1. Tendinosis & Subacromial Impingement Syndrome
Gene Desepoli, LMT, D.C.

2. What is the shoulder joint?
Shoulder joint or shoulder “region?”
There is an interrelatedness of all moving parts of the shoulder and dysfunction in one joint may cause dysfunction and pain in the others!

3. “He who treats the site of pain is lost.
- Karel Lewit

4. 7 Joints of the Shoulder Region
1. Glenohumeral
2. Subdeltoid (false joint)
3. Acromioclavicluar
4. Scapulothoracic (false joint)
5. Sternoclavicular
6. Costosternal
7. Costovertebral

5. The 7 Joints of the Shoulder Region

6. Bony Anatomy Review
Scapula

7. Bony Anatomy Review
Humerus

8. Soft Tissue Review

9. Soft Tissue Review

10. 9 Bursae of Shoulder Region
Only 2 are clinically important:
1. Subacromial (subdeltoid) bursa
susceptible to impingement, esp. if
swollen or inflamed. Frequently
ruptures due to a calcium deposit.
2. Subscapular bursa
between anterior scapula and rib cage
Note: Bursitis is rarely a primary condition !!!!

11. Muscle Review 1. Supraspinatus 2. Infraspinatus 3. Teres Minor
4. Subscapularis
5. Levator Scapulae
6. Upper Trapezius
7. Serratus Anterior
8. Biceps brachii
assists abduction when arm is externally rotated.
9. Deltoid: impingement!

12. Rotator Cuff

13. Rotator Cuff
Muscles do not attach as discreet tendons but blend to form a continuous cuff surrounding the glenoid head.
Provides dynamic stabilization of the joint due to blending into the capsule.
Tendons of rotator cuff blend with joint capsule

14. Rotator Cuff Supraspinatus…………Abduction
Infraspinatus…………..External rotation
Teres Minor……………External rotation
Subscapularis…………Internal rotation

15. Rotator Cuff: Supraspinatus
Abduction
Passes under acromion process
Most commonly injured or torn
“Suitcase muscle”

16. Hypovascularity of the Supraspinatus
Supraspinatus is considerably hypovascular with respect to the other cuff tendons: “critical zone”
Tendonitis in this region correlates to hypovascualrity (that progress with age)

17. Rotator Cuff - Infraspinatus
External rotation
Pulls humerus downward with abduction
Eccentric contraction

18. Rotator Cuff – Teres Minor
External rotation
Pulls humerus downward with abduction

19. Rotator Cuff - Subscapularis
Internal Rotation
Adduction
Stabilizes humerus
Pulls humerus downward w/ abduction
Eccentric contraction

20. Glenohumeral Joint
Designed for flexibility at the expense of stability
Static stabilizers – capsule and ligaments
Dynamic stabilizers – rotator cuff muscles

21. Posture and the Glenohumeral Joint

22. Glenohumeral Joint Assuming good, normal posture:
Gravity’s tendency to pull the humerus downward is overcome by superior joint capsule tightness. (vector: pulls humeral head inward for stability)
Little or no deltoid or rotator cuff muscular effort is needed. (even w/ a small weight in the hand)

23. Glenohumeral Joint
With thoracic kyphosis (round shoulders): the rotator cuff must increase tone to compensate for loss of capsular stabilization. Round shoulders may even be a cause of frozen shoulder!!!!
Increased capsular stress leads to increased collagen production and increased fibrosis

24. Capsular Support
Capsule taut
Capsule loose

25. Glenohumeral Joint
With the arm elevated or with round shoulder posture:
Tension is lost in sup. joint capsule
The rotator cuff muscles contract to provide
stabilization. Over time, they fatigue!
Conditions which compromise stabilization:
1. postural changes
- round shoulders = downward scapular
rotation
2. rotator cuff weakness/ dysfunction / trigger
points

26. Biomechanics of Abduction of the Humerus

27. Abduction of Humerus ● Scapula rotates upward (scapulohumeral
rhythm) from upper traps and serratus anterior
● Clavicle elevates & rotates backward
● Upper thoracic vertebrae must extend,
rotate and bend to same side. The
contribution of spinal movement to full
arm elevation is often overlooked!

