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= Supraspinatus tear  =
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'''Original Editor''' - [[User:Brecht Haex|Brecht Haex]]


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== Definition/Description ==
[[File:Supraspinatus muscle - Kenhub.png|alt=Supraspinatus muscle (highlighted in green) - posterior view|right|frameless|500x500px|Supraspinatus muscle (highlighted in green) - posterior view]]
A supraspinatus tear is a tear or rupture of the tendon of the [[supraspinatus]] muscle. The supraspinatus is part of the [[Rotator Cuff|rotator cuff]] of the shoulder. Most of the time, it is accompanied by another [[Rotator Cuff Tears|rotator cuff muscle tear]]. This can occur due to trauma or repeated micro-trauma and present as a partial or full-thickness tear.<ref name=":0">American Academy of Orthopedic Surgeons, Ortho Info. Rotator cuff tears, http://orthoinfo.aaos.org/topic.cfm?topic=a00064 (accessed 29/08/2018).</ref> Quite often, the tear occurs in the tendon or as an avulsion from the greater tuberosity.<ref name=":6">Benazzo F, Marullo M, Pietrobono L. [https://link.springer.com/article/10.1007/s10195-013-0271-x Supraspinatus rupture at the musculotendinous junction in a young woman.] Journal of Orthopaedics and Traumatology 2014;15(3):231-4.</ref>


Databases used: Pubmed, Web of Sience, google scholar VUBIS catologus, the book ‘Oefentherapie voor schouderaandoeningen’ van A. Cools.  
Image: Supraspinatus muscle (highlighted in green) - posterior view<ref >Supraspinatus muscle (highlighted in green) - posterior view image -  © Kenhub https://www.kenhub.com/en/library/anatomy/supraspinatus-muscle</ref>


Supraspinatus tear – rotator cuff tear – supraspinatus rupture – rotator cuff rupture – supraspinatus tendon tear – supraspinatus strain – supraspinatus injuries – supraspinatus avulsion – shoulder disabilities
== Clinical Relevant Anatomy ==
The [[Shoulder|shoulder joint]] is made up of three bones: the [[humerus]], [[scapula]] and clavicle. The head of the humerus and the glenoid of the scapula form a ball-and-socket joint<ref name=":0" />. The supraspinatus muscle is located on the back of the shoulder, forming part of the [[Rotator Cuff|rotator cuff]]. The rotator cuff consists of [[Supraspinatus|Supraspinatus,]] [[Infraspinatus]], [[Subscapularis]] and [[Teres Minor|teres minor]]. The rotator cuff covers the head of the humerus and keeps it in place. These muscles help to lift and rotate the arm. Visit the [[shoulder]] for more detailed information.
[[File:Muscles of the scapular region anterior aspect Primal.png|thumb]]


Most successful keyword was supraspinatus tear or in combination with rotator cuff tear. <br><br>  
=== Supraspinatus ===
* '''Origin''':  Supraspinous fossa of the scapula
* '''Insertion''':  Greater tubercle of the humerus
* '''Innervation''':  Supraspinatus nerve (C5-C6)
* '''Function''':  Abduction of the glenohumeral joint; assists the rotator cuff in stabilizing, control and movement the shoulder; assists in preventing subluxation at the shoulder
<ref name=":0" /><ref>Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus: Algemene anatomie en bewegingsapparaat, 2010. p600.</ref><ref>Physioworks, Rotator Cuff Tear.http://physioworks.com.au/injuries-conditions-1/rotator-cuff-tears (accessed 29/08/2018).</ref> <u></u>
== Epidemiology/Aetiology ==
The aetiology of supraspinatus tears is multifactorial, consisting of age-related degeneration, microtrauma, and macrotrauma. It mostly affects the dominant arm with about 50% of people in their 80s experiencing this condition. <ref name=":10">Tashjian RZ. [https://www.sportsmed.theclinics.com/article/S0278-5919(12)00044-0/abstract Epidemiology, natural history and indications for treatment of rotator cuff tears]. Clinics in Sports Medicine 2012:31(4):589-604.</ref><ref name=":11">Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. [https://www.sciencedirect.com/science/article/pii/S1058274609002043 Prevalence and risk factors of a rotator cuff tear in the general population.] Journal of shoulder and elbow surgery 2010:19(1):116-20.</ref> Injury and degeneration are the two main causes of rotator cuff tears. Rotator cuff tears are associated with older patients, those with a history of trauma and mostly affect the dominant arm.


<br>  
=== Mechanism of Injury ===
Acute tear:  Can occur with other shoulder injuries (e.g. clavicle fracture of [[Shoulder Dislocation|shoulder dislocation]])
* Fall on an outstretched arm
* Lifting something too heavy
Degenerative:  Wear and tear of the tendon slowly over time
* Increases with the age
* More common in the dominant arm 
* When you have a degenerative tear in one shoulder, you have a greater risk for a tear in the opposite shoulder, even if you have no pain in the opposite shoulder.
=== Risk Factors ===
* > 40 years old
* Male > Female
* Smoking
* Genetics
* Hypercholesterolemia
* Body mass index
* Height
* Repetitive stress/lifting
* History of trauma
* Lack of blood supply
* Bony spurs
* Overhead activities and other people who do overhead work: Tennis players, Baseball pitchers, Painters, Carpenters, and Plumbers.
* Traumatic injury e.g. fall (more common cause in younger individuals)<ref name=":0" />
== Characteristics/Clinical presentation ==
Supraspinatus tears are normally present as partial or full-thickness tears. It can be asymptomatic or symptomatic. 


