1. Supraspinatus Tendinitis
RAHILA NAJIHAH ALI
DPH/0102/11
30th MAY 2013

2. Skeletal Structure

3.  Humans have a strong and
well developed clavicle that
acts as a lateral strut
(support) to the scapula and
the humerus.
 This increase glenohumeral
mobility to permit reaching
& climbing activities
Laura K.Smith, 1995, Brunnstrom’s Clinical Kinesiology, 5th
Edition, Book Promotion & Service LTD

4. Scapulo-Humeral rhythm
 describes the timing of movement at these
joints during shoulder elevation
1st 30° of shoulder elevation :
glenohumeral jt. : large
scapulothoracic jt. : small & inconsistent
after 1st 30° of shoulder elevation :
glenohumeral jt. & scapulothoracic jt. move
simultaneously
ratio : 2 : 1
 Function :
1) preserves the length-tension relationships of
the glenohumeral muscles
2) Prevent impingement
Laura K.Smith, 1995, Brunnstrom’s Clinical Kinesiology, 5th Edition, Book
Promotion & Service LTD
http://moon.ouhsc.edu/dthompso/namics/scapryme.htm

5. Ligament & Capsule

6. Muscles

7. Supraspinatus Muscle
 Origin - supraspinous fossa of scapula
 Insertion - greater tubercle of humerus
 Action – Assists deltoid muscle in
abducting arm at shoulder joint
Joseph E. Muscolino, . The Muscle and Palpation Manual with Trigger
Points, Refferal Patterns, and Stretching

8. Supraspinatus Tendon
 Most frequently irritated tendon of most
superior tendons of glenohumeral joint
 Vulnerability of this tendon to
inflammation is due to its anatomical
location

9. Supraspinatus Tendinitis
 Inflammation of
supraspinatus tendon
 Most common affected
structure in rotator cuff
muscle that lead to
development of pain due
to impingement in
shoulder

10. Impingement
 Occur beneath coraco-acromial
arch
 Most vulnerable structures
between undersurface of
acromion and head of humerus
are greater tuberosity, the
overlying supraspinatus tendon
and long head of biceps
 Major site of compression is slightly
anterior to angle of acromion
 Proper term is painful arc
syndromeJohn Ebnezar,2011, Essential of Orthopaedics for Physiotherapy, 2nd
edition,India, Jaypee Brother

11. Painful Arc Syndrome
 painful arc occur on resisted
abduction between 60 and
120 degrees when the
inflamed tendon presses
against the acromium
 outside of this
range, abduction is painless
Patricia A.Downie,1983, Cash’s textbook of Orthopaedics and
rheumatology for physiotherapists, London, JP

12. Causes
 Repeated use of arm overhead in
occupation, functional or sports stresses
 Arm kept at the side or moved with
horizontally adducted position
 Over stress to tendon due to muscle
weakness, tight muscle, tight capsule, or
bony impingement
 Poor posture like kyphosis and shoulder
complex protraction
 Poor body mechanic
Otto D.Payton, 1989, Manual of Physical Therapy, New
York, Edinburgh, London, Churchill Livingstone

13. Signs
 Active movement produce painful arc
with coronal abduction
 Patient complain of pain discomfort
when therapist do passive stretching of
supraspinatus tendon
 Patient complain of pain when therapist
do resisted isometric contracture of
external rotation and both diagonal and
coronal abduction
Otto D.Payton, 1989, Manual of Physical Therapy, New
York, Edinburgh, London, Churchill Livingstone

14. Symptoms
 Pain or limited of ROM
 Pain at rest with highly reactive
condition
 Example
- lying on side of dysfunction
- sit in chair with too high arm rest
 Limitation of function with elevated
diagonal movement
Otto D.Payton, 1989, Manual of Physical Therapy, New
York, Edinburgh, London, Churchill Livingstone

15. Radiograph
 X-ray
 MRI

16. Treatment
 Transverse friction massage to the
supraspinatus tendon
 Use modalities to reduce inflammation like
ultra
sound, iontophoresis, phonophoresis, IFT and
high voltage stimulation
 Educate in posture and body mechanics
 Stretch tight muscle
 Strengthen weak muscle
 Manipulate thigh capsuleOtto D.Payton, 1989, Manual of Physical Therapy, New
York, Edinburgh, London, Churchill Livingstone

17. Transverse Friction Massage
Position of patient : sitting with hand of
injured shoulder placed behind the back
and relax the arm
Position of therapist: Stand in behind of
the client’s shoulder to find the
supraspinatus tendon
Procedure : video
Val Robertson, 2009, Electrotherapy Explained
principles and practise, 4th edition, China, Elsevier

