eMedicine Specialties > Sports Medicine > Neurological
Suprascapular Neuropathy: Treatment & Medication
Updated: Apr 16, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
The treatment for infraspinatus syndrome depends on the cause, severity, and duration of the symptoms; degree of functional disability; and patient preference. In the absence of specific compressive lesions, conservative initial treatment for infraspinatus syndrome is recommended. The natural history of idiopathic suprascapular neuropathy is typically favorable, and most cases respond to conservative care within 6 months.
In athletes without pain or limitations in the performance of sport-specific skills, a simple program of exercises for scapular stabilization and rotator cuff strengthening is probably reasonable. Such a program should prevent not only progression of the condition, but also secondary impingement of the rotator cuff.
A similar program is recommended in symptomatic athletes; however, activity modification to limit symptoms during the acute phase is warranted. The athlete should then progress through a series of functionally oriented exercises designed to restore flexibility and proprioception, scapular control, and balanced rotator cuff strength and endurance. This program should culminate in the resumption of sport-specific skills.
The use of passive modalities (eg, superficial or deep heat application, iontophoresis) and/or injection procedures for pain relief (see Other Treatment) may help symptomatic athletes make the transition to such exercise programs.
Surgical Intervention
Should conservative care fail to resolve the symptoms and allow the athlete to return to the sport activity, surgical intervention may be therapeutic. A degree of controversy exists in the literature because some authors believe that early surgical intervention is the treatment of choice.
Described surgical treatment procedures for suprascapular neuropathy unrelated to a space-occupying lesion include simple widening of the spinoglenoid notch or suprascapular notch, depending on the site of nerve injury. In one retrospective review of 3 cases of idiopathic infraspinatus syndrome refractory to conservative care, subsequent surgery was beneficial in 2 cases.
Some authors argue that documented compressive lesions of the SSN (eg, ganglia) should be promptly resected because of the high failure rate of nonsurgical care in this situation. Any accompanying labral pathology can be simultaneously repaired, if indicated. Both open and arthroscopic procedures have been described.
In general, surgical outcomes reported in the literature are good. Patients in whom the condition is diagnosed promptly and treated with early surgical decompression seem to have a better likelihood of regaining full muscular strength and bulk. The patient should participate in a postoperative program of rehabilitation and/or functional restoration to ensure the return of balanced strength and flexibility.
Other Treatment
In addition to the approaches discussed above (see Physical therapy and Surgical intervention), other nonsurgical treatment options include SSN blocks.41,42,43 Because such blocks have been used to manage perioperative shoulder pain and adhesive capsulitis in addition to other painful shoulder conditions, the diagnostic utility and specificity of such blocks is debatable. Nevertheless, blocks may provide symptomatic relief, thereby permitting the patient to more fully participate in a rehabilitation program.
The injection of an anesthetic and/or corticosteroid admixture into the suprascapular notch may provide temporary benefit. In select cases, radiofrequency SSN ablative procedures may provide longer symptomatic relief. Several injection approaches to minimize the inherent risk of pneumothorax are described. However, such interventions are purely palliative, and they do not alter or address the underlying mechanism of suprascapular neuropathy.
Related eMedicine topics:Adhesive Capsulitis
Pneumothorax, Tension and Traumatic
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Recovery Phase
Rehabilitation Program
Physical Therapy
The goal of the recovery phase of a rehabilitation program is to maintain active range of motion in the shoulder girdle while helping the athlete progress through a strengthening program designed to improve scapular stabilization and strengthen the rotator cuff. Interventions include concentric and eccentric isotonic exercises that emphasize sport-specific movement patterns. Eventually, the patient can progress to upper limb plyometric exercises.
Maintenance Phase
Rehabilitation Program
Physical Therapy
On the basis of reports in the available literature, nonsurgical care should result in a satisfactory outcome in most idiopathic cases within 6-8 months. Most reports indicate that patients who are treated conservatively are generally able to resume their previous level of function, including high-level sports participation.
Longitudinal follow-up findings suggest that muscular atrophy is generally not reversible to a significant extent, although symptoms of pain may improve with time. The athlete may return to play when he or she is able to perform appropriate skills without provoking symptoms.
Ideally, the rehabilitation program should extend beyond the mere resolution of symptoms to address the other facets of Kibler's "vicious cycle." This program should include an analysis of the athlete's technique to determine if any flaws or compensatory biomechanical changes need to be corrected to minimize the risk of recurrent injury or overload of other soft tissues further down the kinetic chain. (A formal discussion of the vicious cycle is beyond the scope of this article. For further information, the reader is referred to Kibler WB, Herring SA, Press JM, Lee PA, eds. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, Md: Aspen Publishers; 1998.3 )
Medication
To the author's knowledge, enteral pharmaceutical intervention to relieve symptoms associated with infraspinatus syndrome has not been studied or reported in the literature. For individuals with pain, a trial of nonsteroidal anti-inflammatory drugs early in the course of treatment seems reasonable. Alternatively, a trial of the gamma aminobutyric acid (GABA) analogue gabapentin may provide some analgesia.