== 2. Definition/Description ==
'''Partial thickness''': 
* Incomplete disruption of muscle fibres<ref name=":0" />
* Can progress to complete tear - Increasing pain is normally the first sign of the progression of a tear
'''Full thickness''': Complete disruption of muscle fibres 
* Large tears (1-1,5cm) have a high rate of progression 
* If progression is suspected in conservatively managed cases - further investigation is warranted 
* Smaller tears (<1cm) progress slower 
<ref name=":10" /><ref name=":11" /> 


<br>A supraspinatus tear is a tear or rupture of the tendonof the supraspinatus muscle. The supraspinatus is part of the rotator cuff of the shoulder. The rotator cuff consists of M. Supraspinatus, M. Infraspinatus, M. Subscapularis and M. Teres minor (&lt;R&gt; http://www.physio-pedia.com/Rotator_Cuff). Most of the time it is accompanied with another rotator cuff muscle tear (&lt;R&gt; http://www.physio-pedia.com/Rotator_Cuff_Tears ) . This tear can occur in 2 ways. Due to a trauma or due repeated micro-trauma. The supraspinatus tear can be partial or full thickness tear<sup>1</sup> . A partial tear means that the soft tissue (the muscle fibers) will not be completely disrupted. A complete tear on the other hand means that all the muscle fibers are disrupted. It is common that disrupted tendons begin by fraying and when the damage progresses the partial tear evolves into a complete tear<sup>1</sup>. Most of the time the tear occurs in the tendon or as an avulsion from the greater tuberosity<sup>2 </sup>. The supraspinatus muscle is responsible for the abduction of the upper limb<sup>1</sup>.<br>  
=== Signs and Symptoms ===
Patients normally present with:<ref name=":0" /><ref name=":11" /><ref name=":13">Mayo Clinic Rotator cuff injury. http://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/symptoms-causes/dxc-20126923 (accessed 30/08/2018).</ref>


<br>
* Pain/worsening pain (in cases where tears are progressing), the most common symptoms are:


== 3. Clinical Relevant Anatomy ==
:* Pain when lifting and lowering your arm or with specific movement
:* Pain at rest
:* Pain at night, predominantly when you lie on the affected shoulder
:* Traumatic tears: Sudden, intense pain often accompanied by a snapping sensation and immediate weakness in the upper arm
:* Located anterolaterally and superiorly
:* Referred to the level of the [[deltoid]] insertion with full-thickness tears
:* Repetitive strain tear: Starts off mild and only when lifting your arm; over time the pain can become more noticeable at rest
:* Aggravated in overhead or forward-flexed position


<br>The shoulder joint is made up of three bones: the humerus (the upper arm), the scapula (shoulder blade) and the clavicle (collarbone). The head of the humerus fits into a fordable socket in the scapula so it is a ball-and-socket joint<sup>4</sup> . The supraspinatus muscle is located on the back of the shoulder. This muscle arises from the supraspinous fossa of the scapula and inserts on the greater tubercle of the humerus. The supraspinatus muscle is innervated by the nervus supraspinatus (C5-C6)<sup>5</sup> .<br> <br>The supraspinatus muscle is part of the rotator cuff. The rotator cuff is a group of muscles<sup>4</sup>. It consists of the supraspinatus muscle, the infraspinatus muscle, the teres minor and the subscapularis. These muscles with their tendons stabilize, control and move the shoulder <sup>6</sup>. It also prevents from luxation of the shoulder.
* Limited range of motion


The rotator cuff covers the head of the humerus and keeps it into place. The muscles help to lift and rotate the arm. <br>Position of the arm to be able to palpate the tendon to apply deep transvers friction or Ultrasound to the full width of the tendon: the shoulder should be rotated internally (forearm behind the back) so the supraspinatus tendon appears more in the frontal plane of the shoulder.
:* Reduced forward elevation, external rotation and abduction
:* Struggle with activities like reaching behind back, combing hair and overhead activities
:* Stiffness


<u>Joints: </u><u></u><br>-Glenohumeral<br>-Acromioclavicular<br>-Sternoclavicular<br>-Scapulathoracal<br><br>
* Weakness when rotating or lifting your arm


<br>
* Crepitus, Clicking, and Instability


== 4. Epidemiology/Etiology  ==
=== Differential Diagnosis ===
* [https://www.physio-pedia.com/Acromioclavicular_Joint_Disorders Acromioclavicular joint injury]
* [https://www.physio-pedia.com/Brachial_plexus_injury Brachial plexus injury]
* Bicipital tendinopathy
* [[Cervical Radiculopathy|Cervical radiculopathy]]
* Cervical spine sprain
* Cervical strain injuries
* [http://www.physio-pedia.com/Disc_Herniation Cervical disc injuries]
* [[Cervical Radiculopathy|Cervical nerve root injury]]
* [[Cervical Spondylosis]]
* Cervical discogenic pain syndrome
* [[Clavicula fracture|Clavicular fracture]]
* [[Sternoclavicular Joint Disorders|Sternoclavicular joint disorders]]
* Infraspinatus syndrome
* Contusions
* [[Rotator Cuff Tears|Rotator cuff tear]]
* [[Shoulder Dislocation|Shoulder dislocation]]
* [[Myofascial pain|Myofascial pain]]
* [[Internal Impingement of the Shoulder|Shoulder impingement syndrome]]
* [[SLAP Lesion|Superior labrum lesions]]
* [[Shoulder Subluxation|Shoulder subluxation]]
* Angina pectoris
* [[Myocardial Infarction|Myocardial infarction]]
* [[Subacromial Impingement|Subacromial impingement]]
* [[Osteoarthritis]]
* [[Rheumatoid Arthritis|Rheumatoid arthritis]]
* Subscapular nerve entrapment
* [[Shoulder Instability|Shoulder instability]]
** [[Anterior Shoulder Instability|Anterior instability]]
** [[Posterior Shoulder Instability|Posterior instability]]
<ref name=":1">Medscape. Supraspinatus tendonitis: Differential diagnoses, http://emedicine.medscape.com/article/93095-differential (Accessed 20/03/2015).</ref><ref name=":2">Medscape. Rotator cuff injury: Differential diagnoses, http://emedicine.medscape.com/article/92814-differential, (Accessed 25/03/2015).</ref>


The etiology is multifactorial consisting of age-related degeneration , microtrauma and macrotrauma. The incidence increases with the age. The half of individuals have a supraspinatus tear in their 80s. Smoking, hypercholesterolemia, and genetics affect the development of tearing. Substantial full-thickness tears progress and enlarge with time. Pain, or worsening pain, usually signals tear progression in asymptomatic and symptomatic tears and should warrant further investigation if the tear is treated conservatively. Smaller symptomatic full-thickness tears ( &lt; 1 cm ) and partial – thickniss tears have a slower rate of progression and can be treated with a nonoperative treatment. In both cases increasing pain should alert physicians to obtain further imaging as it can signal tear progression. Larger symptomatic full-thickness tears ( &gt; 1cm -1,50 cm )have a high rate of progression and should be considered for earlier surgical repair in younger patients if the tear is reparable and the muscle degeneration is limited. This is important to avoid irreversible changes to the cuff. A nonoperative treatment can be used in older patients ( older than 70 years ) who have a chronic tear , in patients with irreparable tears with irreversible changes , in patients of any age with small (&lt;1 cm) full-thickness tears or in patients without a full-thickness tear. An operative treatment can be used in acute tears (&gt;1 cm-1.5 cm) or young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes.<sup>8</sup>
== Diagnostic Procedures ==
=== Physical Examination ===


