Acute Phase
Rehabilitation Program
Physical Therapy
The treatment for suprascapular neuropathy 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 suprascapular neuropathy is recommended. The natural history of 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/mobilization 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. [49]
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. [50, 51] 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 suprascapular nerve blocks. [52, 53, 54] Because such blocks have been used to manage perioperative shoulder pain and adhesive capsulitis in addition to other painful shoulder conditions, the diagnostic use 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 mixture into the suprascapular notch may provide temporary benefit. Given the variability in sensitivity and specificity of electromyography and nerve conduction studies, [28] injections can be an important diagnostic tool to confirm that the pain is in fact from suprascapular neuropathy.
Several studies have reported good clinical results with ultrasound-guided paralabral cyst aspiration; thus, it can be considered as an alternative to operative management. [28, 42] However, cyst recurrence rate has been reported between 75-100%. [28]
In select cases, radiofrequency suprascapular neuropathy 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 do not alter or address the underlying mechanism of suprascapular neuropathy.
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] )
Return to Play
Most individuals with suprascapular neuropathy are asymptomatic and compete with little to no discernible performance deficit. This observation complicates the issue of how to handle the return-to-play decision in an athlete who is asymptomatic and whose physical examination incidentally reveals suprascapular neuropathy.
In practical terms, elite athletes (in whom the prevalence is highest) can probably continue to compete while they are concurrently participating in a rehabilitation program. However, to minimize the progression of the condition, the extent to which the athlete performs overhead skills during practice should be limited.
In symptomatic athletes, a more restrictive course seems reasonable. Once the athlete can perform sport-specific skills (eg, spiking and blocking in volleyball) in a pain-free manner, he or she can return to play. Athletes who undergo surgical decompression should participate in an appropriate postoperative rehabilitation program to restore their strength, flexibility, and endurance before returning to play.
In patients with dynamic primary compression, the overall outcomes of conservative management are good. Pain relief is achieved in more than 80% of patients, and nearly all can return to sport activities within 3 months. [32]
Prevention
Ferretti proposed that suprascapular neuropathy in volleyball players is related to performance of the floater serve. If so, the incidence of volleyball shoulder is expected to decrease because, with the advent of the jump serve or spike serve, the floater serve has become less popular.
To the author's knowledge, no definitive study findings implicate specific spiking styles in suprascapular neuropathy; thus, providing technical advice about biomechanics to volleyball athletes with suprascapular neuropathy is difficult. Additional considerations remain unanswered; for example, the duration and magnitude of the load that is sufficient to precipitate volleyball shoulder through chronic overuse is unknown. Furthermore, the extent to which a SICK scapula is associated with the incidence of suprascapular neuropathy deserves further investigation.
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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.
