The Supraspinatus is one of the four muscles that comprise the Rotator Cuff which collectively serve as the primary dynamic stabilisers of the Glenohumeral Joint and consequently, The Shoulder Girdle . Of these muscles, the Supraspinatus is the most proximally situated, traversing between the Supraspinous Fossa of Scapula and proximal Head of Humerus . This course within the narrow Suprahumeral Joint (Subacromial Space) leaves the Muscle particularly vulnerable to injury, as described in Subacromial Impingement .
Traditional descriptions of the Supraspinatus are highly variable and likely attributed to a lack of specificity. Generally speaking, the Supraspinatus has a triangular-shape as the origin from the medial two-thirds of theSupraspinous Fossaand Spine of Scapula is roughly two-fold wider than its tendinous insertion on theGreater Tuberosityof Humerus (SOURCE-2+3). A more nuanced description of the Supraspinatus identifies two distinct muscle bellies that converge on their lateral course under the Acromion to form the thick Supraspinatus Tendon (SOURCE-2+12+15):
Anterior Belly - this portion arises exclusively from theSupraspinous Fossaand contains an internal thick tendinous cord upon which all muscle fibres make their attachment. The anterior portion has a fusiform (or bipennate) architecture with more obliquely oriented fibres which suggest a greater capacity to withstand stress. This may be necessary as the Cross-Sectional Area (CSA) of the muscle belly is ~2.45x that of the posterior belly while the tendinous CSA is actually slightly smaller
Posterior Belly - the flatter, wider posterior portion originates from the Spine of Scapula and to a lesser extent, theGlenoid Neck. This portion contains no tendinous core and has a unipennate architechture with parallel fibres, a structure that appears less suited to force generation. At its lateral end, the posterior fibres account for ~60% of the Supraspinatus Tendon
The tendinous lateral extention of the Supraspinatus represents a specialised transition zone from the musculotendinous junction to its humeral attachment, which is described to have four distinct regions (SOURCE-12+15):
Tendon Proper- comprised predominately of Type I Collagen and a small proportion of Decorin
Attachment Fibrocartilage- comprised predominately of Type II and III Collagen , with small amounts of Type I, IX and X Collagen which forms Fibrocartilage
Calcified Fibrocartilage- a mineralised Fibrocartilage comprised of Type II and X Collagen and Aggrecan
Bone
The Supraspinatus Tendon is structurally continuous and functionally integrated with the surrounding capsule and ligaments to reinforce The Shoulder Girdle and distribute load (SOURCE-2+12+13+15):
Deep Continuity - roughly 1cm prior to the humeral attachment, the deep surface of the Tendon blends inseperably with the Glenohumeral Joint Capsule
Superior Continuity - the superior portion of the Tendon is reinforced by and continuous with the Coracohumeral Ligament and Transverse Humeral Ligament . Together these structures help form theRotator Cable, that distributes tensile stressors
Lateral Continuity - near the attachment, the Tendon blends with the Infraspinatus Tendon
Distal Continuity - in roughly half of instances the Supraspinatus Tendon extends an aponeurosis to the adjacent Bicipital Aponeurosis which distally blends with the superior aspect of the Pectoralis Major Tendon (discussed underVariation)
Associated Fascia fixes the Supraspinatus to the margins of the Fossa and sports a Fat Pad which distinguishes it from the inferior margin of the Trapezius (SOURCE-2)
The Supraspinatus received nervous innervation from the Suprascapular Nerve , C5 - C6 Nerve Roots (SOURCE-2+12).
