What is the treatment for supraspinatus tendinosis?

Treatment for Supraspinatus Tendinosis

The most effective treatment for supraspinatus tendinosis involves a stepwise approach starting with relative rest, eccentric strengthening exercises, and analgesics for pain management, followed by more advanced interventions if conservative measures fail. 1

Initial Conservative Management

• Relative Rest: Reduce activities that cause repetitive loading of the supraspinatus tendon to prevent further damage and promote healing 1

  • Avoid overhead activities and those that reproduce pain
  • Complete rest is not recommended as it may lead to muscle atrophy

• Cryotherapy: Apply ice through a wet towel for 10-minute periods to provide acute pain relief 1

  • Most effective when used immediately after pain-provoking activities

• Eccentric Strengthening Exercises: The cornerstone of tendinopathy treatment 1

  • Gradually progressive exercises focusing on the supraspinatus muscle
  • May reverse degenerative changes in the tendon structure
  • Should be continued for at least 3-6 months for optimal results

• Pain Management:

  • NSAIDs (oral): Effective for short-term pain relief but do not alter long-term outcomes 1
  • Topical NSAIDs: May provide pain relief with fewer systemic side effects than oral NSAIDs 1
  • Other analgesics may be considered if NSAIDs are contraindicated 1

Intermediate Interventions

If symptoms persist after 4-6 weeks of initial conservative management:

• Physical Modalities:

  • Therapeutic ultrasound: May decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
  • Extracorporeal shock wave therapy (ESWT): Safe and potentially effective for pain relief, though optimal treatment protocols are still being established 1
  • Iontophoresis/phonophoresis: Can deliver topical medications to affected tissues, though well-designed studies supporting their use are lacking 1

• Corticosteroid Injections:

  • May provide better acute pain relief than NSAIDs but do not improve long-term outcomes 1
  • Should be used with caution as they may inhibit healing and reduce tendon strength, potentially predisposing to rupture 1
  • Avoid injecting directly into the tendon substance 1

• Newer Injection Therapies:

  • Platelet-rich plasma (PRP): A single ultrasound-guided injection has shown non-inferiority to ESWT at 6-month follow-up 2
  • Hypertonic dextrose prolotherapy: May provide short-term (up to 2 weeks) relief of pain and improved shoulder range of motion 3

Advanced Interventions

For cases resistant to 3-6 months of conservative management:

• Percutaneous Electrolysis: More effective than trigger point dry needling for pain relief and improving range of motion, with benefits lasting up to one year 4

• Surgical Management:

  • Consider if pain persists despite well-managed conservative treatment for 3-6 months 1
  • Typically involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1
  • Effective in carefully selected patients 1

Common Pitfalls and Caveats

• Misdiagnosis: Ensure proper diagnosis through clinical tests (Hawkins' and Neer's tests) which are sensitive but not specific for supraspinatus impingement 1

• Inadequate Exercise Progression: Starting with too aggressive exercises can worsen symptoms 1

• Overreliance on Passive Treatments: Active rehabilitation with eccentric exercises should remain the foundation of treatment 1, 5

• Premature Return to Activities: Returning to full activities before adequate healing can lead to symptom recurrence 1

• Delayed Referral: Consider surgical consultation if symptoms persist despite 3-6 months of appropriate conservative management 1