<sup></sup><br>Rotator cuff tears were associated with older patients, males, a history of trauma and affected the dominant arm. Patients have also a reduced forward elevation , external rotation and abduction. We can conclude that the risk factors for a tear consist of a history of trauma, dominant arm and age. <sup>9</sup>
==== Subjective interview: ====
* Onset: Spontaneous or after injury
* Duration of pain
* Pain provocation/aggravating factors
* Night rest
* Same problems in the past?
* Activity limitations
* Localize pain
* Past medical history
* Recreational or sport activities (possible overhead activities)


<sup></sup><br>Injury and degeneration are the two main causes of rotator cuff tears.
==== Observation: ====
** Any atrophy present


<br>An acute tear can be get when you fall down on your outstretched arm or when you lift something too heavy. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.
==== Range of motion: ====
* Expect reductions in flexion, abduction and external rotation
* If passive abduction range is more than active range, it is an indication of a rotator cuff tear


<br>Most of the cases are the result of a wearing down of the tendon that occurs slowly over time. That is called a degenerative tear. This degeneration increases with the age and are more common in the dominant arm. When you have a degenerative tear in one shoulder , you have a greater risk for a tear in the opposite shoulder, even if you have no pain in the opposite shoulder.
==== Muscle power: ====
* Test supraspinatus by resisting abduction at 90° and internal rotation
* Scapular movement may be affected


<br>There are several factors that contribute to degenerative or chronic tears.<br>• Repetitive stress<br>• Lack of blook supply<br>• Bone spurs ( bone overgrowth )
==== Palpation:  ====
* Forearm behind back to palpate rotator cuff just anterior and below the acromion
** Muscle atrophy present
** Tenderness


<br><u>'''Risk factors:'''</u>  
==== Special tests: ====
* Drop-arm test:  Active shoulder abduction to 90°, then return <ref name=":4">Hughers PC, Taylor NF, Green RA. [https://ac.els-cdn.com/S0004951408700229/1-s2.0-S0004951408700229-main.pdf?_tid=8b887d9e-8135-4347-a25d-3c50c63efd54&acdnat=1535600075_4f552aaa403df67a5cac32ef4184113d Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review.] Aust J Physiother 2008;54(3):159-70.</ref>
** Positive:  Dropping the arm down with pain indicates a positive test
{{#ev:youtube|6AUlMbdzaDE}}
<clinicallyrelevant id="83864746" title="Drop Arm Test" /><br>
:* Jobe/supraspinatus/empty can test:  Resist shoulder abduction and internal rotation<ref name=":4" />
:** Positive: Pain/weakness
{{#ev:youtube|nSlrWoCfs4w}}
<clinicallyrelevant id="83864751" title="Empty Can Test" />
:* Full can test:  Resisted shoulder abduction in external rotation
:** Positive: Pain/weakness
{{#ev:youtube|05TCh3VXMOU}}
<clinicallyrelevant id="83864778" title="Full Can Test" />
:* Subacromial grind test:  Patient standing and examiner standing facing the patient, the examiner grasps the patient's flexed elbow. The shoulder is passively abducted in the scapular plane to 90°. The examiner's other hand is placed over the patient's shoulder overlying the anterior acromion and greater tuberosity. The examiner passively internally and externally rotates the shoulder detecting the presence of palpable crepitus.
:** Positive: Palpable crepitus.<ref name=":12">Sawalha S, Fischer J. The accuracy of “subacromial grind test” in diagnosis of supraspinatus rotator cuff tears. International journal of shoulder surgery 2015;9(2):43-46.</ref>
{{#ev:youtube|f5yOT2hpTac}}
<ref>Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.</ref><ref name=":5">Orthop J. Rotator cuff tear: physical examination and conservative treatment. Department of Orthopaedic Surgery Tohoku University, 2013:197–204.</ref>


• Older than 40 years old have a greater risk.<br>• Body mass index <br>• Height<br>• Repetitive lifting or overhead activities <br>• Tennis players , baseball pitchers , painters , carpenters and other people who do overhead work have a greater risk.<br>• Traumatic injury ( a fall ) ( most common cause in young people ) <sup>10</sup>
=== Special Investigations ===


So we can conclude that rotator cuff tears are associated with older patients, a history of trauma and affected the dominant arm. Patients have also a reduced forward elevation, external rotation and abduction. The most common risk factors for a tear consist of a history of trauma, dominant arm and age.<br><br>
=== X-rays ===
*  Excluding sclerosis and osteophyte formation on the acromion
* [[X-Rays|X-ray]]s measure the size of the subacromial space
* Unable to see the tendon
[[File:Tear of supraspinatus tendon.png|thumb|Supraspinatus tear as seen in radiographics]]


== <br>5. Characteristics/Clinical Presentation  ==
==== MRI ====
* [[MRI Scans|MRI]] Scan shows partial or full tears in the tendons of the rotator cuff, inflammation to weak structures and cracks in the capsule


<br>The most common symptoms of a rotator cuff tear include:<br>• Pain at rest and at night, particularly if lying on the affected shoulder<br>• Pain when lifting and lowering the arm or with specific movements<br>• Weakness when lifting or rotating the arm<br>• Crepitus or crackling sensation when moving the shoulder in certain positions<br>A rotator cuff injury can make it painful to lift the arm out to the side.<br>Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in the upper arm. <br>Tears that develop slowly due to overuse also cause pain and arm weakness. The patient may have pain in the shoulder when the patient lifts the arm to the side, or pain that moves down the arm. At first, the pain may be mild and only present when lifting the arm over the head, such as with reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.<br>Over time, the pain may become more noticeable at rest, and no longer goes away with medications. The patient may have pain when the patient lies on his painful side at night. The pain and weakness in the shoulder may make routine activities such as combing hair or reaching behind the back more difficult.
==== CT Scan ====
* [[CT Scans|CT scan]] is able to localize tendon when patient positioned with forearm behind the back