Antiepileptics
The use of certain antiepileptics (AEDs), such as the GABA analogue Neurontin (gabapentin), is helpful in some cases of neuropathic pain. Although unstudied, a trial of an AED agent might provide some analgesia in symptomatic athletes with suprascapular neuropathy.
Gabapentin (Neurontin)
Has anticonvulsant properties and antineuralgic effects; however, the exact mechanism of action is unknown.
Structurally related to GABA but does not interact with GABA receptors.
Titration to effect can take place over several days (eg, 300 mg on day 1, 300 mg bid on day 2, 300 mg tid on day 3).
Adult
300 mg PO tid
Pediatric
Not established
Antacids may significantly reduce bioavailability (administer at least 2 h after antacids); may significantly increase norethindrone levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in the presence of severe renal disease
Analgesic, Cox-2 Inhibitor
Cyclooxygenase (COX)-2 inhibitors have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action may be inhibition of COX activity and prostaglandin synthesis. Others may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, the COX-1 isoenzyme is not inhibited; thus, the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs. Seek the lowest dose for each patient.
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; downregulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; and may increase CSF IgG (10%).
Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.
Adult
100 mg PO bid or 200 mg PO qd
Pediatric
Not recommended
Coadministration with fluconazole may cause an increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in patients with compromised cardiac function, hypertension, conditions predisposing to fluid retention; caution in the presence of severe heart failure and hyponatremia because circulatory hemodynamics may deteriorate; NSAIDs may mask the usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
More on Suprascapular Neuropathy |
| Overview: Suprascapular Neuropathy |
| Differential Diagnoses & Workup: Suprascapular Neuropathy |
 Treatment & Medication: Suprascapular Neuropathy |
| Follow-up: Suprascapular Neuropathy |
| Multimedia: Suprascapular Neuropathy |
| References |
| « Previous Page | Next Page » |
References
Cummins CA, Schneider DS. Peripheral nerve injuries in baseball players. Neurol Clin. Feb 2008;26(1):195-215; x. [Medline].
Gosk J, Urban M, Rutowski R. Entrapment of the suprascapular nerve: anatomy, etiology, diagnosis, treatment [Polish, English]. Ortop Traumatol Rehabil. Jan-Feb 2007;9(1):68-74. [Medline]. [Full Text].
Kibler WB, Herring SA, Press JM, Lee PA, eds. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, Md: Aspen Publishers; 1998.
Cummins CA, Messer TM, Schafer MF. Infraspinatus muscle atrophy in professional baseball players. Am J Sports Med. Jan-Feb 2004;32(1):116-20. [Medline].
Ravindran M. Two cases of suprascapular neuropathy in a family. Br J Sports Med. Dec 2003;37(6):539-41. [Medline].
Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. Jul-Aug 2003;19(6):641-61. [Medline].
Witvrouw E, Cools A, Lysens R, et al. Suprascapular neuropathy in volleyball players. Br J Sports Med. Jun 2000;34(3):174-80. [Medline].
Meister K. Injuries to the shoulder in the throwing athlete. Part two: evaluation/treatment. Am J Sports Med. Jul-Aug 2000;28(4):587-601. [Medline].
Kugler A, Krüger-Franke M, Reininger S, Trouillier HH, Rosemeyer B. Muscular imbalance and shoulder pain in volleyball attackers. Br J Sports Med. Sep 1996;30(3):256-9. [Medline].
Jackson DL, Farrage J, Hynninen BC, Caborn DN. Suprascapular neuropathy in athletes: case reports. Clin J Sport Med. 1995;5(2):134-6; discussion 136-7. [Medline].
Côelho TD. Isolated and painless (?) atrophy of the infraspinatus muscle. Left handed versus right handed volleyball players. Arq Neuropsiquiatr. Dec 1994;52(4):539-44. [Medline].
Ferretti A, De Carli A, Fontana M. Injury of the suprascapular nerve at the spinoglenoid notch. The natural history of infraspinatus atrophy in volleyball players. Am J Sports Med. Nov-Dec 1998;26(6):759-63. [Medline].
Holzgraefe M, Kukowski B, Eggert S. Prevalence of latent and manifest suprascapular neuropathy in high-performance volleyball players. Br J Sports Med. Sep 1994;28(3):177-9. [Medline].