18. Strengthening weak muscle
 Muscle that need to be strengthen:
-external and internal rotators
-deltoid
-scapular stabilizers
(rhomboids, trapezius, serratus
anterior, latissimus dorsi)
 Do the proprioceptive neuromuscular
facilitation (PNF)
http://morphopedics.wikidot.com/physical-therapy-management-
of-supraspinatus-tendinitis

19. • D1 Flexion pattern: shoulder flexion, elbow flexion, forearm
supination, wrist flexion, and finger flexion.
• D1 Extension pattern: shoulder extension, elbow extension, forearm
pronation, wrist and finger extension.
• D2 Flexion pattern: shoulder flexion, elbow extension, forearm
supination, wrist extension, and finger extension.
• D2 Extension pattern: shoulder extension, elbow flexion, forearm
pronation, wrist and finger flexion
http://morphopedics.wikidot.com/physical-therapy-management-
of-supraspinatus-tendinitis

20. Increase ROM
 pendulum exercises
 active assisted ROM exercises
 active exercises in all planes
 self-stretches concentrating mainly on
posterior joint capsule
http://morphopedics.wikidot.com/physi
cal-therapy-management-of-
supraspinatus-tendinitis

21. Manipulate tight capsule
 Joint mobilization of the shoulder joint
 inferior, anterior, and posterior glides of
shoulder
http://morphopedics.wikidot.com/physical-therapy-
management-of-supraspinatus-tendinitis

22. CASE STUDY
SOAPIER

23. Subjective
NAME : Madam Y
AGE : 63 years old
GENDER : Female
OCCUPATION : Housewife
DOMMINANT HAND: Left hand
DATE OF ASSESSMENT : 22nd Mei 2013
CHIEF COMPLAINT : Patient complaint pain at her left
shoulder when lifting up the left hand above the head
level and try to lift heavy things. Patient also complain
difficulty in dressing especially when trying to wear bra
and take out her cloth.

24. PRESENT HISTORY : Patient had fall down about 4 weeks ago
due to wet floor at a bank. She fall with outstretched left
hand. She only felt pain after 3 days prior to the injury. She
went to traditional Chinese doctor and did massage but the
pain became worse.
PAST HISTORY : NIL
SOCIAL HISTORY : She stays with her husband and daughter
at a terrace house in Kuala Lumpur. She takes care of her
husband that has Alzheimer's disease since 12 years and also
does a lot of housework. Sometimes she takes her husband
for morning walk around her housing area. Patient is a non-
smoker and doesn’t consume alcohol.

25. SPECIAL QUESTION
General health : High blood pressure and depression
PMHx/Surgery : ankle sprain on 2006 and low back pain since
2008
Lx/X-Ray/MRI :
i) X-Ray for ankle on 2006
ii) MRI for whole body on 2008
MEDICATION/STEROID : under medication
i) Patenolol 100mg 1 tablet, 2 times per day for high blood
pressure
ii) Patient taking another type of high blood pressure
medicine but does not remember it’s name
iii) Lexapio 5mg 2 tablet per day for depression

26. Pain assessment
Site : Anterior and posterior shoulder near to glenohumeral joint
Pain scale :
4/10 when rest
6/10 when lift up the hand above head level and carry heavy
things
Nature of pain : Pulling pain
Aggravating factor : Lift up the hand above head level and carry
heavy things
Easing factor : Resting hand on the abdomen in internal position
of shoulder
Irritability : Medium
24 hours :am : No pain
pm : sometime disturb sleep
Onset : Gradual

27. Body Chart
xx X

28. Objective
 On observation
- Body built : Medium
- Deformities : NIL
- Swelling : mild swelling around the left shoulder
- Posture : Slightly kyphotic
 On palpation
- Spasm : on the anterior and posterior part of left
shoulder
- Warmth : no
- Tightness : on anterior part of left shoulder

29.  On examination (Range of motion )
1) Shoulder
*( )-degree where patient start feel pain
patient feel pain when do the flexion, extension, abduction and medial
rotation of left shoulder
all action of right shoulder is FROM
ACTIVE PASSIVE ACTION ACTIVE PASSIVE
0-180° 0-180° Flexion 0-160° (150°) 0-170°
0-60° 0-60° Extension 0-50° (30°) 0-60°
0-180° 0-180° Abduction 0-165° (70-
120°)
0-170°
Adduction
0-80° 0-80° Medial
Rotation
0-70° (60°) 0-80°
0-90° 0-90° Lateral
Rotation
0-90° 0-90°
Right Left