<br>
==== Ultrasound ====
* '''[[Ultrasound Scans|Ultrasound]] helps in''' localising  tendon


== 6. Differential Diagnosis  ==
== Outcome Measures ==
* [[36-Item Short Form Survey (SF-36)|Short Form-36]] (SF-36)
* Rotator Cuff Quality of Life (RC-QOL) scale
* [[Western Ontario Rotator Cuff (WORC) Index|Western Ontario Rotator Cuff (WORC) index]]
* [https://www.physio-pedia.com/DASH_Outcome_Measure Disabilities of the Arm, Shoulder and Hand (DASH)]<ref name=":0" /><sup></sup><u></u><sup></sup>
== Medical Management ==


<br>- Acromioclavicular injury<br>- Cervical nerve root injury<br>- Cervical Radiculopathy<br>- Cervical Spondylosis<br>- Subacromial Impingement<br>- Osteoarthritis<br>- Rheumatoid Arthritis<br>- Shoulder Instability<br>- Subscapular nerve entrapment<br>7. Diagnostic Procedures<br>Diagnosis should be based on: <br>- History<br>- Clinical examination<br>- X-rays<br>- MRI<br>X-rays may be used as an extra test exclude sclerosis and osteophyte-formation on the acromion. The size of the subacromial space can also be measured. MRI can show full or partial tears in the tendons of the rotator cuff, cracks in the capsule and inflammation to weak structures.
=== Conservative Management ===


<br>  
Indications:<ref name=":10" /><ref name=":11" /> 
* Older (>70 years) patients with a chronic tear 
* Patients with irreparable tears with irreversible changes 
* Patients of any age with small (&lt;1 cm) full-thickness tears 
** As a result of the slow rate of progression of these tears 
* Patients without a full-thickness tear 


== 8. Outcome Measures  ==
Management includes:<ref>Björkenheim JM, Paavolainen P, Ahovuo J, Slätis P. [https://europepmc.org/abstract/med/3180567 Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results.] Clinical orthopaedics and related research 1988;(236):148-53.</ref>


<br>- DASH (http://www.dash.iwh.on.ca/scoring)<br>ICC: 0.96 [13] Cronbach alpha: 0.97 [13]<br>- Quick DASH (http://www.dash.iwh.on.ca/scoring)<br>ICC: 0.94 [13] Cronbach alpha: 0.94 [13]<br>- Penn Shoulder Score: to measure outcome of patients with various shoulder disorders<br>ICC: 0.94 [14] Cronbach alpha: 0.93 [14]<br>- Global Rating of Change Scale: to measure improvement<br>ICC: 0.74 [15]
NSAID's:
* Ibuprofen
Corticosteroid injections:
* Eliminate pain for a period of time, making physiotherapy management easier
* Tendon tissue can be weakened by these injections (which would have an adverse effect on the outcome of a possible surgery)
* Limited to 2 injections


== <br>9. Examination  ==
* Physiotherapy (see Physiotherapy management below)


<br>Physical examination starts with inspection. Atrophy of the shoulder muscles is a common finding in patients with rotator cuff tears. The position and motion of the scapula is also important. The scapula rotates upward and downward during arm elevation/depression. This smooth movement of the scapula on the thorax may have deteriorated because of subacromial impingement or rotator cuff defect. For the purpose of identifying which tendon is ruptured, various location-specific physical examinations have been reported. A tear of the supraspinatus tendon can be detected by the empty-can test or full-can test&nbsp;: apply downward force to the arm in 90° scaption and in internal rotation (thumb down). If there is a supraspinatus tear, the patient cannot resist this force because of muscle weakness. [3]
=== Surgical Management ===
'''Indications''':<ref name=":10" /><ref name=":11" /><ref name=":3" />
* Failed conservative management
* Larger symptomatic full-thickness tears (1-1,5cm) as a result of the high rate of progression. Should be considered for earlier surgical repair in younger patients if the tear is repairable and the muscle degeneration is limited
* Acute large tears (&gt;1 cm-1.5 cm) or  
* Young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes
* Complete tear with significant pain and dysfunction after 6 months of treatment
* Repeated dislocations


<br>  
==== Rotator cuff repair ====
Most repairs are done arthroscopically<ref name=":3">Millar NL, Wu X, Tantau R, Silverstone E, Murrell GA. Open versus two forms of arthroscopic rotator cuff repair. Clinical orthopaedics and related research 2009;467(4):966-78.</ref>. Severity (partial vs full-thickness) will determine the approach.
* Partial repair: The tendon and surrounding bone will be smoothed to avoid further damage and therefore allowing the tendon to heal mostly on its own<ref>American Academy of Orthopedic Surgeons. Rotator Cuff Tears: Surgical Treatment Options. https://orthoinfo.aaos.org/en/treatment/rotator-cuff-tears-surgical-treatment-options/ (accessed 30/08/2018).</ref>


== 10. Medical Management ==
* Complete tear: Tear in middle of tendon:  Suture the two parts of the tendon back together. Tear close or on its point of attachment on the head of the humerus: Attach the tendon back to its original place by an anchor (sometimes two). This anchor actually consists of a small screw that is bored into the head of the humerus with on the back surgical wires which hold the tendon in place<ref>Akpınar S, Uysal M, Pourbagher MA, Ozalay M, Cesur N, Hersekli MA. [https://europepmc.org/abstract/med/21908964 Prospective evaluation of the functional and anatomical results of arthroscopic repair in small and medium-sized full-thickness tears of the supraspinatus tendon.] Acta orthopaedica et traumatologica turcica 2011;45(4):248-53.</ref>.


