Murrell Inflammation, degeneration, and partial-thickness tearing of the rotator cuff may occur in isolation, but they are commonly associated with SAIS. , Ash N, Cameron MC, House J. Mondelli As stated, sporting activities like tennis which require frequent overhead positioning of the arm may cause Suprascapular Neuropathy. This can occur due to winging of the scapula. JD . Mr Walsworth and Mr Mills provided concept/idea/project design, data collection, subjects, and facilities/equipment. We speculate that the poor outcome was due to severe nerve entrapment for a prolonged period. RA There are several potential causes of nerve entrapment along this path, particularly at the vulnerable suprascapular and spinoglenoid notches, where . Etiologies for suprascapular neuropathy may include repetitive overhead activities, traction from a rotator cuff tear, and compression from a space-occupying lesion at the . Thus, false positive results are likely.37,57 The painful arc test, which has higher specificity, may be more useful in ruling in SAIS.37 Lateral rotation weakness and atrophy may be useful in differentiating SSN from SAIS because, in our experience, these symptoms are typically more severe in patients with SSN. The patient who was managed surgically had only minimal improvement in symptoms and function. The course of the nerve through narrow osseoligamentous structures renders it susceptible to compressional and traction injuries at the suprascapular and spinoglenoid notches. [1][2][3][4] The latter are often readily grouped together with other clinical manifestations of SSN . We have found very reliable outcome in our patients with arthroscopic release of the nerve giving profound pain relief in 71% within 9 weeks of surgery. The reliability or diagnostic accuracy of observations of atrophy in these muscles has not been investigated. Nerve conduction studies (NCS) were performed with electrical stimulation at the supraclavicular fossa while using needle recording electrodes in the supraspinatus or infraspinatus muscle. MA M T The interventions and outcomes are summarized in Table 4. The condition may be more common than once thought as it is being diagnosed more frequently. SR Horiguchi Compression or traction of the suprascapular nerve in these regions can result from space-occupying lesions, traumatic injury, viral syndrome, repetitive use, or perioperative injury, or it can occur idiopathically.8,1320 Repetitive scapular movements may cause traction or tethering of the nerve, because the suprascapular nerve is fixed proximally at the cervical spine and distally at the scapula as it passes through the suprascapular notch and around the spinoglenoid notch. The upper,right image (courtesy of L. Lafosse) shows the nerve (yellow) and the suprascapular artery (red). Two patients were managed surgically for SAIS with acromioplasty, 1 patient was managed surgically with C45 diskectomy, 3 patients were managed with cervical traction, 1 patient was managed with a cervical soft collar, and 1 patient was managed for acromioclavicular joint sprain. A fluoroscopic (x-ray)-guided or ultrasound-guided injection into the area of the nerve at the suprascapular notch may confirm irritation of the nerve if it significantly reduces pain, even temporarily. The suprascapular nerve is a mixed nerve of the upper limb. Although the size of the muscle may improve in some patients, the fatty infiltration of the muscle is not expected to change postoperatively. DJ This opening is normally wide, but it can be narrow or the ligament over the top of the notch can be solid bone. 2010 Oct 6;92(13):2348-64. Surgical Measures: In case if conservative treatments fail to relieve symptoms then the next route taken is a surgical approach to treat the condition, although there are contradictory theories in the literature in which some studies suggest that surgery should be the treatment of choice for Suprascapular Neuropathy. [1] Anatomy Suprascapular nerve and its muscular innervations The suprascapular nerve branches out from the upper trunk of the brachial plexus. The infraspinatus muscle was tested by having the patients apply a shoulder lateral (external) rotation force with the arm at the side and the shoulder in 45 degrees of medial (internal) rotation.31 The supraspinatus muscle was tested using the empty can technique, resisting shoulder elevation in the scapular plane.30,31 A kinesiologic electromyographic (EMG) study31 has demonstrated the construct validity of data obtained