Suprascapular Neuropathy Clinical Presentation

Updated: Oct 11, 2018
  • Author: Thomas H Trojian, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Presentation

History

Although knowledge of the clinical symptom complex has improved since Kopell and Thompson first reported shoulder pain as the result of suprascapular nerve injury in 1959, from a practical standpoint, the diagnosis of suprascapular neuropathy 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, the athlete can have painless atropy presenting as supraspinatus and/or infraspinatus weakness, depending on the location of the suprascapular nerve.

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 on anatomic considerations, athletes with more proximal lesions of the suprascapular nerve 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.

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; however, Ferretti et al reported one series of 38 athletes in which the incidence was approximately equal among males and females. [12]

More often than 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.

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 suprascapular n Clinically relevant anatomy of the suprascapular 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 or internal rotation [28] of the ipsilateral upper limb.

Pressure applied over the suprascapular or spinoglenoid notches may elicit pain. Tenderness may between the clavicle and the spine of the scapula or deep and posterior to the acromioclavicular joint. [27]

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. 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 suprascapular nerve 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, suprascapular 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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