<br>This consists of NSAID’s like ibuprofen, injections with corticosteroids and a surgical treatment. 5<br>The corticosteroid injections cannot heal the tear but in some cases it can make the tear<br>painless for a period of time in which the patient is capable of undergoing physical therapy more easily. However the tendon tissue can be weakened by these injections which would have an adverse effect on the outcome of a possible surgery, therefore one should not get more than 2 injections. [9] When an injection is chosen it will be placed in the sub-acromial space as seen below.<br> [[Image:Inj.jpg]]<br>These treatments are conservative medical treatments, if these and physical therapy (see below) don’t work the patient will have to undergo surgery<br>The operative treatment is done mostly arthroscopically which is less invasive (than open/mini-open surgery) and leaves only a few small scars. Being less invasive the patients need to use less painkillers and will be able to start rehabilitation sooner. With time and development of better techniques the arthroscopic approach of rotator cuff tendon repair now even has a higher(20%) long term success rate. This was measured with the American Shoulder and Elbow Surgeons scores an reoccurrence of the supraspinatus tears. [4] <br>Depending on the severity of the tear (partial/complete) a different approach will be used.<br>If there is just a partial repair necessary the tendon and surrounding bone will be smoothed to avoid further damage and therefor allowing the tendon to heal mostly on its own.[5] In case of a complete tear in the middle of the tendon the surgeon will have to suture the two parts of the tendon back together. When the tear has occurred close or on its point of attachment on the head of the humerus another approach will be taken. This will be the case most of the times. The surgeon will attach the tendon back to its original place by way of an anchor(sometimes two). This anchor actually consists of a small screw that is bored into the head of the humerus with on the back surgical wires with witch to hold the tendon in place. [6]<br> [[Image:2.jpg]][[Image:3.jpg]]4
== Physiotherapy Management  ==


== <br>11. Physical Therapy Management  ==
Physiotherapy management depends on the extent of the tear, and plays in important role in both conservative management as well as post-surgical rehabilitation. More details can also be obtained from the [[Rotator Cuff Tears|rotator cuff]] page.


<br>In case of a complete tear of the supraspinatus muscle, significant pain and dysfuction after six months of treatment or repeated dislocations surgery will be preferred as treatment. However if it is only a partial tear in most cases a conservative treatment will reduce pain(2-6weeks) and over time even allow the patient to regain function (up to three months). [11] The reduced pain is not just the direct effect of the pain reducing abilities of NSAID’s. The long term effects will mostly be attributable to a well preformed physical therapy. This will consist of different parts: reduce pain, manipulate blood flow (control inflammation and speed up healing), increase range of motion, increase control of muscles and their strength. Massage can be used to reduce pain, cryotherapy is useful to reduce pain, but only in the first 48 hours after injury. Corticosteroid injection may be useful to reduce pain as well, but only works on short term. . To increase range of motion one can use stretching exercises of the ruptured muscle (not to soon in recovery since premature stretching might aggravate the injury)(see below), passive- and active range of motion exercises such as pendulum exercises and symptom limited active-assisted range of motion exercises(see below). To increase control and strength the patient will also be prescribed strengthening exercises for the rotator cuff specifically the functions of the supraspinatus muscle (abduction and exorotation) explain SS and external rotation [3] [12] (see below for a few examples).<br> [[Image:4.png]][17]<br> <br> [[Image:5.png]][[Image:6.png]]  
=== Conservative Management ===
'''Physiotherapy goals''':
* Improve pain together with NSAID’s (2-6 weeks)
* [[Cryotherapy]] (only in first 48 hours)
* [[Massage]]
* Improve circulation (to control inflammation and speed up the healing process)
* Improve range of motion:
** [[Stretching]] (careful with timing, as stretching of acute injury may aggravate the tear):<ref name=":8">Kuhn JE. [http://kinesiologiarcb.com.ar/wp-content/uploads/2016/05/Exercise-in-the-treatment-of-rotator-cuff-impingement-A-systematic-review-and-a-synthesized-evidence-based-rehabilitation-protocol.pdf Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol.] Journal of shoulder and elbow surgery 2009;18(1):138-60.
</ref> 
*** Crossover arm stretch: 12 seconds, 5 times a day; 5-6days/week 
[[Image:4.png|400x400px]]


[[Image:7.png|300x300px]][[Image:8.png|300x300px]]
''Kristian Berg. Prescriptive stretching; Human Kinetics''&nbsp;<ref name=":7">Kristian Berg, Human Kinetics:. Prescriptive stretching. 2011.</ref>
* Door stretch: 5 x 30 seconds (5 second rest in between)


[[Image:9.png|300x300px]][[Image:10.png|300x300px]][[Image:11.png|300x300px]][11]  
* Passive/Active range of motion:<ref>Joseph Berman MD. Supraspinatus tear, http://www.josephbermanmd.com/diagnosis-treatament-of-the-shoulder/rotator-cuff-tear/ (accessed 29/04/2015).</ref>
** Pendulum exercises: Forward and back, side-to-side, circular motion. 2 sets of 10 a day, 5-6days/week
** Symptom limited active-assisted range of motion exercises
[[Image:5.png|270x270px]]  


<br>Home exercises consisting of stretching and strengthening exercises prove to be effective, no matter what type of injury (partial defects, full thickness tears of the supraspinatus tendon or massive rotator cuff defects). Patients with rotator cuff defects do benefit from simple home exercises independent from the size of the defect. There is an improvement in range of motion and a downward trend for impingement. [7]
''Kristian Berg. Prescriptive stretching; Human Kinetics <ref name=":7" />''
* Increase strength:<ref name=":9">Physioroom. Exercises to Strengthen the Rotator Cuff Muscles in the Shoulder.http://www.physioroom.com/experts/asktheexperts/answers/qa_mb_20050225.php (accessed 31/08/2018).</ref><ref>Heers G, Anders S, Werther M, Lerch K, Hedtmann A, Grifka J. [https://europepmc.org/abstract/med/15776325 Efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect.] Sportverletzung Sportschaden: Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin 2005;19(1):22-7.
</ref>
** Rotator cuff (especially supraspinatus) strengthening to improve muscle control and strength
** Prone Horizontal Abduction progress by using resistance bands
** Prone Row with External Rotation


== 12. References  ==
* Regain function of affected upper limb (up to 3 months)
* Home exercise programme
'''<u></u>'''<sup></sup>


<br>1. Heers G. et al. Efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. (2005) Klinik für Orthopädie der Universität Regensburg, Bad Abbach. <br>Level&nbsp;: 3B
== Clinical Bottom Line  ==


<br>2. Jobe F.W., Moynes D.R. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. (1982) Am J Sports Med, 10, 336–339. <br>Level&nbsp;: 5
A supraspinatus tear can occur due to trauma or repeated micro-trauma and present as a partial or full-thickness tear.<ref name=":0" /> Most of the time, the tear occurs in the tendon or as an avulsion from the greater tuberosity<ref name=":6" />. The tear can be partial or full-thickness. Pain, loss of range of motion and weakness is the 3 most common symptoms.<ref name=":0" /><ref name=":11" /><ref name=":13" /> Supraspinatus tears can be managed conservatively, with NSAID's and physiotherapy, as well as surgically to repair the tear.
 
