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Suprascapular Neuropathy

Suprascapular Neuropathy

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Published by borninbrooklyn
Suprascapular neuropathy as an etiology of shoulder pain in the athlete
Suprascapular neuropathy as an etiology of shoulder pain in the athlete

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Published by: borninbrooklyn on Jun 30, 2011
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12/22/2012

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ORIGINAL STUDY 
 Acta Orthop. Belg.
,2005,
71
,269-272
Entrapment neuropathy of the suprascapular nerve(SNE),although a recognised clinical entity,is a rela-tively rare cause of shoulder pain and subjectiveweakness in the athlete involved in overhead sportslike volleyball and badminton.This study deals with the presentation and manage-ment of four unusual cases of suprascapular nerveentrapment in volleyball players. Four male volley-ball players presented to our department withintractable shoulder pain and subjective sensation of shoulder weakness. They all had visible wasting of both supraspinatus and infraspinatus muscles,together with weakness of abduction and externalrotation of the arm. They all responded temporarilyto a diagnostic injection of local anaesthetic. MRimaging was useful in diagnosing space occupyinglesions in three cases and the presence of a hyper-trophic suprascapular ligament in one case.Due to failure of non- operative treatment,whichincluded activity modification,rest,analgesics andrehabilitation programme over 6 months,surgerywas then required to decompress the suprascapularnerve.All patients were symptom free at 6 months postop-eratively and after an intensive rehabilitation pro-gramme,they were able to return to their normallevel of activity including sport.
INTRODUCTION
The suprascapular nerve is a mixed peripheralnerve arising from the upper trunk of the brachialplexus,which is formed by the roots of C
5
and C
6
nerves. It passes laterally deep to the trapezius andomohyoid muscles and then traverses the supras-capular notch,innervating the supraspinatus mus-cle and gives off variable articular and sensorybranches before passing around the lateral borderof the spine of the scapula through the spinoglenoidnotch to innervate the infraspinatus muscle.By far the most common cause of suprascapularneuropathy is trauma,with fractures of the scapulaand proximal humerus and shoulder dislocationaccounting for the majority of cases
(
3
)
.In addition,an overuse type mechanism of injury to the nerve atthe suprascapular or spinoglenoid notches has beenreported
(
4
)
. Space occupying lesions such astumours,ganglia and haematomas can cause nerveimpingement,though some cases of nerve dysfunc-tion remain idiopathic.
PATIENTS AND METHODS
Four patients between the ages of 22 to 28 presentedto our department with intractable shoulder pain and asubjective sensation of shoulder weakness. All weremale volleyball players.
Acta Orthopædica Belgica, Vol.71 - 3 - 2005
Suprascapular neuropathy in volleyball players
Asterios D
RAMIS
,Ashvin P
IMPALNERKAR
From the Royal Centre for Defence Medicine,Birmingham,UK &Good Hope Hospitals NHS Trust,Birmingham,UK 
Asterios Dramis MRCS,Senior House Officer.
Surg Cdr Ashvin Pimpalnerkar,RN,MCh Orth,FRCSOrth,Consultant Orthopaedic & Sports Surgeon.Correspondence:Asterios Dramis,38 Pakenham Road,Edgbaston,Birmingham,B15 2NE,United Kingdom.E-mail :ad199@doctors.org.uk.©2005,Acta Orthopædica Belgica.
 
