Supraspinatus Tendinopathy

Shoulder problems: a daily nuisance that cannot be ignored. From menial everyday tasks like washing your hair to exercising or working, a painful shoulder can completely disrupt your life. This blog focuses on one particular shoulder condition that physiotherapists often encounter: supraspinatus tendinopathy. But how does this complex shoulder condition arise, and which treatment shows the most promise?

To answer any questions about supraspinatus tendinopathy, we’ve conducted a literature review and spoken with leading physiotherapists and shoulder specialists. Read on to dive head-first into the world of evidence-based treatment options such as eccentric exercise and shockwave therapy and gain valuable insights from experienced experts.

How does supraspinatus tendinopathy develop?

Supraspinatus tendinopathy is one of the pathologies underlying subacromial pain syndrome, a standard shoulder pain complaint in adults. How this particular tendinopathy develops depends on several factors, which, according to Seitz et al.,¹ are divided into two major categories: 

Intrinsic mechanisms:

• Age-related degenerative changes
• Poor blood circulation
• Biological factors (composition of the tendon matrix)
• Poor mechanical properties

Extrinsic mechanisms:

• Anatomical factors
  •   Shape and/or orientation of the acromion
  •   Prominent bone spurs inferior to the AC joint
• Biomechanical factors
  •   Scapular/glenohumeral dyskinesia
  •   Posture, muscle weakness, soft tissue tension

When a tendinopathy arises from internal factors and causes a narrowing of the subacromial space, it can even lead to a combination of the internal and external mechanisms mentioned above.

Various treatment options for supraspinatus tendinopathy There is an abundance of interventions available, but the current agreed-upon treatment policy for supraspinatus tendinopathy consists of the following elements:

• NSAIDs, pain medication
• Education and advice
• Exercise therapy (mobility, eccentric strength exercises), if needed supplemented with manual therapy
• Shockwave therapy (in case of an inadequate response to conservative therapy)
• Corticosteroid injection
• Surgical intervention (in some cases of calcification or rupture)

Considering the wide variety of mechanisms that can bring about supraspinatus tendinopathy, it is not surprising that many treatment options are available. Seitz et al. suggest that categorising patients into subgroups can improve treatment efficiency. Lewis’ ² review includes a handy classification in which local imaging, clinical presentation, and treatment are intertwined.

 

Below, we’ll explore some treatment options available, such as exercise therapy, shockwave therapy, and percutaneous electrolysis. Further, experienced shoulder specialists Chris and Henry will share valuable tips that can assist you in making the right treatment choices for your patients.

Exercise therapy for supraspinatus tendinopathy

Lewis’s table also indicates that eccentric training is crucial for this condition. Eccentric training stimulates fibroblasts and the production of new collagen fibres, thereby reducing neovascularisation and improving tendon organisation.

The exact dosage of eccentric exercise therapy remains a matter of contention in the literature. Nevertheless, physiotherapist Martin Ophey³ suggests a clear guideline for shoulder rehabilitation based on the following fundamental principles:

1. Place the patient at the centre of the treatment process.

2. Aim for optimal atherogenic mobility

3. Treat both the primary cause and any secondary disorders

4. Build rehabilitation from proximal to distal

5. Aim for optimal intermuscular coordination

6. Let the patient exercise pain-free

Follow the established training principles, progress from isometric to dynamic, and preferably opt for a progression in time rather than repetitions. Also, the aspect of coordination should be kept in mind. The scapula must be a stable base. In case of scapular dyskinesia, the rotator cuff muscles, and thus the supraspinatus, cannot function properly. That means that if your patient has scapular dyskinesia, treating that issue first should be high on your priority list.

Large and small exercise equipment for shoulder rehabilitation

Exercise equipment can significantly contribute to effective training. This includes traditional exercises on a pulley and more modern training methods using a portable flywheel training device that can be used indoors and outdoors.

However, smaller exercise equipment can also be vital in shoulder rehabilitation. Such aids are indispensable, especially in stability training. In case of mobility problems, the shoulder stretcher is essential, or, as physiotherapist Chris likes to say: "In case of mobility problems, the shoulder stretcher is my best friend."

Shockwave therapy for supraspinatus tendinopathy

Today, shockwave therapy is an integral part of the established treatment policy for supraspinatus tendinopathy. Supported by numerous literature reviews, shockwave therapy is considered an efficient intervention method for calcifying and non-calcifying tendinopathies. However, the level of scientific evidence favouring non-calcifying tendinopathy is slightly lower.

Pellegrino et al. (2022): "Various mechanisms of action have been described for the effect of ESWT, including an analgesic effect due to overstimulation of the nociceptors and microlesions of the tendon tissue due to the physical effects of the sound waves, which stimulate the tendon’s healing process. The success rate ranges from 60 to 90%, and complications are negligible."⁴

Due to the excellent research results, an evidence-based treatment protocol for supraspinatus tendinopathy with calcification has been included in the ShockMaster 500. Through our personal experience, we firmly believe that the intensity level of the Gymna ShockMaster 500 is high enough to achieve said reabsorption of calcification in the supraspinatus tendon. Physiotherapist Toon would like to share his experience with the Gymna ShockMaster 500:

"I regularly help patients overcome a calcifying supraspinatus tendon tendinopathy. My secret weapon? The Gymna ShockMaster 500, with which I carefully increase the dosage to up to 5 bar. After only 2 to 3 sessions, my patients experience considerable pain relief and improved mobility. The most satisfying part is that surgical intervention can be postponed or avoided entirely. Often, the effectiveness of this particular approach is confirmed by ultrasound evidence of calcium breakdown months after my treatments."