The Muscle Architecture of the Supraspinatus has been described in multiple ways, from fusiform to circumpennate, which may be attributed to the muscles distinct portions as noted above (SOURCE-6+9+12). For a low mass the muscle has a notablePhysiologic Cross-Sectional Area (PCSA)(SOURCE-9+10). The Supraspinatus also has a high fibre length (117±7mm) to muscle length (127±7-12mm) ratio and parallel fibre arrangement (0º pennation angle), making it well-suited for Range of Motion and velocity (SOURCE-9+10). This fibre orientation and notable PCSA affords a significant force-producing capacity for its limited size that is efficiently transmitted linearly towards the Humerus . While certain metrics are heavily contingent on the population evaluated, the following has been reported:5 cadavers, average age of ~73 years (SOURCE-9):
Mass - 30 ± 4g
Physiologic Cross-Sectional Area (PCSA)- 2.48 ± 0.94 cm²
Fibre Length - 117 ± 7mm
Muscle Length - 127 ± 7mm
Pennation Angle - 0º
MRI of 10 subjects (5 female, 5 male) 24-37 years, 158-188cm tall and a bodyweight of 50-86kg (SOURCE-10):
Muscle Length - 127 ± 12mm
PCSA - 4.8±1.6 cm²
The following variations have been described for the Supraspinatus:
Additional Insertion - one study found the Supraspinatus to have an additional insertion on the Lesser Tuberosity of the Humerus in 21% of cases (SOURCE-3)
Supraspinatus Aponeurosis - in roughly half of cases the anterior portion of the Supraspinatus Tendon extends an aponeurosis to the adjacent Bicipital Groove which distally blends with the superior aspect of the Pectoralis Major Tendon , near its Humeral insertion (SOURCE-12+13). The size and shape of this extension is also variable (SOURCE-13)
Collectively the Rotator Cuff affords dynamic stability to the Glenohumeral Joint , in part through its regulation of the arthrokinematics and contraction on the Glenohumeral Joint Capsule (as described on its page) (SOURCE-16). Unlike the other Rotator Cuff Muscles which exert an integral inferior pull on the Head of Humerus , the Supraspinatus compresses the Humeral Head and draws it superomedially to create a superior roll (SOURCE-16). This action is most pronounced during GH Joint - Abduction where it works in concert with the Deltoid which has a more directly superior draw on the Humerus (SOURCE-2+16). While some texts describe the Supraspinatus as simply an initiator of GH Joint - Abduction , afterwhich the Deltoid facilitates the full range, the Supraspinatus displays notable contribution throughout the entirety of the movement (SOURCE-2+12+16). This is emphasised by the fact that in the presence of Deltoid paralysis, full GH Joint - Abduction is still possible by the compensatory action of the Supraspinatus (SOURCE-2+16). Conversely, absence of the superior roll due to Supraspinatus insufficiency likely restricts full GH Joint - Abduction as the near vertical draw of the Deltoid compresses the Humeral Head against the Coracoacromial Arch (SOURCE-2+16). When weight-bearing with The Hand , the Supraspinatus and Deltoid resist excesive inferior translation of the Humerus (SOURCE-2+12). The Supraspinatus is also described as a weak GH Joint - External Rotation contributor (SOURCE-12).
The more favorable Muscle Architecture and considerably larger Cross Sectional Area suggests the anterior muscle belly of Supraspinatus may be more suited to force generation (SOURCE-12).
The compressive and tensile demands of the Supraspinatus leaves it particularly vulnerable to injury, making it one of the most commonly compromised tissues in The Shoulder Girdle (SOURCE-26+27). While there are several distinct aveunes by which the Supraspinatus may be compromised, they are highly interrelated.
A traditional (inflammatory) model of Supraspinatus degeneration initiates with acute Tendinitis which progresses to Tendinosis and eventually onto Tear s; however, the lack of inflammatory cells in Pain ful Tendons has challenged this perspective (SOURCE-15). While Inflammation may play a transient or reactive role, the chronic pain and structural failure are primarily driven by degenerative processes independent of it. The more modern perspective on Supraspinatus degeneration is consistent with other Tendinopathy , where excessive stress exceeds the healing capacity of the Tenocytes and causes the Tendon to repair improperly (SOURCE-15). Vulnerability is most prominent at theCritical Zonenear the tendinous Humeral insertion of Supraspinatus as it is most hypovascular (SOURCE-30). In a healthy healing process, Type-III Collagens are rapidly laid down in haphazard fashion as a temporary “patch-job” and eventually succeeded by more permanent and organised Type-I Collagens (SOURCE-20). When the demand for repair exceeds the rate at which this healthy healing process can occur, tendons are left in a vulnerable, disorganised state. The severity of the Supraspinatus degradation may be graded based on the quality of its matrix (SOURCE-19):
Grade I (normal) - Collagen bundles have a wavy outline with easily discernible fibres. Tenocytes are elongated with their long axis parallel with the bundles