30. 
2) Elbow
The ROM of right and left elbow joint is FROM
There’s no complain of pain when do all the movement
ACTIVE PASSIVE ACTION ACTIVE PASSIVE
0-140° 0-140° Flexion 0-140° 0-140°
140-0° 140-0° Extension 140-0° 140-0°
0-80° 0-80° Pronation 0-80° 0-80°
0-80° 0-80° Supination 0-80° 0-80°
Right Left

31.  3) Wrist
The ROM of wrist joint is FROM
there’s no complain of pain when do all the
movements
ACTIVE PASSIVE ACTION ACTIVE PASSIVE
0-70° 0-70° Flexion 0-70° 0-70°
0-60° 0-60° Extension 0-60° 0-60°
0-20° 0-20° Ulnar dev. 0-20° 0-20°
0-30° 0-30° Radial dev. 0-30° 0-30°
Right Left

32.  Muscle girth
*Differences of the muscle girth are 0.5 cm. There’s no muscle
wasting
MUSCLE MEASUREMENT (RIGHT) MEASUREMENT (LEFT)
DELTOID 31.5 CM 31.0 CM
BICEPS 30.5 CM 30.0 CM
TRICEPS 29.5 CM 29.0 CM
BRACHIALRADIALIS 23.0 CM 22.5 CM

33.  Muscle Power (Shoulder)
MUSCLE ACTION RIGHT LEFT
Anterior Deltoid &
Coracobranchialis
FLEXION 4/5 3/5
Latisimus Dorsi,
Teres Major,
Posterior Deltoid
EXTENSION 4/5 3/5
Middle Deltoid &
Supraspinatus
ABDUCTION 4/5 3/5
Pectoralis Major ADDUCTION 4/5 3/5
Subscapularis MEDIAL
ROTATION
4/5 3/5
Infraspinatus &
Teres Major
LATERAL
ROTATION
4/5 3/5

34.  Special Test
TEST RESULT
Neer Impingement Test Negative
Hawkins-kennedy Impingement Test Negative
Empty Can Test Positive

35. Analysis
 Physiotherapy impression
- pain at the anterior and posterior site of left shoulder
-reduce full ROM of left shoulder due to pain
-reduce muscle power in left hand due to weakness
-left Supraspinatus tendinitis
 Goals
Short Term Goal
- To reduce pain at the left shoulder
- To increase range of motion of flexion, extension, abduction and medial
rotation of left shoulder
- Improve the muscle power of left shoulder
Long Term Goal
- To improve functional activity of daily life ( patient can take care of her
husband and able to do housework with no pain )

36. Plan of treatment
- Pain relief
- Soft tissue manipulation
- Home program exercise
- Patient education

37. Intervention
1) Pain releif
 Interferential therapy
site : around the left shoulder
position of patient : sitting with shoulder in relax position
procedure : apply 4 pole at left shoulder
duration: 10 minutes
purpose : relieve pain
 Ultrasound
site : anterior site of the left shoulder
position of patient : sits with his arm behind the back in medial rotation
duration : 5 minutes
purpose : promote healing process
 Crayo cuff
site : left shoulder
position : sit with the shoulder in relax position
duration :10 minutes
purpose : to reduce swelling

38. 2) Soft tissue manipulation
 Superficial soft tissue manipulation
site: around the left shoulder
procedure : apply Repairil and Ultimax gel around the left
shoulder
purpose : relaxing the muscle
 Transverse friction massage
Site : anterior to acromion process
Duration : 5 minutes
Position of patient : patient sits with his arm behind the back in
medial rotation
Procedure : index finger of the ipsilateral hand, reinforced by the
middle finger. The thumb should be placed quite far down the
arm. So that a downward pressure is exerted on the greater
tuberosity, the index finger-nail remaining horizontal.
Purpose : to break the adhesion around the joint

39. Contd.
3) Home program exercise
Stretching the Supraspinatus muscle
position of patient : sitting or standing
action : patient’s left hand is extended and
adducted behind the body
repetition : 10 repetition 3 times daily

40. 4) Patient education
 Put ice on swelling part of the shoulder
 Avoid heavy lifting
 Rest the affected shoulder
 Don’t lean on affected side during
sleeping
 Avoid sudden movement of the affected
shoulder

41. Evaluation
 Patient fell better after do the
treatments
 Patient able to lift up the hand over the
head with less pain after Transverse
Friction Massage at the shoulder joint
Review
 Reassess ROM , muscle girth for next visit
 Review the muscle power