Black KP, Lombardo JA. Suprascapular nerve injuries with isolated paralysis of the infraspinatus. Am J Sports Med. May-Jun 1990;18(3):225-8. [Medline].
Ferretti A. Volleyball injuries. Federation Internationale de Volleyball, Lausanne, Switzerland. International Olympic Committee Medical Commission. 1994.
Ringel SP, Treihaft M, Carry M, Fisher R, Jacobs P. Suprascapular neuropathy in pitchers. Am J Sports Med. Jan-Feb 1990;18(1):80-6. [Medline].
Safran MR. Nerve injury about the shoulder in athletes, part 1: suprascapular nerve and axillary nerve. Am J Sports Med. Apr-May 2004;32(3):803-19. [Medline].
Sandow MJ, Ilic J. Suprascapular nerve rotator cuff compression syndrome in volleyball players. J Shoulder Elbow Surg. Sep-Oct 1998;7(5):516-21. [Medline].
Tengan CH, Oliveira AS, Kiymoto BH, et al. Isolated and painless infraspinatus atrophy in top-level volleyball players. Report of two cases and review of the literature. Arq Neuropsiquiatr. Mar 1993;51(1):125-9. [Medline].
Agre JC, Ash N, Cameron MC, House J. Suprascapular neuropathy after intensive progressive resistive exercise: case report. Arch Phys Med Rehabil. Apr 1987;68(4):236-8. [Medline].
Ferretti A, Cerullo G, Russo G. Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am. Feb 1987;69(2):260-3. [Medline]. [Full Text].
Karatas GK, Gögüs F. Suprascapular nerve entrapment in newsreel cameramen. Am J Phys Med Rehabil. Mar 2003;82(3):192-6. [Medline].
Asami A, Sonohata M, Morisawa K. Bilateral suprascapular nerve entrapment syndrome associated with rotator cuff tear. J Shoulder Elbow Surg. Jan-Feb 2000;9(1):70-2. [Medline].
Rossi F. Shoulder impingement syndromes. Eur J Radiol. May 1998;27(suppl 1):S42-8. [Medline].
Chochole MH, Senker W, Meznik C, Breitenseher MJ. Glenoid-labral cyst entrapping the suprascapular nerve: dissolution after arthroscopic debridement of an extended SLAP lesion. Arthroscopy. Dec 1997;13(6):753-5. [Medline].
Berry H, Kong K, Hudson AR, Moulton RJ. Isolated suprascapular nerve palsy: a review of nine cases. Can J Neurol Sci. Nov 1995;22(4):301-4. [Medline].
Zeiss J, Woldenberg LS, Saddemi SR, Ebraheim NA. MRI of suprascapular neuropathy in a weight lifter. J Comput Assist Tomogr. Mar-Apr 1993;17(2):303-8. [Medline].
Cummins CA, Bowen M, Anderson K, Messer T. Suprascapular nerve entrapment at the spinoglenoid notch in a professional baseball pitcher. Am J Sports Med. Nov-Dec 1999;27(6):810-2. [Medline].
Montagna P, Colonna S. Suprascapular neuropathy restricted to the infraspinatus muscle in volleyball players. Acta Neurol Scand. Mar 1993;87(3):248-50. [Medline].
Ajmani ML. The cutaneous branch of the human suprascapular nerve. J Anat. Oct 1994;185 (pt 2):439-42. [Medline]. [Full Text].
Antoniadis G, Richter HP, Rath S, Braun V, Moese G. Suprascapular nerve entrapment: experience with 28 cases. J Neurosurg. Dec 1996;85(6):1020-5. [Medline].
Aszmann OC, Dellon AL, Birely BT, McFarland EG. Innervation of the human shoulder joint and its implications for surgery. Clin Orthop Relat Res. Sep 1996;330:202-7. [Medline].
Bigliani LU, Dalsey RM, McCann PD, April EW. An anatomical study of the suprascapular nerve. Arthroscopy. 1990;6(4):301-5. [Medline].
Lee BC, Yegappan M, Thiagarajan P. Suprascapular nerve neuropathy secondary to spinoglenoid notch ganglion cyst: case reports and review of literature. Ann Acad Med Singapore. Dec 2007;36(12):1032-5. [Medline]. [Full Text].
Demirhan M, Imhoff AB, Debski RE, et al. The spinoglenoid ligament and its relationship to the suprascapular nerve. J Shoulder Elbow Surg. May-Jun 1998;7(3):238-43. [Medline].
Ticker JB, Djurasovic M, Strauch RJ, et al. The incidence of ganglion cysts and other variations in anatomy along the course of the suprascapular nerve. J Shoulder Elbow Surg. Sep-Oct 1998;7(5):472-8. [Medline].