270
A
.
DRAMIS
,
A
.
PIMPALNERKAR
They presented with typical deep-seated long-standing
shoulder pain localised over the scapula. On examina-tion the patients had deep-seated tenderness over thesupraspinatus fossa and visible wasting of the supra-spinatus and infraspinatus muscle was noted (fig1).They all had weakness of abduction and external rota-tion of the arm. Plain radiographs of neck and shoulderwere normal in all cases.The pain was reduced after a diagnostic injection of local anaesthetic. The site of injection was based onanatomical landmarks as well as by noting the point of maximum tenderness on pressure over the spine. A line(A) was drawn on the skin over the spine of the scapulaand another one (B) bisecting the inferior angle of thescapula (fig 2). The outer triangle formed by the twointersecting lines was bisected and a wheal was formedon this bisector about 1.5 cm from the angle. Throughthis wheal,a needle was introduced so that its shaftwas directed towards the supraspinatus fossa. Theneedle was then withdrawn and reintroduced until thetip entered the suprascapular notch. Five milliliters of 1% lignocaine and 5 ml of 0.5% bupivacaine solutionwas injected into this area,giving the patients temporarysymptomatic relief.Further investigations were done and included anMRI image and electromyography studies (EMG). TheMRI showed that three patients had space-occupyinglesions,two of them were ganglia and one lipoma(fig3). The EMG studies showed increased spontaneousactivity,fibrillations and positive sharp waves in bothsupraspinatus and infraspinatus muscles confirming thediagnosis of SNE syndrome.All four patients eventually underwent surgicaldecompression of the suprascapular nerve through thetraditional posterior approach. The patients were operat-ed on in a ‘beach chair’position. The skin incision wasmade parallel and slightly proximal to the spine of thescapula. The trapezius was split in the axis of its fibres.The suprascapular muscle was carefully retracted toexpose the spine of the scapula and the suprascapularnotch. In three patients the space occupying lesions wereidentified and excised together with the suprascapularligament,whereas in the fourth case simple excision of the hypertrophic suprascapular ligament was sufficient.The suprascapular nerve was identified,decompressedfocally and preserved throughout the whole procedure inall cases. A formal neurolysis was not performed in anyof the cases. The trapezius was repaired and the woundclosed.
RESULTS
Initial treatment included activity modification,rest,analgesics and a graduated rehabilitation pro-gram over 6 months. Due to persistent andintractable symptoms,all underwent surgicaldecompression of the suprascapular nerve throughthe traditional posterior approach as describedabove.
Acta Orthopædica Belgica, Vol.71 - 3 - 2005
 Fig. 1.
— A patient with wasting of the supraspinatus andinfraspinatus muscles.
 Fig. 2.
— Technique of suprascapular nerve block 
 
SUPRASCAPULARNEUROPATHYINVOLLEYBALLPLAYERS
271The patients were advised to take anti-inflam-matories for two weeks,followed by an earlyrehabilitation programme starting 24 hours post-operatively. At a follow up of six months allwere pain free,the scapular muscle contour hadimproved and shoulder abduction and externalrotation strength returned to normal. All were ableto return to the same level of sport as compared tothe pre-injury level.
DISCUSSION
Suprascapular nerve entrapment is becomingmore commonly recognised as a cause of thepainful shoulder especially in the overhead athletessuch as volley-players due to the repetitive ‘spik-ing’manoeuvre. Since Kopell and Thomson firstdescribed this injury in 1959,more than 100 arti-cles addressing this topic have been written,most-ly in the last decade
(
2
)
.The cardinal symptom of SNE syndrome isshoulder pain. Patients often suffer for months oryears before seeking medical attention. Weaknessof abduction and external rotation of the arm andatrophy of the supraspinatus and infraspinatus mus-cles are common secondary symptoms
(
1
)
.Plain radiography of the shoulder and cervicalspine should be performed to exclude the morecommon causes of true or referred shoulder pain.EMG studies are diagnostic of SNE syndrome.MRI can demonstrate the presence of a spaceoccupying lesion around the suprascapular nerve orexclude other coincidental shoulder lesions such asrotator cuff tears. Ganglia seem to be the mostcommon lesion causing suprascapular nerveentrapment
(
5
)
. Cummins
et al
(
2
)
identified twenty-one patients with suprascapular injury secondary toganglion cysts. Other space occupying lesions likelipomas are very rare
(
2
)
.Local anaesthetic and steroid injection into thesuprascapular or spinoglenoid notch has beenfound to be helpful in diagnosing SNE; the speci-ficity of this test is however unclear
(
2
)
.The mechanism by which injury occurs at thesuprascapular notch has been termed the slingeffect by Rengachary
et al
(
9
)
. They noted that thenerve was often apposed to the sharp inferior mar-gin of the superior transverse scapular ligament andthat the contact was accentuated with depressionand retraction,or hyperabduction of the shoulder.Kopell and Thompson
(
)
reported that shouldermovements that involve either abduction or cross-adduction exert a pull on the nerve and may causeits compression. Such movements are typical insports such as volleyball. It is interesting to notethat the cause of nerve entrapment in three of ourpatients was a space occupying lesion and not arepetitive overhead activity type mechanism.The exact cause of ganglion cysts has not yetbeen clearly defined. The proximity of many of these cysts to neighbouring joints has led someauthors to theorise that trauma to the capsular tis-sues about the joint may contribute to the formationof the ganglion cyst.Also in support of this theory are imaging andarthroscopic findings of posterior capsulo-labraltears adjacent to and communicating with ganglioncysts
(
2
)
.None of our patients with the ganglion cysts hada lesion of the adjacent glenoid labrum.Timing of surgery for SNE is still debatable.Conservative treatment including activity modifi-cation,physical therapy and use of anti-inflamma-tory agents for 3 to 6 months is often recommend-ed. Many authors have reported complete recovery
Acta Orthopædica Belgica, Vol.71 - 3 - 2005
 Fig. 3.
— An MRI of a shoulder showing a ganglion cystcompressing the suprascapular nerve.

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