Grade II (mild) - Collagen bundles are mostly aligned and inconsistently wavy. Individual fibres are not as discernible and the nuclei of Tenocytes are shorter and aligned in short chains
Grade III (moderate) - with the wavy architecture lost, the tendon begins to resemble homogeneous, glassy hyaline material (Hyalinisation). This pathomorphology signifies a profound loss of tendon strength and elasticity. The lack of orientation between Collagen fibres and with their corresponding nuclei reflects a disturbance to mechanical signalling. An increased number of Tenocytes and their plump circular shape reflects an increased demand for remodeling
Grade IV (severe) - there is diffuse hyalinisation throughout the tendon and complete disorganisation of its Collagen s. A reduction in the size and presence of nuclei represents the stage ofAcellularity(cell death) and a suppressed attempt to repair damaged tissue
Impaired functionality, including a loss of elasticity and inability to withstand load, corresponds to matrix degradation and with chronicity may develop complications such as calcification or fibrovascularisation (SOURCE-15). Additionally, the neovascularisation infiltrates Tear sites of tendons and displaces the Collagen matrix, leading to further compromise (SOURCE-15). Sites of greatest load are left most vulnerable, namely the humeral insertion (SOURCE-15). Age is correlated with Supraspinatus tendinopathy and these aforementioned metrics of degradation (SOURCE-15)
Supraspinatus insufficiency may impact joint compression and the ability of the Humeral Head to superiorly roll. Without this superomedial pull, the near vertical pull of the Deltoid impinges the Humeral Head against the Coracoacromial Arch (SOURCE-2+16). This notion is supported by the finding that pre-fatigue of the Rotator Cuff reduced the subacromial space by 6-40% (SOURCE-17). Subacromial Impingement , forms the basis for numerous shoulder pathologies, most of which relating to soft-tissue injury. Initially, tissues that reside within the subacromial space such as the Subacromial Bursa and Supraspinatus accumulate Inflammation which increases friction by narrowing the space further and suppressing the lubricative function of the Bursa (SOURCE-18). Like several other Connective Tissue s, the Supraspinatus Tendon is subject to morphological changes under states of significant compression. This state triggers a notable shift in the expression of cells from an abundance of Fibroblasts to becoming predominately invested by Chondrocytes. With further mineral deposition this tissue may form Cartilage (SOURCE-8). The Anterior Supraspinatus often develops early signs of damage, following a disease progression with chronicity from Rotator Cuff Tendinopathy to partial Tear to full rupture (SOURCE-18)
Rotator Cuff Tears are described to be one of the most common pathologies to affect The Shoulder Girdle with an estimated prevalence of 22% in the general population (SOURCE-23+24). This number increases dramatically with age, with 70-80% of those over the age of 80 expected to develop tears, which signifies the bidirectional relationship between Rotator Cuff degeneration and tears (SOURCE-8+21+24). Of the Rotator Cuff , the Supraspinatus is most commonly affected as is often subject to degenerative changes and experiences routine compressive and tensile forces (SOURCE-15+21). Those with degenerative Supraspinatus tears display particular clinical features their traumatic equivalents do not, including a narrower subacromial space and greater Acromion slope, which suggest these forms of tears are related to an external impingement mechanism (SOURCE-25). Conversely, the less common traumatic tears are often the result of forceful hyperextension or like other Rotator Cuff Tear s, GH Joint - External Rotation and/or GH Joint - Abduction during a fall such as a FOOSH type mechanism (SOURCE-28+29). Traumatic tears of the Supraspinatus are more likely to result in full-thickness compromise and occur concomitantly with SLAP Lesion s, or lesions of the Long Head of Biceps , Infraspinatus , Teres Minor , Subscapularis and superior Glenohumeral Joint Capsule (SOURCE-27). Acromial morphology also relates to the type of tear where Type-II (curved) Acromion are equally prevalent between degenerative and traumatic tear s, Type-I (flat) more commonly associated with trauma and Type-III (hooked) with degeneration (SOURCE-25).
The considerably larger anterior muscle belly exerts force through a tendon that is comparably sized to the tendon of its posterior counterpart. This suggests the anterior portion experiences considerably more mechanical stress, with one study reporting the anterior portion is subject to ~288% more stress than the posterior portion (SOURCE-12). Tears of the anterior-third of the Supraspinatus may compromise theRotator Cableand consequently lead to a greater risk of tear propagation (SOURCE-22). With any Supraspinatus tear , it appears the larger the lesion the less load is required to propagate (SOURCE-22).