== References ==
<br>3. Orthop J. Rotator cuff tear: physical examination and conservative treatment<br>(2013) Department of Orthopaedic Surgery, Tohoku University, 18, 197–204.<br>Level&nbsp;: 5
<references />
 
[[Category:Shoulder]]
<br>4. Millar N.L. et al. Open versus two forms of arthroscopic rotator cuff repair. (2009) Clinical Orthopaedics and Related Research, 467, 966-78
[[Category:Conditions]]
 
[[Category:Shoulder - Conditions]]
<br>
[[Category:Sports_Injuries]]
 
[[Category:Sports Medicine]]
5. American Academy of Orthopedic Surgeons. Rotator Cuff Tears: Surgical Treatment Options (2011) <br>Level: 5
 
<br>
 
6. Akpinar S. et al. Prospective evaluation of the functional and anatomical results of arthroscopic repair in small and medium-sized full-thickness tears of the supraspinatus tendon.(2011) Acta Orthop Traumatol Turc 45, 248-253<br>Level&nbsp;: 2B
 
<br>
 
7. Manhattan Orthopedic &amp; Sports Medicine. Rotator Cuff Tendon Tears / Shoulder Arthroscopy. (2012) from: http://manhattanorthopedic.com/2010/09/rotator-cuff-tendon-tears-shoulder-arthroscopy/<br>Level: 5
 
<br>
 
8. Codsi M.J. The painful shoulder: When to inject and when to refer. (2007)Department of Orthopaedics, Cleveland Clinic, 74, 473-480<br>Level&nbsp;: 5
 
<br>9. Bjorkenheim J.M. et al. Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results. (1988) Clinical Orthopaedic Relations, 236
 
<br>  
 
10. Sarwark J.F. Essentials of Musculoskeletal Care. (2010) American Academy of Orthopaedic Surgeons, Rosemont<br>Level&nbsp;: 5
 
<br>11. Dr. Romanski C., Schuldt J. Conservative Treatment of Rotator Cuff Injuries to Avoid Surgical Repair. (2009)<br>Level: 5
 
<br>  
 
12. Tanaka M. et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. (2010) Journal of Medical Sciences, Upsala, 115, 193–200<br>Level&nbsp;: 3B
 
<br>13. <br>14.  
 
<br>15. Leggin B.J. et al. The Penn Shoulder Score: Reliability and Validity. (2006) from: http://www.jospt.org/issues/articleID.1021,type.14/article_detail.asp<br>Level&nbsp;: 3B
 
<br>16. Kamper S.J. et al. Global Rating of Change Scales: A Review of Strengths and Weaknesses and Considerations for Design. (2009) from: level&nbsp;: 4
 
<br>17. Kristian Berg. Prescriptive stretching; Human Kinetics; 2011<br><br>
 
[[Category:Shoulder]] [[Category:Shoulder_Conditions]]

Latest revision as of 13:32, 22 May 2023

Original Editor - Brecht Haex

Top Contributors - Kim Jackson, Leana Louw, Mats Vandervelde, Brecht Haex, Fasuba Ayobami, Vidya Acharya, Saimat Lachinova, Habibu Salisu Badamasi, Wendy Walker, Naomi O'Reilly, Simisola Ajeyalemi, Wout Van Hees, Joao Costa, Shreya Pavaskar, Anthony Mertens, Wanda van Niekerk and Rachael Lowe

Definition/Description[edit | edit source]

Supraspinatus muscle (highlighted in green) - posterior view

A supraspinatus tear is a tear or rupture of the tendon of the supraspinatus muscle. The supraspinatus is part of the rotator cuff of the shoulder. Most of the time, it is accompanied by another rotator cuff muscle tear. This can occur due to trauma or repeated micro-trauma and present as a partial or full-thickness tear.[1] Quite often, the tear occurs in the tendon or as an avulsion from the greater tuberosity.[2]

Image: Supraspinatus muscle (highlighted in green) - posterior view[3]

Clinical Relevant Anatomy[edit | edit source]

The shoulder joint is made up of three bones: the humerus, scapula and clavicle. The head of the humerus and the glenoid of the scapula form a ball-and-socket joint[1]. The supraspinatus muscle is located on the back of the shoulder, forming part of the rotator cuff. The rotator cuff consists of Supraspinatus, Infraspinatus, Subscapularis and teres minor. The rotator cuff covers the head of the humerus and keeps it in place. These muscles help to lift and rotate the arm. Visit the shoulder for more detailed information.

Muscles of the scapular region anterior aspect Primal.png

Supraspinatus[edit | edit source]

  • Origin: Supraspinous fossa of the scapula
  • Insertion: Greater tubercle of the humerus
  • Innervation: Supraspinatus nerve (C5-C6)
  • Function: Abduction of the glenohumeral joint; assists the rotator cuff in stabilizing, control and movement the shoulder; assists in preventing subluxation at the shoulder

[1][4][5]

Epidemiology/Aetiology[edit | edit source]

The aetiology of supraspinatus tears is multifactorial, consisting of age-related degeneration, microtrauma, and macrotrauma. It mostly affects the dominant arm with about 50% of people in their 80s experiencing this condition. [6][7] Injury and degeneration are the two main causes of rotator cuff tears. Rotator cuff tears are associated with older patients, those with a history of trauma and mostly affect the dominant arm.

Mechanism of Injury[edit | edit source]

Acute tear: Can occur with other shoulder injuries (e.g. clavicle fracture of shoulder dislocation)

  • Fall on an outstretched arm
  • Lifting something too heavy

Degenerative: Wear and tear of the tendon slowly over time

  • Increases with the age
  • More common in the dominant arm
  • When you have a degenerative tear in one shoulder, you have a greater risk for a tear in the opposite shoulder, even if you have no pain in the opposite shoulder.

