Supraspinatus Tear

Original Editor - Brecht Haex

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

Definition/Description

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. Quite often, the tear occurs in the tendon or as an avulsion from the greater tuberosity.

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

Clinical Relevant Anatomy

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. 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.

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

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. 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

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

• > 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)

Characteristics/Clinical presentation

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

Partial thickness:

• Incomplete disruption of muscle fibres
• 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

Signs and Symptoms

Patients normally present with:

• 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

• Acromioclavicular joint injury
• Brachial plexus injury
• Bicipital tendinopathy
• Cervical radiculopathy
• Cervical spine sprain
• Cervical strain injuries
• Cervical disc injuries
• Cervical nerve root injury
• Cervical Spondylosis
• Cervical discogenic pain syndrome
• Clavicular fracture
• Sternoclavicular joint disorders
• Infraspinatus syndrome
• Contusions
• Rotator cuff tear
• Shoulder dislocation
• Myofascial pain
• Shoulder impingement syndrome
• Superior labrum lesions
• Shoulder subluxation
• Angina pectoris
• Myocardial infarction
• Subacromial impingement
• Osteoarthritis
• Rheumatoid arthritis
• Subscapular nerve entrapment
• Shoulder instability
  • Anterior instability
  • Posterior instability

Diagnostic Procedures

Physical Examination

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)

Observation:

• • Any atrophy present

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

Muscle power:

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

Palpation:

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

Special tests:

• Drop-arm test: Active shoulder abduction to 90°, then return
  • 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
  • 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.

X-rays

• 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

• 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

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

Ultrasound

• Ultrasound helps in localising tendon

Outcome Measures

• Short Form-36 (SF-36)
• Rotator Cuff Quality of Life (RC-QOL) scale
• Western Ontario Rotator Cuff (WORC) index
• Disabilities of the Arm, Shoulder and Hand (DASH)

Medical Management

Conservative Management

Indications:

• 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:

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

Indications:

• 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

Most repairs are done arthroscopically. 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

• 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.

Physiotherapy 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 page.

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): 
    • Crossover arm stretch: 12 seconds, 5 times a day; 5-6days/week 

Kristian Berg. Prescriptive stretching; Human Kinetics 

• Door stretch: 5 x 30 seconds (5 second rest in between)

• Passive/Active range of motion:
  • 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

Kristian Berg. Prescriptive stretching; Human Kinetics

• Increase strength:
  • 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

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