with these techniques. Suprascapular Neuropathy | Boston Shoulder Institute , Schaffler M, Gilbert S, van Holsbeeck M. Zehetgruber The muscles become weaker due to stretch or compression of the SSN which then does not conduct electrical impulses properly to make the muscle work. Suprascapular neuropathy and cervical radiculopathy are common imitators of cuff disease. The pain also radiates to the arms. P These findings were normal. How is it treated? CS Conservative Measures: In cases where Suprascapular Neuropathy does not cause any pain or limitation of activity then physical therapy exercises in the form of scapular stabilization and mobilization is enough for relieving symptoms if any and resolving the condition. In distal lesions of the suprascapular nerve in the spinoglenoid region, shoulder lateral rotation may be the only detectable weakness due to loss of infraspinatus muscle function. Nerve Blocks: Apart from conservative and surgical approaches, nerve blocks can also be used to treat Suprascapular Neuropathy. In some patients, the nerve may also be released at the base of the spine of the scapula as it runs down to the infraspinatus. Subacromial impingement syndrome and SSN may occur simultaneously in patients. In cases with weakness and without pain, as with a volleyball player who has a stretch injury from overhead sports motion, non-operative treatment is usually the treatment approach. Another important diagnostic tool is the 3T Magnetic Resonance Neurography in cases of Suprascapular Neuropathy, as it helps in identifying any nerve abnormalities or any denervation changes in the muscles. High clinical awareness, imaging studies and electrodiagnostic examination can give further information about the presence of suprascapular neuropathy. S 2. Decompression of the nerve may also be required when there is a cyst compressing it at this location (see image above) though repair of the labrum tearn which leads to the cyst may result in decompression of the cyst and relief of pressure on the nerve in over 80% of cases even without nerve decompression. Patient 1: (A) supraspinatus muscle atrophy, (B) infraspinatus muscle atrophy. , Messer TM, Nuber GW. Therefore, although positive findings are strongly suggestive of radiculopathy, negative tests do not rule out cervical radiculopathy with a high level of confidence.32. We also observed atrophy of the supraspinatus muscle or the infraspinatus muscle in 4 of the 5 patients during the initial evaluation. Due to the low sensitivity of muscle and reflex testing, electrophysiologic examination may be particularly useful in differentiating brachial plexopathies from SSN or cervical radiculopathy.43,51. Apart from x-rays, an MRI of the shoulder may also be done which may reveal muscle edema along with muscle atrophy. JC Differential diagnosis of SSN can be difficult due to overlap in the clinical presentation with other pathologies of the shoulder and cervical spine region. CA An extensive research was performed on PubMed and Clinical Key. 2012; 2012: 516985. doi: 10.1155/2012/516985. Comparison of Key Findings in Suprascapular Neuropathy (SSN) Compared With Subacromial Impingement Syndrome (SAIS), Rotator Cuff Pathology, Cervical Radiculopathy, and Upper Trunk Brachial Plexopathya. Dumitru Callahan Electrodiagnostic ndings aid in the initial diagnosis and may indicate the need for close clinical follow-up based on the severity of the axonal injury. Additional positive findings with 2 tests of provocation of symptoms with the Spurling test and limited cervical rotation increased the positive likelihood of cervical radiculopathy to 65%.32 When a third positive finding was added, relief of symptoms with cervical traction, the positive likelihood increased to 90%.32 Because this evidence was not published at the time we saw our patients, we did not use the ULTT. The suprascapular nerve's roots emerge from the fifth and sixth cervical vertebrae (C5 and C6) in your neck. (Tim Hartshorn, MD; David Privitera, MD; Paul Yannopoulos, BA; Jon JP Warner, MD) December 2012. Bigliani A commonly used approach is a vertical incision over the suprascapular notch. Suprascapular Neuropathy Differential Diagnoses - Medscape Harbaugh Nardin M Suprascapular neuropathy, resulting in shoulder pain and weakness, is frequently misdiagnosed. Retrospectively, we would have ordered MRI for the other 4 patients in an effort to rule out the presence of space-occupying lesions. The patient had full passive range of motion of the shoulder. An Electromyography/Nerve conduction study (EMG/NCV) may be helpful to determine the functioning of the nerve. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Neer In this coronal (side view) the supraspinatus is shown as lighter due to fatty change and the suprascapular nerve is underneath this muscle. The nerve can be clearly seen with the arthroscope (images below). The trapezius muscle attaches up in the cervical spine and can be uncomfortable for many days to weeks due to its retraction during surgery. BT It may also reveal presence of a ganglion cyst with resultant compression of the Suprascapular Nerve. Post As the tendon tears and pulls away from its normal attachment (retracts) the nerve, which is attached to the muscle, is pulled at an angle and may kink as it goes through the suprascapular notch or around the base of the scapular spine where it is in a fixed position. SSN is generally believed to be a rare condition; however, it is well known that anesthesizing (numbing) the SSN with an injection can relieve shoulder pain in many conditions. (See figures below). Peripheral Nerve Entrapment and Injury in the Upper Extremity In some of these patients, the tendon may not be reparable, but release of the nerve may give good relief of pain. Injury to the nerve at the suprascapular notch causes weakness of both the supraspinatus and infraspinatus muscles, whereas injury at the spinoglenoid region affects only the infraspinatus muscle. Patients with SAIS or another rotator cuff injury can have a history of repetitive overhead activities as well as distribution of pain and muscle weakness similar to patients with SSN.2628 Cervical radiculopathy and upper trunk brachial plexopathy also can cause signs and symptoms similar to those of SSN, with weakness of the C5 and C6 innervated muscles, including the infraspinatus and supraspinatus muscles, as well as a similar pain distribution in the shoulder region. Suprascapular Nerve Injury - StatPearls - NCBI Bookshelf Discussion. Treatment of suprascapular nerve entrapment syndrome - PMC This article does not provide medical advice. Imaging Studies. Significant Clinical Improvement Was Predicted in a Cohort of Patients with Low Back Pain Early in the Care Process, Building the Science of Physical Therapy: Conundrums and a Wicked Problem, First Provider Seen for an Acute Episode of Low Back Pain Influences Subsequent Health Care Utilization, Learning Health Systems Are Well Suited to Define and Deliver the Physical Therapy Value Proposition, News From the Foundation for Physical Therapy Research, June 2023, Receive exclusive offers and updates from Oxford Academic, injection (self-report 80% pain improvement), Abdominal surgery for diverticulosis 1 d prior to onset of symptoms, Postpartum 3 d prior to onset of symptoms, Marked supraspinatus and infraspinatus muscle atrophy, No atrophy initially (moderate atrophy of supraspinatus and infraspinatus muscles 2 wk later), Moderate infraspinatus muscle atrophy only, Painful arc (painful from 80-120 of abduction), MMT: supraspinatus muscle (empty-can technique), Hawkins and Kennedy test (impingement sign), Long tendon of biceps brachii muscle and greater tubercle, Compression by superior transverse scapular ligament (determined by surgical observation), No response: infraspinatus and supraspinatus muscles, EMG: supraspinous muscle [insertional activity), EMG: supraspinous muscle (interference pattern), EMG: infraspinatus muscle [insertional activity, EMG: infraspinatus muscle (interference pattern), Proximal to supraspinatus muscle: region of suprascapular notch, Distal to supraspinatus muscle, proximal to infraspinatus muscle: region of spinoglenoid notch, Preoperative and postoperative rotator cuff strengthening, Infraspinatus muscle weakness Possible supraspinatus muscle weakness, Diffuse shoulder pain Typically includes posterior shoulder1-7,41,47, Diffuse shoulder pain May include posterior shoulder, Diffuse neck, shoulder, and brachial pain, Infraspinatus and supraspinatus muscle atrophy possible, Myotomal pattern if present May include infraspinatus and supraspinatus muscle atrophy, Expect more extensive myotomal pattern with sparing of rhomboid, serratus anterior, and paraspinal muscles, Possible decreased biceps and brachioradialis muscles, Typically normal Rarely decreased at lateral shoulder, Likely decreased lateralshoulder, arm, and forearm, Athlete with possible repetitive overhead activity Possible trauma Often insidious, Possible compression or traction to brachial plexus, Abnormalities in C5-6 myotomal distribution, Possible glenoid cyst or other source of compression, Rotator cuff degeneration, partial or complete treating, Normal unless concomitant shoulder pathology, Possible source of brachial plexus compression, Copyright 2023 American Physical Therapy Association. What causes SSN Neuropathy? 