Risk Factors[edit | edit source]

  • > 40 years old
  • Male > Female
  • Smoking
  • Genetics
  • Hypercholesterolemia
  • Body mass index
  • Height
  • Repetitive stress/lifting
  • History of trauma
  • Lack of blood supply
  • Bony spurs
  • Overhead activities and other people who do overhead work: Tennis players, Baseball pitchers, Painters, Carpenters, and Plumbers.
  • Traumatic injury e.g. fall (more common cause in younger individuals)[1]

Characteristics/Clinical presentation[edit | edit source]

Supraspinatus tears are normally present as partial or full-thickness tears. It can be asymptomatic or symptomatic.

Partial thickness:

  • Incomplete disruption of muscle fibres[1]
  • Can progress to complete tear - Increasing pain is normally the first sign of the progression of a tear

Full thickness: Complete disruption of muscle fibres

  • Large tears (1-1,5cm) have a high rate of progression
  • If progression is suspected in conservatively managed cases - further investigation is warranted
  • Smaller tears (<1cm) progress slower

[6][7]

Signs and Symptoms[edit | edit source]

Patients normally present with:[1][7][8]

  • Pain/worsening pain (in cases where tears are progressing), the most common symptoms are:
  • Pain when lifting and lowering your arm or with specific movement
  • Pain at rest
  • Pain at night, predominantly when you lie on the affected shoulder
  • Traumatic tears: Sudden, intense pain often accompanied by a snapping sensation and immediate weakness in the upper arm
  • Located anterolaterally and superiorly
  • Referred to the level of the deltoid insertion with full-thickness tears
  • Repetitive strain tear: Starts off mild and only when lifting your arm; over time the pain can become more noticeable at rest
  • Aggravated in overhead or forward-flexed position
  • Limited range of motion
  • Reduced forward elevation, external rotation and abduction
  • Struggle with activities like reaching behind back, combing hair and overhead activities
  • Stiffness
  • Weakness when rotating or lifting your arm
  • Crepitus, Clicking, and Instability

Differential Diagnosis[edit | edit source]

[9][10]

Diagnostic Procedures[edit | edit source]

Physical Examination[edit | edit source]

Subjective interview:[edit | edit source]

  • Onset: Spontaneous or after injury
  • Duration of pain
  • Pain provocation/aggravating factors
  • Night rest
  • Same problems in the past?
  • Activity limitations
  • Localize pain
  • Past medical history
  • Recreational or sport activities (possible overhead activities)

Observation:[edit | edit source]

    • Any atrophy present

Range of motion:[edit | edit source]

  • Expect reductions in flexion, abduction and external rotation
  • If passive abduction range is more than active range, it is an indication of a rotator cuff tear

Muscle power:[edit | edit source]

  • Test supraspinatus by resisting abduction at 90° and internal rotation
  • Scapular movement may be affected

Palpation:[edit | edit source]

  • Forearm behind back to palpate rotator cuff just anterior and below the acromion
    • Muscle atrophy present
    • Tenderness

Special tests:[edit | edit source]

  • Drop-arm test: Active shoulder abduction to 90°, then return [11]
    • Positive: Dropping the arm down with pain indicates a positive test

Drop Arm Test video provided by Clinically Relevant


  • Jobe/supraspinatus/empty can test: Resist shoulder abduction and internal rotation[11]
    • Positive: Pain/weakness

Empty Can Test video provided by Clinically Relevant

  • Full can test: Resisted shoulder abduction in external rotation
    • Positive: Pain/weakness

Full Can Test video provided by Clinically Relevant

  • Subacromial grind test: Patient standing and examiner standing facing the patient, the examiner grasps the patient's flexed elbow. The shoulder is passively abducted in the scapular plane to 90°. The examiner's other hand is placed over the patient's shoulder overlying the anterior acromion and greater tuberosity. The examiner passively internally and externally rotates the shoulder detecting the presence of palpable crepitus.
    • Positive: Palpable crepitus.[12]

[13][14]

Special Investigations[edit | edit source]

X-rays[edit | edit source]

  • Excluding sclerosis and osteophyte formation on the acromion
  • X-rays measure the size of the subacromial space
  • Unable to see the tendon
Supraspinatus tear as seen in radiographics

MRI[edit | edit source]

  • MRI Scan shows partial or full tears in the tendons of the rotator cuff, inflammation to weak structures and cracks in the capsule

CT Scan[edit | edit source]

  • CT scan is able to localize tendon when patient positioned with forearm behind the back

Ultrasound[edit | edit source]

Outcome Measures[edit | edit source]

Medical Management[edit | edit source]

Conservative Management[edit | edit source]

Indications:[6][7]

  • Older (>70 years) patients with a chronic tear
  • Patients with irreparable tears with irreversible changes
  • Patients of any age with small (<1 cm) full-thickness tears
    • As a result of the slow rate of progression of these tears
  • Patients without a full-thickness tear

Management includes:[15]

NSAID's:

  • Ibuprofen

Corticosteroid injections:

  • Eliminate pain for a period of time, making physiotherapy management easier
  • Tendon tissue can be weakened by these injections (which would have an adverse effect on the outcome of a possible surgery)
  • Limited to 2 injections
  • Physiotherapy (see Physiotherapy management below)

Surgical Management[edit | edit source]

Indications:[6][7][16]

  • Failed conservative management
  • Larger symptomatic full-thickness tears (1-1,5cm) as a result of the high rate of progression. Should be considered for earlier surgical repair in younger patients if the tear is repairable and the muscle degeneration is limited
  • Acute large tears (>1 cm-1.5 cm) or
  • Young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes
  • Complete tear with significant pain and dysfunction after 6 months of treatment
  • Repeated dislocations

Rotator cuff repair[edit | edit source]

Most repairs are done arthroscopically[16]. Severity (partial vs full-thickness) will determine the approach.

