Suprascapular Neuropathy Clinical Presentation

  • Author: Jonathan C Reeser, MD, PhD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Nov 28, 2011
 

History

Although knowledge of the clinical symptom complex has improved since Kopell and Thompson first reported shoulder pain as the result of SSN injury in 1959, from a practical standpoint, the diagnosis of infraspinatus syndrome remains largely a diagnosis of exclusion unless the clinician remains alert to the diagnostic possibility when the affected athlete initially presents for treatment.

The typical patient is a young overhead athlete who reports vague posterior shoulder pain.

Although case reports of bilateral involvement exist, symptoms are typically unilateral and involve the dominant side.

Male athletes account for most of the cases reported in the literature, but Ferretti et al reported one series of 38 athletes in which the incidence was approximately equal among males and females.[12]

More often that not, the pain (when present) is described as a deep, dull, aching discomfort.

Activities that involve overhead motions or sport-specific skills may exacerbate symptoms. Diagnostic signs may include weakness and compromised endurance in performing overhead, sport-specific skills.

Because of the anatomy (see Functional Anatomy), more distal nerve injuries are often relatively painless. In particular, nerve injuries at the spinoglenoid notch that result in selective denervation of the infraspinatus muscle may be insidious in their onset due to the relative lack of pain. In Ferretti et al's series, elite volleyball players with isolated atrophy of the infraspinatus generally did not report any pain or sports-related functional disability.[12]

Based upon anatomic considerations, it is reasonable to predict that athletes with more proximal lesions of the SSN that affect both the supraspinatus and infraspinatus muscles are more likely to have pain and symptom-limited function than are individuals with distal nerve lesions that affect only the infraspinatus.

Genetic factors undoubtedly play a role in the predisposition and susceptibility of individual athletes to suprascapular neuropathy, but the specific factors that are involved have yet to be elucidated.

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Physical

Atrophy of the supraspinatus and/or infraspinatus muscles may be present on the physical examination, depending on the site of the nerve entrapment (see below).

Clinically relevant anatomy of the subscapular nerClinically relevant anatomy of the subscapular nerve (SSN) and the structures it innervates. The SSN is vulnerable to entrapment at the superior scapular notch and the spinoglenoid notch, beneath the inferior transverse scapular ligament. The inset depicts the clinical appearance in an individual with predominantly right-sided atrophy of the infraspinatus muscle due to suprascapular neuropathy.

Note that supraspinatus involvement may be frequently overlooked because of the bulk of the overlying trapezius.

Manual muscle testing may reveal relative weakness of ipsilateral shoulder abduction (a function of the supraspinatus muscle in addition to the deltoid muscle) and/or weakness of external rotation (a function of the infraspinatus muscle in addition to the teres minor muscle).

The athlete may report worsening pain with cross-body adduction of the ipsilateral upper limb.

Pressure applied over the suprascapular or spinoglenoid notches may elicit pain.

Muscle stretch reflexes are unaffected by this condition.

Rarely, cutaneous appreciation of sensory modalities may be affected in an approximate axillary nerve distribution.

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Causes

Sports that place a substantial load on the athlete’s shoulder when the upper limb is in an overhead or abducted and externally rotated position may precipitate this condition.

  • Suprascapular neuropathy causes infraspinatus syndrome.
  • The site of suprascapular neural entrapment determines whether the infraspinatus muscle alone or both the supraspinatus and infraspinatus muscles are affected.

Although sports-related overuse mechanisms of SSN injury are the most common causes, the SSN can also be damaged as a result of direct trauma as well as iatrogenic factors.

The relationship of the nerve to the clavicle makes it vulnerable to injury after a clavicular fracture occurs.

Surgical procedures involving the shoulder (eg, Bankhart repair) can place the nerve at risk for either direct injury or indirect injury. Interestingly, SSN neuropathy has also been reported to occur after positioning patients for spinal surgery.

Other diagnoses should be considered. Most commonly, the clinician diagnoses rotator cuff tendinopathy and prescribes a conservative treatment program. Because the rehabilitation programs for rotator cuff tendinopathy and infraspinatus syndrome are similar, in many (perhaps most) instances, the patient's condition improves, and the correct diagnosis goes unrecognized. Delayed-onset muscular soreness may be present, but this soreness is not expected to progress over 3 weeks. Rather, symptoms of delayed-onset muscular soreness tend to spontaneously resolve over 7-10 days.

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Contributor Information and Disclosures
Author

Jonathan C Reeser, MD, PhD  Office of Research Integrity and Protections, Marshfield Clinic Research Foundation

Jonathan C Reeser, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Sports Medicine, American Medical Association, Association of Academic Physiatrists, Phi Beta Kappa, and State Medical Society of Wisconsin

Disclosure: Nothing to disclose.

Specialty Editor Board

Leslie Milne, MD  Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine

Leslie Milne, MD is a member of the following medical societies: American College of Sports Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

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Clinically relevant anatomy of the subscapular nerve (SSN) and the structures it innervates. The SSN is vulnerable to entrapment at the superior scapular notch and the spinoglenoid notch, beneath the inferior transverse scapular ligament. The inset depicts the clinical appearance in an individual with predominantly right-sided atrophy of the infraspinatus muscle due to suprascapular neuropathy.
 
 
 
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