Understanding Supraspinatus Tendinosis and Corrective Exercise Applications
According to Bass (2012), tendinosis is a “degeneration of the tendon’s collagen in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results”. Bass goes on to sate that tendinosis shows an increase in immature type III collagen fibers as opposed to the mature type I fibers that are normally considered healthy. These fibers are unable to link properly, and as such, their ability to handle load becomes compromised. In addition to this, Weber (2017) notes that there is increased cellularity and neovascularization that are common conditions associated with tenodonosis. Cells found in tendinosis are degenerative in nature, with Khan describing the types of degeneration as mucoid, which causes softening of the area, or lipoid, which is an abnormal increase in lipid material in the tendon. In neovasularization, new blood vessels are arranged randomly, with blood vessels having even been found to form perpendicularly to the original origination of the fibers (Weber). In regards to treatment, Weber (2017) states that treatment starts with stopping the degenerative cycle and then restoring normal collagen synthesis, strength, and function.
From a corrective exercise perspective, Brookbush (2017) suggests addressing joint imbalances with a release, stretch and integration model of therapy, which can be tailored to both training and therapy professions. This process involves first releasing overactive tissue, stretching the same tissue, and then activating and integrating the weak and long structures in the joint.
While this is a simplified model for the purposes of this project, it is an effective implementation process for the corrective exercise specialist.
Based on the findings with the five key positions, the tissues identified as overactive include, but are not limited to the anterior tippers - pectoralis minor and levator scapula specifically - and the internal rotators, primarily the subscapularis, latissimus dorsi, and teres major. An example of the release for the pectoralis minor can be seen below. Basic guidelines for release are dependent on the client, but typically a period of 30-120 seconds works to release the tissue, allowing for the next step of stretching the same tissue. An example of a stretch for the pectoralis minor is also seen below.
Pec Minor Release
Pec Minor Stretch
Lastly, the process comes down to activating and integrating weakened tissue. KIM, SY; et al (2015) found that concentric and eccentric training for the supraspinatus can have equal value in strength development, but that eccentric training may have the added advantage of maintaining or improving muscle fiber bundle length and could help promoted tendon healing. With a focus on utilizing eccentrically-controlled tempos (4.0.1 for example), the goal of strengthening the supraspinatus takes precendence, with the lateral band raise providing an example below. Execution will take the arm angle to about 90°, which is within the active range of motion for the suprapinatus. On top of this, it would be recommended to address the external rotators - teres minor, infrapsinatus, and posterior deltoid - which would help create better balance with the overactive internal rotators listed above, the lower trapezius to aid in strengthening scapular depression, and the serratus anterior, to address scapular winging. Examples of activation exercises are provided below.
Supraspinatus - Lateral Raise with 4.0.1 Eccentrically-controlled tempo.
External Rotators - External Rotation - 4.0.1. Eccentrically-controlled tempo
Lower Trap - Trap 3 Raise - 4.0.1. Eccentrically-controlled tempo
Serratus Anterior - KB Protraction - Controlled
Proper Video Analysis of Overhead Press Movement, Related Biomechanics, and Potential Movement Deficiencies
Bass, E. (2012). Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. Retrieved June 25, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312643/
Brookbush, B. (2017, January 06). Introduction to Activation Exercise. Retrieved June 25, 2017, from https://brentbrookbush.com/articles/corrective-exercise-articles/activation/introduction-to-activation-exercise/
Brookbush, B. (2017, April 08). Upper Body Dysfunction (UBD). Retrieved June 25, 2017, from https://brentbrookbush.com/articles/postural-dysfunction-movement-impairment/upper-body-dysfunction-ubd/
Brookbush, B. (2017, June 21). Shoulder (Glenohumeral) Joint. Retrieved June 25, 2017, from https://brentbrookbush.com/articles/anatomy-articles/joint-anatomy/shoulder-glenohumeral-joint/
Cools, A. M., Johansson, F. R., Borms, D., & Maenhout, A. (2015). Prevention of shoulder injuries in overhead athletes: a science-based approach. Brazilian Journal Of Physical Therapy / Revista Brasileira De Fisioterapia, 19(5), 331-339.
Heber, D. (n.d.). Tendinosis vs. Tendonitis. Retrieved June 25, 2017, from http://elitesportstherapy.com/tendinosis-vs--tendonitis/
Khan, KM., Cook, JK. Overuse Tendon Injuries: Where does the pain come from? Clinical Sports Medicine
Kim, S. Y., Ko, J. B., Farthing, J. P., & Butcher, S. J. (2015). Investigation of supraspinatus muscle architecture following concentric and eccentric training. Journal Of Science & Medicine In Sport, 18(4), 378-382.