42. First follow up

43. Date of assessment : 27th may 2013
Complain : patient is complain of pain increase due to lift the wheel chair
into the car
Pain scale :
5/10 when rest
7/10 when lift up the hand above head level and carry heavy things
On observation
Swelling : mild swelling around the left shoulder
On palpation
- Warmth : no
- Tightness : on anterior part of left shoulder

44.  On examination (Range of motion )
1) Shoulder
right left
*( )-degree where patient start feel pain
patient feel pain when do the flexion, extension, abduction and medial rotation
of left shoulder
all action of right shoulder is FROM
ACTIVE PASSIVE ACTION ACTIVE PASSIVE
0-180° 0-180° Flexion 0-160° (150°) 0-170°
0-60° 0-60° Extension 0-50° (30°) 0-60°
0-180° 0-180° Abduction 0-165° (70-
120°)
0-170°
Adduction
0-80° 0-80° Medial
Rotation
0-70° (60°) 0-80°
0-90° 0-90° Lateral
Rotation
0-90° 0-90°

45.  2) elbow
-the movements are FROM
-there’s no complain of pain when do the
movements
 3) wrist
-the movements are FROM
-there’s no complain of pain when do
the movements
 4) Spasm : on the anterior and posterior
part of left shoulder

46.  Muscle Power (Shoulder)
MUSCLE ACTION RIGHT LEFT
Anterior Deltoid &
Coracobranchialis
FLEXION 4/5 3/5
Latisimus Dorsi,
Teres Major,
Posterior Deltoid
EXTENSION 4/5 3/5
Middle Deltoid &
Supraspinatus
ABDUCTION 4/5 3/5
Pectoralis Major ADDUCTION 4/5 3/5
Subscapularis MEDIAL
ROTATION
4/5 3/5
Infraspinatus &
Teres Major
LATERAL
ROTATION
4/5 3/5

47. Analysis
 Physiotherapy impression
- pain at the anterior and posterior site of left shoulder
-reduce full ROM of left shoulder due to pain
-reduce muscle power in left hand due to weakness
-patient did not do the stretching that had taught by therapist
 Goals
short term goal
- To reduce pain of the left shoulder
- To increase range of motion the flexion, extension, abduction and medial
rotation of left shoulder
- Improve the muscle power of the left shoulder
Long Term Goal
- To improve functional activity of daily life ( patient can take care of her
husband and able to do housework with no pain )

48. Plan of treatment
- Pain relief
- Soft tissue manipulation
- Home program exercise
- Patient education

49. Intervention
1) Pain relief
 Interferential therapy
site : around the left shoulder
position of patient : sitting
procedure: apply 4 pole at left shoulder
duration: 10 minutes
purpose : relieve pain
 Ultrasound
site : anterior site of the left shoulder
position of patient : sitting
duration : 5 minutes
purpose : promote healing process
 Crayo cuff
site : left shoulder
position : 10 minutes
purpose : to reduce swelling

50. 2) Soft tissue manipulation
 Superficial soft tissue manipulation
site: around the left shoulder
procedure : apply Repairil and Ultimax gel around the left
shoulder
purpose : relaxing the muscle
 Transverse friction massage
Site : between glenohumeral joint
Duration : 5 minutes
Position of patient : patient sits with his arm behind the back in
medial rotation
Procedure : index finger of the ipsilateral hand, reinforced by the
middle finger. The thumb should be placed quite far down the
arm. So that a downward pressure is exerted on the greater
tuberosity, the index finger-nail remaining horizontal.
Purpose : restoring mobility to muscles

51. Contd.
3) Home program exercise
Stretching the Supraspinatus muscle
position of patient : sitting or standing
action : patient’s left hand is extended and
adducted behind the body
repetition : 10 repetition 3 times daily

52. 4) Patient education
 Avoid heavy lifting
 Rest the affected shoulder
 Don’t lean on affected side during
sleeping
 Avoid sudden movement of the affected
shoulder
 Therapist emphasize the importance of
stretching

53. Evaluation
 Patient fell better after do the treatment
 Patient able to lift up the hand over the
head with less pain after Transverse
Friction Massage at the shoulder joint
Review
 Reassess ROM , muscle girth for next visit
 Review the muscle power

54. Second follow up

55. Date of assessment : 29th may 2013
complain : patient fell pain decrease
Pain scale :
3/10 when rest
5/10 when lift up the hand above head level and carry heavy things
On observation
Swelling : mild swelling around the left shoulder
On palpation
- Spasm : on the anterior and posterior part of left shoulder
- Warmth : no
- Tightness : on anterior part of left shoulder