28. Abduction There is the danger of the greater tubercle
hitting the acromion, subjecting the soft
tissue to repeated trauma!
The head of the humerus must be guided
into inferior glide / depression to prevent
impingement during abduction (actively or
passively) AND it must externally rotate!

29. Biomechanics of Abduction
External rotation of the humerus occurs due to untwisting of the capsule
Tight internal rotators my prevent this!

30. Impingement (pinching)
Bones: acromion and greater tubercle
Soft tissue:
supraspinatus tendon
& subacromial bursa

31. Coracoacromial Ligament
Runs from coracoid process to the acromion.
Important for a/c joint stability
May be a source of impingement
Forms a protective arch over the glenohumeral area
together with the acromion and clavicle (functions as a
secondary restraining arch to prevent superior humeral
head dislocation
Can impinge the supraspinatus tendon and subdeltoid
bursa.

32. Coracoacromial Arch
An additional site of impingement

33. Altered Biomechanics
Impingement is prevented by proper biomechanics and by the proper placement of the humerus during abduction.
Causes of impingement therefore can be:
muscle imbalance, trauma, trigger points, weakness, inhibition, pain, arthritis, capsular tightness, muscle memory following injury
eg. scapula doesn’t rotate
bursa is swollen and the space is reduced
Shoulder forward shrugging causes impingement.

34. Scapulohumeral Rhythm

35. Deltoid Muscle

36. Muscular Force Couple
During abduction the humerus must be properly situated for full pain-free movement.
Force coupling occurs to create smooth pain free movement
eg. trapezius and serratus anterior
rotator cuff muscles with deltoid

37. Abduction of Humerus
Infraspinatus & Teres Minor

38. Force Coupling

39. The Painful Arc
There is pain during abduction in the range from to 120 degrees.

40. Assessment Tests Painful Arc Hawkins’ Test / Speeds Test +++
Subacromial push button (Dawbarn’s)
Rotator cuff tendonitis assessment
A/C joint tests
Labrum disruption tests
Rotator cuff tears

41. Progression of Rotator Cuff Tears
Tight pectoral muscles 
Round shoulders 
Impingement 
Supraspinatus Tendonosis/
Tendonitis 
Calcific Tendonitis 
Rotator cuff tear !!

42. Surgery may be preventable.
The real heroes and competent level of massage therapy deals with early recognition and prevention.

43. Corrective exercises Correct round shoulders/ergonomics
Restore mobility
Eliminate trigger points
Stretch tight muscles
Strengthen weak muscles
Rehabilitate supraspinatus with scaption.
glenoid cavity faces forward, laterally and
superiorly

44. Tendonitis / Tendonosis

45. Tendonitis / Tendonosis
Causes
overuse
poor body mechanics
Pathology
muscle cell damage (tearing, irritation)
microinflammation
fibroblasts
microscarring

46. Tendinosis / Tendonitis
Not a true inflammatory condition
Cell damage causes fibroblasts to
proliferate
Creates a disorganized scar
(massage and movement)
Leads to pain and further micro-tearing

47. Tendinitis / Tendinosis
Accurate Assessment!
1. pinpoint pain
2. painful active (resisted) contraction
3. painful passive overstretching
Highly accurate!
Can be applied to any muscle for assessment.

48. Rotator Cuff Tendinosis
Supraspinatus:
pinpoint pain at greater tubercle
painful active abduction
painful passive adduction stretch

49. Rotator Cuff Tendinosis
Infraspinatus & Teres Minor:
pinpoint pain at greater tubercle
painful active external rotation
painful passive internal rotation stretch

50. Rotator Cuff Tendinosis
Subscapularis:
pinpoint pain at lesser tubercle
painful active internal rotation
painful passive external rotation stretch

51. Treatment of Tendinosis
General Massage
Remove TrPs which maintain a shortened / tight muscle
Transverse Friction massage
creates a mobile flexible scar
causes “good damage” to allow healing
Strengthen muscle / tendon to tolerate more stress
Full recovery = the patient can perform 3 sets of 10
strong repetitions
Ice may be needed before and after Tx. to decrease pain