 

Percutaneous electrolysis for supraspinatus tendinopathy

The best intervention - or combination of interventions - for shoulder complaints has yet to be discovered. 

Because there is no decisive solution for shoulder issues, it’s up to new technologies that are being developed as we speak. In recent years, percutaneous electrolysis has been an increasingly used (part of the) treatment for supraspinatus tendinopathy. Although there’s currently little research into this particular therapy, it’s still a physiotherapy technique worth considering, especially in cases where the standard approach bears no fruit and surgical intervention must be avoided (whether for financial, medical, or practical reasons).

The added value of percutaneous electrolysis

Percutaneous electrolysis should always be performed legally and under ultrasound guidance by a doctor. However, physiotherapists can treat the trigger points responsible for the patient’s symptomatology. Some physiotherapists and their patients report that the effect of a percutaneous electrolysis treatment lasts longer than the effect of a regular dry needling treatment, but scientific evidence is still lacking.

Physiotherapist Tessa has experienced the positive result of percutaneous electrolysis firsthand: "I was treating a patient who had been struggling with shoulder complaints for over two years. I tried everything, but nothing yielded sufficient results. That is until I started applying percutaneous electrolysis with the Gymna Acure (after having undergone the necessary training, of course). After three days, my patient's elevation had already increased by 25°."

Practical tips from physiotherapists for successful shoulder rehabilitation

It is essential to offer your patient a scientifically supported treatment. However, sharing experiences with colleagues can provide valuable insights for selecting the proper treatment. That's why we’ve asked some experienced physiotherapists to share their ultimate tips for successfully treating patients with supraspinatus tendinopathy.

Sports physiotherapist Chris starts with these words of advice: "When treating ankle sprains, physiotherapists routinely look at neuromuscular control, proprioception. However, when it comes to shoulder rehabilitation, these aspects are often forgotten even though they contribute to the perseverance of complaints.  Additionally, it is important to start the rehabilitation process with scapular stabilisation, as the scapula is the shoulder’s foundation. And as a final tip, I recommend starting exercises with large levers later in the rehabilitation process because the force couples must work well first."

Manual therapist Sara would like to emphasise the importance of informing and instructing your patient: "People must be consciously involved in their rehabilitation at home as well. Some patients constantly exceed their limits, while others hardly dare to use their shoulder, creating a fear of movement. Your patient must know how and to what extent they can use their shoulder to stay engaged while not exceeding their limits."

Physiotherapist Henry also regularly sees patients with subacromial pain syndrome in his practice. His tip goes beyond physiotherapy: "Sometimes, as physiotherapists, we like to solve a patient’s problems alone, but there are so many factors contributing to the onset of your patient’s complaints. Factors like nutrition and sleep also play a significant role. My tip: do not forget these factors and refer your patient to your (para)medical colleague in time."

Physiotherapist Ron would like to add one more tip: "I always advise my patients to look for a physiotherapist who specialises in shoulder complaints. This way, patients will always receive the best physiotherapeutic care for their shoulder complaints."

Do you also want to offer the best shoulder rehabilitation?

We learned how vital exercise therapy is in shoulder rehabilitation and how shockwave therapy and percutaneous electrolysis can significantly contribute to the recovery of supraspinatus tendinopathy.

Please get in touch if you want to know more about using shockwave or percutaneous electrolysis.

 

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^{[1] Seitz, A. L., McClure, P. W., Finucane, S., Boardman, N. D., 3rd, & Michener, L. A. (2011). Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clinical biomechanics (Bristol, Avon), 26(1), 1–12. https://doi.org/10.1016/j.clinbiomech.2010.08.001}

^{[2] Lewis J. S. (2010). Rotator cuff tendinopathy: a model for the continuum of pathology and related management. British journal of sports medicine, 44(13), 918–923. https://doi.org/10.1136/bjsm.2008.054817}

^{[3] Ophey, M. (2013). Actieve schouderrevalidatie bij hobby- en prestatiegerichte sporters (deel 1). InFysio, 9(3), 6–11. https://www.schoudernetozl.nl/wp-content/uploads/2013/02/InFysio-2013-03-Schouder_artikel.pdf}

^{[4] Pellegrino, R., Di Iorio, A., Brindisino, F., Paolucci, T., Moretti, A., & Iolascon, G. (2022). Effectiveness of combined extracorporeal shock-wave therapy and hyaluronic acid injections for patients with shoulder pain due to rotator cuff tendinopathy: a person-centred approach with a focus on gender differences to treatment response. BMC musculoskeletal disorders, 23(1), 863. https://doi.org/10.1186/s12891-022-05819-3}