In terms of Fascia l connections, the Supraspinatus is included in the following:
Myofascial Chains - the Supraspinatus is described as one of the more proximal muscles in the Dorsal Arm Chain (SOURCE-46)
A restriction at any point along the line/ chain could result in Pain or dysfunction of the Supraspinatus.
While the Supraspinatus is capable of producing full GH Joint - Abduction in the presence of Deltoid paralysis, Supraspinatus paralysis may compromise the full Abduction ability (SOURCE-2). Despite a fully functioning Deltoid , Supraspinatus insufficiency hinders its compressive function and ability to roll the Head of the Humerus superiorly during GH Joint - Abduction . This may lead to overpowering action of the Deltoid pulling the Humeral Head superiorly, causing it to impinge against the Coracoacromial Arch during movement (SOURCE-2).
The accumulation of myofascial trigger points or Inflammation within the Supraspinatus may result in Referred Pain . The Pain pattern of the Supraspinatus courses from The Shoulder Girdle down the lateral arm to extend as far as the lateral forearm (SOURCE-11). Pain is often most pronounced over the Deltoid and Lateral Epicondyle of Humerus / Head of the Radius (SOURCE-11). Pain is usually provoked by overhead movement (SOURCE-29).
With constant compressive and tensile demands, integral muscle functions and tight proximity within The Shoulder Girdle , the Supraspinatus is closely related to several shoulder pathologies:
Subacromial Impingement - Rotator Cuff pathology, for which the Supraspinatus is most often implicated, can notably reduce the Subacromial Space to predispose impingement (SOURCE-17). Additionally, insufficent action from the Rotator Cuff may cause abnormal arthokinematics at the Glenohumeral Joint or Scapulothoracic Joint which may result in secondary impingement. The Supraspinatus is left particularly vulnerable as it courses within the narrow Subacromial Space, with repeated impingment predisposing Tendinopathy and/or Tear . This vulnerability is most pronounced between 60-120º of GH Joint - Abduction (SOURCE-7).
Subacromial Bursitis - with often a shared origin from impingement, it is often difficult to ascertain whether this Bursitis occurs concomitantly with Supraspinatus pathology, in response to Supraspintus pathology or contributes to the muscles degeneration. Inflammatory states of either tissue encroaches on the Subacromial Space, predisposing the consequences of impingement to the other (SOURCE-17). Increased friction may lead to the accumulation of microtrauma, alter the local environment and lead to the deposition of Hydroxyapatite Crystals and consequent calcification of tendons (SOURCE-40). It is postulated these crystals may fragment into sharp acicular structures with the capacity to mechanically induce significant inflammation (SOURCE-40). This is supported by the findings that the region of the Subacromial Bursa closest to tendons is most subjected to this pathological change (SOURCE-40).
Adhesive Capsulitis - Rotator Cuff pathology is considered a major intrinsic predisposing factor for secondary Frozen Shoulder (SOURCE-41). In the initialInflammatory Stage, shoulder motion becomes restricted despite full Rotator Cuff strength (SOURCE-41+42). From theFreezing Stageand beyond GH Joint - Abduction becomes one of the shoulders major restrictions, which may lead to atrophy of the Supraspinatus (SOURCE-42+43).
Glenohumeral Instability - shares a bidirectional relationship with Supraspinatus pathology. Rotator Cuff insufficiency is associated with recurrence of unstable events (SOURCE-44). An isolated Supraspinatus Tear may lead to a non-significant increase in contact path length (altered Glenohumeral mechanics); however, instability is not associated with tear size (SOURCE-38). Instability may also predispose Rotator Cuff injury as it disturbs its length-tension relationships, leading to excessive strain or overuse. Both conditions often occur concomitantly from traumatic injuries such as Glenohumeral Dislocation (SOURCE-45).
Suprascapular Nerve may be injured as it passes under the transverse scapular ligament (through the suprascapular notch), wich could lead to atrophy or paralysis of the supraspinatus and infraspinatus (SOURCE-7).