2003;19:E15-21. This is a study done for other common nerve problems such as carpel tunnel syndrome. There may also be atrophy of the infraspinatus muscle in the back of the shoulder (see figure) and when this occurs it is usually associated with marked weakness in the setting of a chronic SSN dysfunction. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. bench press. Suprascapular Neuropathy : JBJS - LWW Ringel 2008;90:523-30. However, interrater reliability for grading weakness with MMT is not high.33 Posterior shoulder pain also may be a discriminator because patients with SAIS do not typically have pain in this region.26,27,56,57. Manage Settings AM The specificity for diagnosing cervical radiculopathy in the presence of 2 or 3 abnormalities with these tests ranges from 0.74 to 0.98.34. Three of the patients presented in this case report were managed nonsurgically and had complete or nearly complete return of strength and resolution of pain in the time that they were followed. Continue with Recommended Cookies. MacDonald Th treatment period may last for a month. Moreover, in some patients there may be evidence of atrophy of fatty change in the muscle as a consequence of long-standing nerve compression. Clinical Presentation Suprascapular neuropathy is typically unilateral and affects the dominant side more frequently. Thus the suprascapular nerve does control pain in the shoulder. Suprascapular neuropathy is rare; thus, a definitive diagnosis of SSN requires the exclusion of alternative diagnoses. The differential diagnosis of patients with suprascapular neuropathy is presented and illustrated using 5 patients with this condition. , Serra G, Traina GC, Tugnoli V. Cohen , Dines DM, Moorman CT. Mallon (10) Overhead motions may exacerbate symptoms. , Stiles RG, Fajman WA, et al. 2001;7 (6): 358-67. Hayes The suprascapular nerve is the only branch of the upper trunk (C5 and C6) of the brachial plexus, supplying the supraspinatus and infraspinatus muscles and sensation to the acromioclavicular and glenohumeral joints.. 2012 Feb;40(1):72-83. The diagnostic process and a table with key findings based on evidence and clinical experience is presented for differential diagnosis. The suprascapular nerve is a mixed nerve branched out from the c5 and c6 roots of the brachial plexus at Erb's point. Of 10 patients with SSN reported by Post and Mayer,6 8 patients were initially misdiagnosed, leading to inappropriate intervention. The suprascapular nerve gives motor branches to the supraspinatus distal to the suprascapular notch and proximal to the spinoglenoid notch. Leroux Subacromial impingement syndrome involves abnormal contact between the coracoacromial arch and subacromial soft tissues (rotator cuff tendons, long biceps tendon, and bursae). Boykin RE, Friedman DJ, Higgins LD, Warner JJ. Lichtenberg S, Magosch P, Habermeyer P. Compression of the suprascapular nerve by a ganglion cyst of the spinoglenoid notch: the arthroscopic solution. Many of the clinical examination techniques used to diagnosis SSN and many of those used to rule out alternative diagnoses have imperfect reproducibility and diagnostic accuracy. First, the nerve may be compressed by a local mass as it runs through the suprascapular notch and around the scapular spine. Gross anatomy Origin. , Walton JR, Szomor ZR, Murrell GA. Kendall K Both of these variations can predispose the nerve to irritation. Structure[ edit] Origin[ edit] Chen AL, Ong BC, Rose DJ. This usually is the result of a tear in the labrum which is the lining of the joint. Because the Neer and Hawkins tests have low specificity for the diagnosis of SAIS, but the painful arc test has high specificity, we thought the evidence for a diagnosis of SAIS was strong for patients 1 to 4 and was weaker for patient 5. M There can be many reasons for nerve entrapment, especially at the suprascapular and spinoglenoid notches where nerve deviation is limited by bony and ligamentous structures. Therefore, impingement at the suprascapular notch. , Ma DM. Evaluation and Management of Suprascapular Nerve Palsy Suprascapular Neuropathy | EquiMed - Horse Health Matters