Moore TP, Fritts HM, Quick DC, Buss DD. Suprascapular nerve entrapment caused by supraglenoid cyst compression. J Shoulder Elbow Surg. Sep-Oct 1997;6(5):455-62. [Medline].
Hashimoto BE, Hayes AS, Ager JD. Sonographic diagnosis and treatment of ganglion cysts causing suprascapular nerve entrapment. J Ultrasound Med. Sep 1994;13(9):671-4. [Medline].
Inokuchi W, Ogawa K, Horiuchi Y. Magnetic resonance imaging of suprascapular nerve palsy. J Shoulder Elbow Surg. May-Jun 1998;7(3):223-7. [Medline].
Gerscovich EO, Greenspan A. Magnetic resonance imaging in the diagnosis of suprascapular nerve syndrome. Can Assoc Radiol J. Aug 1993;44(4):307-9. [Medline].
Ritchie ED, Tong D, Chung F, et al. Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?. Anesth Analg. Jun 1997;84(6):1306-12. [Medline]. [Full Text].
Jones DS, Chattopadhyay C. Suprascapular nerve block for the treatment of frozen shoulder in primary care: a randomized trial. Br J Gen Pract. Jan 1999;49(438):39-41. [Medline]. [Full Text].
Brown DE, James DC, Roy S. Pain relief by suprascapular nerve block in gleno-humeral arthritis. Scand J Rheumatol. 1988;17(5):411-5. [Medline].
Boardman ND 3rd, Cofield RH. Neurologic complications of shoulder surgery. Clin Orthop Relat Res. Nov 1999;368:44-53. [Medline].
Bredella MA, Tirman PF, Fritz RC, et al. Denervation syndromes of the shoulder girdle: MR imaging with electrophysiologic correlation. Skeletal Radiol. Oct 1999;28(10):567-72. [Medline].
Casazza BA, Young JL, Press JP, Heinemann AW. Suprascapular nerve conduction: a comparative analysis in normal subjects. Electromyogr Clin Neurophysiol. Apr-May 1998;38(3):153-60. [Medline].
Costouros JG, Porramatikul M, Lie DT, Warner JJ. Reversal of suprascapular neuropathy following arthroscopic repair of massive supraspinatus and infraspinatus rotator cuff tears. Arthroscopy. Nov 2007;23(11):1152-61. [Medline].
Cummins CA, Anderson K, Bowen M, Nuber G, Roth SI. Anatomy and histological characteristics of the spinoglenoid ligament. J Bone Joint Surg Am. Nov 1998;80(11):1622-5. [Medline].
Cummins CA, Messer TM, Nuber GW. Suprascapular nerve entrapment. J Bone Joint Surg Am. Mar 2000;82(3):415-24. [Medline]. [Full Text].
Ide J, Maeda S, Takagi K. Does the inferior transverse scapular ligament cause distal suprascapular nerve entrapment? An anatomic and morphologic study. J Shoulder Elbow Surg. May-Jun 2003;12(3):253-5. [Medline].
Kiss G, Kómár J. Suprascapular nerve compression at the spinoglenoid notch. Muscle Nerve. Jun 1990;13(6):556-7. [Medline].
Luo ZP, Hsu HC, An KN. An in vitro study of glenohumeral performance after suprascapular nerve entrapment. Med Sci Sports Exerc. Apr 2002;34(4):581-6. [Medline].
Martin SD, Warren RF, Martin TL, et al. Suprascapular neuropathy. Results of non-operative treatment. J Bone Joint Surg Am. Aug 1997;79(8):1159-65. [Medline].
Padua L, LoMonaco M, Padua R, et al. Suprascapular nerve entrapment. Neurophysiological localization in 6 cases. Acta Orthop Scand. Oct 1996;67(5):482-4. [Medline].
Post M. Diagnosis and treatment of suprascapular nerve entrapment. Clin Orthop Relat Res. Nov 1999;(368):92-100. [Medline].
Post M, Mayer J. Suprascapular nerve entrapment. Diagnosis and treatment. Clin Orthop Relat Res. Oct 1987;223:126-36. [Medline].
Raasch W, Zebrack J. Suprascapular nerve injuries. Curr Opin Orthoped. 2003;14:252-4.
Shaffer JW. Suprascapular nerve injury during spine surgery. A case report. Spine. Jan 1 1994;19(1):70-1. [Medline].
Further Reading
Keywords
volleyball shoulder, suprascapular neuropathy, shoulder pain, infraspinatus muscle, rotator cuff tendinopathy, suprascapular nerve, infraspinatus syndrome