Traumatic tears of the Supraspinatus are more likely to result in full-thickness compromise and occur concomitantly with the following conditions (SOURCE-27):
Proximal Long Head of Biceps Tendon Tear
Superior Glenohumeral Joint Capsule
The following observations may be visible with Supraspinatus dysfunction:
Resting Posture
Supraspinatus Atrophy - may indicate Suprascapular Nerve palsy or chronic Rotator Cuff Tear (SOURCE-7)
Pain localised to lateral Deltoid - could indicate a Supraspinatus tear , particularly when (SOURCE-30):
Worse at night
Lying on the symptomatic shoulder
Sulcus Sign - indicates Glenohumeral Instability which may arise from Tears (SOURCE-30)
Movement
Disturbed or Pain ful Scapulohumeral Rhythm - in particular through GH Joint - Abduction (SOURCE-29). Painful Arc usually experienced between 60-120º of arm elevation (SOURCE-30)
Reproduction of Pain or reduced performance with overhead activities (SOURCE-30).
Restriction - greater restriction may be seen with partial Supraspinatus tears as remaining fibres tension (SOURCE-30)
GH Joint - External Rotation may serve as a compensatory pattern for Deltoid/ Supra insufficeincy as the LHB can act as an abductor (SOURCE-7)
The following findings on Range of Motion assessment may be indicative of Supraspinatus pathology, with slight differences between a Tendinopathy and Tear :
Passive Range of Motion - for tendinopathies, the unloaded Tendon during passive motion should be capable of full, Pain -free overhead movement. Similarly, irrespective of size, an isolated tear typically restricts passive range to a minimal extent (SOURCE-38)
Active Range of Motion - for tendinopathies, full range of motion is usually possible but limited by Pain . Pain is often experienced at initiation and 60º-120º of arm elevation depending on the plane of movement (SOURCE-15+39). For Tears active range is likely compromised, with arm elevation beyond 90º likely to result in impingement as action of the Deltoid is not sufficiently offset by the Supraspinatus (SOURCE-2+16+38)
Isometric Tests - despite the shared potential for Pain , active resisted range of motion is more likely to be compromised with tears than tendinopathies. Supraspinatus tears appear to most notably affect GH Joint - External Rotation , followed by GH Joint - Internal Rotation , while all other ranges remained relatively unaffected (SOURCE-38). The size of isolated Supraspinatus tear does not appear to be associated with the strength deficit (SOURCE-38)
The Supraspinatus can be assessed for relative strength through active resisted GH Joint - Abduction , either seated against gravity or lying supine without gravity. This is the same test used to evaluate the relative strength in the Middle fibres of the Deltoid . Compensation from the Upper Trapezius , Long Head of Biceps or lateral flexion of the Trunk is common.
Several Shoulder - Special Tests can be used to specifically investigate the integrity of the Supraspinatus (SOURCE-30):
Empty Can - sensitivity 0.41-0.89, specificity 0.50-0.98
Drop Arm Test - sensitivity: 0.24, specificity: 0.93
External Rotation Lag Sign - sensitivity 0.45-.056, specificity 0.91-0.98
Hawkins-Kennedy - may be provocative
Neers - may be provocative
Spurling’s Test - for suspected Nerve Root involvement ( Radiculopathy )
The Supraspinatus can be palpated just superior of the spine of the Scapula , in theSupraspinous Fossa. As the muscle resides under the upper fibres of the Trapezius , these associated tissues must be moved aside before fingers can be sunk into the Supraspinatus. Given its deep location it is unlikely that any TRPs will be palpable, rather the patient will report points of heightened sensitivity. The Supraspinatus is often difficult to palpate unless the overlying Trapezius is underdeveloped (SOURCE-2).
Relevant neurological assessments for the Supraspinatus focus primarily on its motor and sensory innervation from C5 and C6 Nerve Roots (SOURCE-7):
Myotomes - active resisted GH Joint - Abduction
Cervical - Dermatomes - C5 provides cutaneous sensory innervation over the lateral arm from Deltoid to base of the Thumb
As imaging findings alone do not consistently correlate with a patients symptoms and findings are often identified in asymptomatic shoulders, they should be complimented by physical examination before reaching a diagnosis and establishing a treatment protocol (SOURCE-35).