  • Partial repair: The tendon and surrounding bone will be smoothed to avoid further damage and therefore allowing the tendon to heal mostly on its own[17]
  • Complete tear: Tear in middle of tendon: Suture the two parts of the tendon back together. Tear close or on its point of attachment on the head of the humerus: Attach the tendon back to its original place by an anchor (sometimes two). This anchor actually consists of a small screw that is bored into the head of the humerus with on the back surgical wires which hold the tendon in place[18].

Physiotherapy Management[edit | edit source]

Physiotherapy management depends on the extent of the tear, and plays in important role in both conservative management as well as post-surgical rehabilitation. More details can also be obtained from the rotator cuff page.

Conservative Management[edit | edit source]

Physiotherapy goals:

  • Improve pain together with NSAID’s (2-6 weeks)
  • Cryotherapy (only in first 48 hours)
  • Massage
  • Improve circulation (to control inflammation and speed up the healing process)
  • Improve range of motion:
    • Stretching (careful with timing, as stretching of acute injury may aggravate the tear):[19] 
      • Crossover arm stretch: 12 seconds, 5 times a day; 5-6days/week 

4.png

Kristian Berg. Prescriptive stretching; Human Kinetics [20]

  • Door stretch: 5 x 30 seconds (5 second rest in between)
  • Passive/Active range of motion:[21]
    • Pendulum exercises: Forward and back, side-to-side, circular motion. 2 sets of 10 a day, 5-6days/week
    • Symptom limited active-assisted range of motion exercises

5.png

Kristian Berg. Prescriptive stretching; Human Kinetics [20]

  • Increase strength:[22][23]
    • Rotator cuff (especially supraspinatus) strengthening to improve muscle control and strength
    • Prone Horizontal Abduction progress by using resistance bands
    • Prone Row with External Rotation
  • Regain function of affected upper limb (up to 3 months)
  • Home exercise programme

Clinical Bottom Line[edit | edit source]

A supraspinatus tear can occur due to trauma or repeated micro-trauma and present as a partial or full-thickness tear.[1] Most of the time, the tear occurs in the tendon or as an avulsion from the greater tuberosity[2]. The tear can be partial or full-thickness. Pain, loss of range of motion and weakness is the 3 most common symptoms.[1][7][8] Supraspinatus tears can be managed conservatively, with NSAID's and physiotherapy, as well as surgically to repair the tear.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 American Academy of Orthopedic Surgeons, Ortho Info. Rotator cuff tears, http://orthoinfo.aaos.org/topic.cfm?topic=a00064 (accessed 29/08/2018).
  2. ↑ 2.0 2.1 Benazzo F, Marullo M, Pietrobono L. Supraspinatus rupture at the musculotendinous junction in a young woman. Journal of Orthopaedics and Traumatology 2014;15(3):231-4.
  3. ↑ Supraspinatus muscle (highlighted in green) - posterior view image - © Kenhub https://www.kenhub.com/en/library/anatomy/supraspinatus-muscle
  4. ↑ Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus: Algemene anatomie en bewegingsapparaat, 2010. p600.
  5. ↑ Physioworks, Rotator Cuff Tear.http://physioworks.com.au/injuries-conditions-1/rotator-cuff-tears (accessed 29/08/2018).
  6. ↑ 6.0 6.1 6.2 6.3 Tashjian RZ. Epidemiology, natural history and indications for treatment of rotator cuff tears. Clinics in Sports Medicine 2012:31(4):589-604.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. Prevalence and risk factors of a rotator cuff tear in the general population. Journal of shoulder and elbow surgery 2010:19(1):116-20.
  8. ↑ 8.0 8.1 Mayo Clinic Rotator cuff injury. http://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/symptoms-causes/dxc-20126923 (accessed 30/08/2018).
  9. ↑ Medscape. Supraspinatus tendonitis: Differential diagnoses, http://emedicine.medscape.com/article/93095-differential (Accessed 20/03/2015).
  10. ↑ Medscape. Rotator cuff injury: Differential diagnoses, http://emedicine.medscape.com/article/92814-differential, (Accessed 25/03/2015).
  11. ↑ 11.0 11.1 Hughers PC, Taylor NF, Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Aust J Physiother 2008;54(3):159-70.
  12. ↑ Sawalha S, Fischer J. The accuracy of “subacromial grind test” in diagnosis of supraspinatus rotator cuff tears. International journal of shoulder surgery 2015;9(2):43-46.
  13. ↑ Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.
  14. ↑ Orthop J. Rotator cuff tear: physical examination and conservative treatment. Department of Orthopaedic Surgery Tohoku University, 2013:197–204.
  15. ↑ Björkenheim JM, Paavolainen P, Ahovuo J, Slätis P. Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results. Clinical orthopaedics and related research 1988;(236):148-53.
  16. ↑ 16.0 16.1 Millar NL, Wu X, Tantau R, Silverstone E, Murrell GA. Open versus two forms of arthroscopic rotator cuff repair. Clinical orthopaedics and related research 2009;467(4):966-78.
  17. ↑ American Academy of Orthopedic Surgeons. Rotator Cuff Tears: Surgical Treatment Options. https://orthoinfo.aaos.org/en/treatment/rotator-cuff-tears-surgical-treatment-options/ (accessed 30/08/2018).
  18. ↑ Akpınar S, Uysal M, Pourbagher MA, Ozalay M, Cesur N, Hersekli MA. Prospective evaluation of the functional and anatomical results of arthroscopic repair in small and medium-sized full-thickness tears of the supraspinatus tendon. Acta orthopaedica et traumatologica turcica 2011;45(4):248-53.
  19. ↑ Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Journal of shoulder and elbow surgery 2009;18(1):138-60.
  20. ↑ 20.0 20.1 Kristian Berg, Human Kinetics:. Prescriptive stretching. 2011.
  21. ↑ Joseph Berman MD. Supraspinatus tear, http://www.josephbermanmd.com/diagnosis-treatament-of-the-shoulder/rotator-cuff-tear/ (accessed 29/04/2015).
  22. ↑ Physioroom. Exercises to Strengthen the Rotator Cuff Muscles in the Shoulder.http://www.physioroom.com/experts/asktheexperts/answers/qa_mb_20050225.php (accessed 31/08/2018).
  23. ↑ Heers G, Anders S, Werther M, Lerch K, Hedtmann A, Grifka J. Efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. Sportverletzung Sportschaden: Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin 2005;19(1):22-7.
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