56.  On examination (Range of motion )
1) Shoulder
right left
*( )-degree where patient start feel pain
patient feel pain when do the flexion, extension, abduction and medial rotation
of left shoulder
all action of right shoulder is FROM
ACTIVE PASSIVE ACTION ACTIVE PASSIVE
0-180° 0-180° Flexion 0-160° (150°) 0-170°
0-60° 0-60° Extension 0-50° (30°) 0-60°
0-180° 0-180° Abduction 0-165° (70°) 0-170°
Adduction
0-80° 0-80° Medial
Rotation
0-70° (60°) 0-80°
0-90° 0-90° Lateral
Rotation
0-90° 0-90°

57.  2) elbow
-the movements are FROM
-there’s no complain of pain when do the
movements
 3) wrist
-the movements are FROM
-there’s no complain of pain when do
the movements

58.  Muscle Power (Shoulder)
MUSCLE ACTION RIGHT LEFT
Anterior Deltoid &
Coracobranchialis
FLEXION 4/5 3/5
Latisimus Dorsi,
Teres Major,
Posterior Deltoid
EXTENSION 4/5 3/5
Middle Deltoid &
Supraspinatus
ABDUCTION 4/5 3/5
Pectoralis Major ADDUCTION 4/5 3/5
Subscapularis MEDIAL
ROTATION
4/5 3/5
Infraspinatus &
Teres Major
LATERAL
ROTATION
4/5 3/5

59. Analysis
 Physiotherapy impression
- pain at the anterior and posterior site of left shoulder
-reduce full ROM of left shoulder due to pain
-reduce muscle power in both hand due to weakness
- patient did not do the stretching that already taught by therapist
 Goals
short term goal
- To reduce pain
- To increase range of motion
- Improve the muscle power
Long Term Goal
- To improve functional activity of daily life

60. Plan of treatment
- Pain relief
- Soft tissue manipulation
- Home program exercise
- KIV shoulder exercise
- Patient education

61. Intervention
1) Pain relief
 Interferential therapy
site : around the left shoulder
position of patient : sitting
procedure: apply 4 pole at left shoulder
duration: 10 minutes
purpose : relieve pain
 Ultrasound
site : anterior site of the left shoulder
position of patient : sitting
duration : 5 minutes
purpose : promote healing process
 Crayo cuff
site : left shoulder
position : 10 minutes
purpose : to reduce swelling

62. 2) Soft tissue manipulation
 Superficial soft tissue manipulation
site: around the left shoulder
procedure : apply Repairil and Ultimax gel around the left
shoulder
purpose : relaxing the muscle
 Transverse friction massage
Site : between glenohumeral joint
Duration : 5 minutes
Position of patient : patient sits with his arm behind the back in
medial rotation
Procedure : index finger of the ipsilateral hand, reinforced by the
middle finger. The thumb should be placed quite far down the
arm. So that a downward pressure is exerted on the greater
tuberosity, the index finger-nail remaining horizontal.
Purpose : restoring mobility to muscles

63. Contd.
3) Home program exercise
Stretching the Supraspinatus muscle
position of patient : sitting or standing
action : patient’s left hand is extended and
adducted behind the body
repetition : 10 repetition 3 times daily

64. 4) Patient education
 Avoid heavy lifting
 Rest the affected shoulder
 Don’t lean on affected side during
sleeping
 Avoid sudden movement of the affected
shoulder

65. Evaluation
 Patient fell better after do the treatment
 Patient able to lift up the hand over the
head with less pain after Transverse
Friction Massage at the shoulder joint
Review
 Reassess ROM , muscle girth for next visit
 Review the muscle power

66. Reference
 Laura K.Smith, 1995, Brunnstrom’s Clinical Kinesiology, 5th
Edition, Book Promotion & Service LTD
 Joseph E. Muscolino, . The Muscle and Palpation Manual
with Trigger Points, Refferal Patterns, and Stretching
 John Ebnezar,2011, Essential of Orthopaedics for
Physiotherapy, 2nd edition,India, Jaypee Brother
 Patricia A.Downie,1983, Cash’s textbook of Orthopaedics
and rheumatology for physiotherapists, London, JP
 Otto D.Payton, 1989, Manual of Physical Therapy, New
York, Edinburgh, London, Churchill Livingstone
 Val Robertson, 2009, Electrotherapy Explained principles
and practise, 4th edition, China, Elsevier
 http://morphopedics.wikidot.com/physical-therapy-
management-of-supraspinatus-tendinitis
 http://moon.ouhsc.edu/dthompso/namics/scapryme.htm