Radiographs (X-Rays)- generally the first line of imaging, used to determine presence of Acromial morphology or other related abnormalities such as Subchondral Cysts or a “notch” on the Greater Tuberosity or ligamentous calcification which may predispose impingement (SOURCE-30). X-Rays are also a reliable measure of theAcromiohumeral Interval, which quantifies the extent of impingement through determining the shortest distances between the inferior cortex of the Acromion and the peak of the Humeral Head (SOURCE-31). A distance of 7-14mm is considered normal, ≤ 7mm indicative of a large Rotator Cuff Tear and a distance smaller than 6mm indicates a chronic and complete tear of the Infraspinatus (SOURCE-31). The following views may be relevant (SOURCE-30+31+32+33+34):
AP view in the Scapula plane - also known asGrashey view, provides a (~20%) higher detection rate when compared to a conventional AP for the following conditions:
Osteophytes on the Greater Tuberosity of the Humerus or under the Acromion
Outlet view - reveals morphology of the Acromion, including bony spurs as well as ligamentous calcification and other causes of impingement
Axillary view - evaluates for Os Acromiale and rules out Dislocation in cases of trauma
When X-Ray findings are unremarkable, CT Scans and MRI’s may be indicated (SOURCE-34).
Ultrasonography (Ultrasound)- an accessible imaging modality with dynamic, real-time capabilities for the evaluation of Rotator Cuff pathology and Subacromial Impingement via certain metrics (SOURCE-30+35+36):
Rotator Cuff Pathology
“focal heterogenous hypoechogenicity”, or a localised portion of the tendon that has a dark and abnormal appearance, indicates the presence of a Rotator Cuff Tear . This may result from accumulated fluid within the cuff surface or its substance. Linear appearing echogenicity within the substance with or without muscle atrophy may also suggest a tear . A complete non-echogenic (black) gap extending the thickness of the tendon indicates a full tear, while in partial tears attachment is still visible
a decrease in tendon thickness was associated with Subacromial Impingement which is indicative of degenerative changes associated with chronicity
Bursa - the thickening of associated bursa as seen in Subacromial Bursitis is indicative of Subacromial Impingement. Similarly, an increased width of the Subdeltoid Bursa may be indicative of impingement. This Inflammation is visualised as an increase in anechoic fluid within the bursa
Subacromial Space - like other imaging modailities, the Acromiohumeral Inverval may be established with Ultrasounds to quantify impingement. A side-to-side differential of <2.1mm was considered normal.
AStandard I (transverse plane) Viewtaken approximately 15mm lateral of the Long Head of Biceps may be used to evaluate the rotator cuff, although this distance is subject to anatomical variation (SOURCE-36). AStandard II (longitudinal plane) Viewmay be used to determine the Acromiohumeral Interval with the Humerus neutrally rotated (SOURCE-36). Other views that may be relevant include Standard Auxiliary Views I, II and III (SOURCE-36). A downfall of this imaging modality is that accuracy is clinician dependent (SOURCE-36).
Magnetic Resonance Imaging MRI- can be used to evaluate the integrity of the Rotator Cuff , the presence of concomitant injuries such as Subacromial Bursitis or SLAP Lesions or associated morphologies (SOURCE-30+35+37). The following findings may be indicative of Rotator Cuff pathology (SOURCE-30):
T1-weighted images - an increased signal without tendon discontinuity indicates a partial- tear . On T1 and proton-density images an increased signal and loss of anatomic definition suggests Tendinitis
T2-weighted images - a signal increase with intra-tendinous focal defect suggests partial- tear . Conversely, Tendinitis may have moderate or decreased signal
Computed Tomography (CT) Scan- akin to MR-arthrography, used most often for the evaluation of Cartilage or the Glenoid Labrum (SOURCE-35). Typically reserved as a complement to other imaging modalities for the assessment of bony changes or when MRI’s are contraindicated (SOURCE-35).
The treatment of Supraspinatus pathology can be applied directly to the tissue or indirectly through its associated Fascia l and nervous structures.
