eAedicineJs patient
education articles !endinitis and :otator 8uff 'n/ury
*ISC&##AN&OUS
*edical.#egal %italls
'f the diagnosis of a rotator cuff tendonitis is missed, no immediate
catastrophic se9uela occursC although, without prompt and correct
diagnosis and treatment, the patient may "ecome progressi.ely disa"led
7ther complications may include progression to adhesi.e capsulitis, cuff
tear arthropathy, and refle, sympathetic dystrophy 7ther complications
may result from surgery, in/ection, physical therapy, or medications

Iith any complaint of shoulder pain, the clinician must rule out disorders
that may ha.e catastrophic conse9uences if action is not ta&en
immediately, such as infection, cardiac etiologies, tumor, dislocation,
fracture, .ascular in/ury, peripheral neurologic in/ury, and cer.ical spine
neurologic in/ury !hese diagnoses must "e &ept in mind in the differential
and tested for when assessing a shoulder pro"lem in any patient
Special Concerns
Supraspinatus tendonitis is managed similarly in all populations Ihether
it is managed more or less aggressi.ely depends on the patientJs acti.ity
le.el, reliance on the shoulder for an occupation or athletics #recreational
or competiti.e%, age, and comor"id medical illnesses

'n pregnant women, nursing mothers, young children, and patients with
comor"id medical illnesses, caution should "e used when administering
medications to ensure the medication chosen is compati"le with the
patient Age, accompanying medical illnesses, low acti.ity le.el, poor
healing potential, poor anesthetic candidacy, and pregnancy status may
preclude the patient from "eing a surgical candidate
27