The following Stretching techniques can be used to restore length to the Supraspinatus or reduce compromising mechanics such as impingement:
Door Frame Neck Stretch - Supraspinatus variation
Genie Stretch - rudimentary horizontal adduction stretch
Sleeper Stretch - greater emphasis on GH Joint - Internal Rotation
Sleeper Stretch MWM - internal rotation stretch combined with Humerus Mobilisation
Dead Hangs - whole body traction for Pull and Push muscles with large overhead range
Shoulder Dislocates - mobility exercise that emphasises the greatest circumduction range possible
The following Strength exercises can be used to restore and improve functionality of the Supraspinatus:Early Phase:
Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head
Shoulder Sling - Scapula setting exercise
Scaption > 120º with GH Joint - Internal Rotation - achieves 74±33% Maximum Voluntary Isometric Contraction(SOURCE-5)
Scaption > 120º with GH Joint - External Rotation - achieves 64±28% Maximum Voluntary Isometric Contraction(SOURCE-5)
GH Joint - Flexion > 120º with GH Joint - External Rotation - achieves 67±14% Maximum Voluntary Isometric Contraction (SOURCE-5)
Prone Horizontal Abduction - variation at 100º with GH Joint - External Rotation displays very high activity 82±37% Maximum Voluntary Isometric Contraction(SOURCE-5)
Side-Lying Shoulder External Rotations - maximises effect of gravity against External Rotation with upper arm fixed against torso
Mid-Phase:
Side Raises - isotonic GH Joint - Abduction exercise with many variations
Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion
Overhead Press - achieves 80±48% Maximum Voluntary Isometric Contraction (SOURCE-5)
Straight Arm Lat Pulldown - isotonic motion that emphasises Lats and straight arm strength
Late Phase:
Push Press - wholebody, explosive variation of the Overhead Press
Kneeling Landmine Press - wholebody, explosive vertical pressing exercise with large overhead range
Pull-Up - bodyweight or greater load through large overhead motion
Split Stance Landmine Press - crossbody, standing variation of the Kneeling Landmine Press
DB Snatch - unilateral isotonic, explosive shoulder exercise with large overhead range
Rope Climb - pull-up variation with entire load bestowed on alternating arm
DB Snatch to Step-Up - wholebody DB Snatch variation that emphasises diagonal functional patterns
The Supraspinatus can be treated directly or along the Fascial Lines / Myofascial Chains it belongs to, particularly when hypertonicity is identified.
Practitioner Guided- using the Thumb or pads of Fingers , the Supraspintus can be palpated just superior of the Spine of Scapula and under the Upper Trapezius . Pushing superficial tissue aside, sustained pressure may be applied to the Muscle with or without active movement ( GH Joint - Abduction / GH Joint - Adduction ). Deeper more rhythmic pressure may also be applied.
Altered arthrokinematics at The Shoulder Girdle can hinder tone and functionality of the Supraspinatus or leave it vulnerable to mechanical injury (as seen in secondary Subacromial Impingement ). While treating the muscle directly may improve said arthrokinematics, so too can mobilisations which in turn may improve Supraspinatus dysfunction. Similarly, mobilisations of the Cervical Spine may be relevant when Radiculopathy is suspected.
Joint Play - passive accessory movements performed without active movement
Cervical Spine - for instances of Radiculopathy a PACVP , PAUVP or TVP may be applied to relevant Cervical segment(s) in addition to the following techniques:
Mobilisation with Movement - mobilisations applied with active movement
Shoulder - MWM 3 - applied to the Scapula and Humerus
Shoulder - MWM 4 - applied to the Scapula and Humerus
Shoulder - MWM 5 - applied to the Scapula and Humerus
Sleeper Stretch MWM - self-guided Posterior Capsule release
AC Joint - MWM 1 - GH Flexion or Horizontal Adduction
Cervical Spine - for suspected Radiculopathy , the following techniques may be indicated:
SMWAM - Cervical mobilisations with arm movement
Neurodynamic SMWAM - Cervical mobilisations with neurodynamic arm movement
Cervical SNAGS - Cervical mobilisations with neck movement
NAGS - particularly useful for restriction or Pain associated with movement for C2-C7
The following highlights points of focus when applying Dry Needling to the Supraspinatus (SOURCE-14):Starting Position:
Patient can be seated or prone with arm either:
Resting by side ( GH Joint - Adduction )
At 90º GH Joint - Abduction when prone so lower arm falls over table - be sure to account for Scapulothoracic Joint - Upward Rotation when identifying landmarks
Procedure:
Typically 30-40mm needles
Push superficial Upper Trapezius fibres proximally from the spine of the Scapula to reveal the Supraspinatus
Needle is inserted at a 45º angle to skin in a medial to lateral direction towards the muscles insertion
Muscle can be needled along the superior border of the spine of the Scapula or under the lateral lateral border of the Acromion
Precautions:
The Lungs / Thorax - these structures lie 1.5-3cm below the surface of the skin. Needle at a shallow angle or between a pincer grip to avoid the risk of Pneumothorax
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