Brian Wolf, MD
Sports Medicine Conference
July 6, 2006
Case study
]
Hx: 19 yo RHD female competitive volleyball player with 3 week h/o
of right shoulder pain and weakness, night pain.
]
Pain worst with ABER position of shoulder
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Still able to play VB
]
Occasional painful popping in shoulder
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Denies numbness, tingling, other symptoms
Case study
]
PMH: otherwise healthy o/t bilat
PF pain
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PSH: bilat patellar surgeries in
past
]
PE: full ROM, 4/5 strength on
resisted ER, 5/5 FF in scap plane, mild tender deep posterior joint line, no
significant atrophy, Pain with O’Brien’s testing, +posterior labral click and
pain with translational testing, pain with appreh test
Case study
Suprascapular Nerve
Injury
Brian R. Wolf, MD
Univ. of Iowa Sports Medicine
Neuro and Vascular injuries
]
Often a diagnostic challenge
]
Uncommon
]
Neuropathies of shoulder make up 2% of all patients with pain &
weakness
]
Symptoms overlap with other disorders
]
Vague complaints and symptoms
Suprascapular Neuropathy
]
Anatomy:
]
C5 and C6 roots
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Suprascapular notch below
transverse lig
]
Anatomic variation and
calcification of ligament have been seen.
Suprascapular Neuropathy
]
Motor branches to supraspinatus
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Sensory br to GH jt and AC jt.
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Two branches to Infra-spinatus
after spinoglenoid notch
Suprascapular Neuropathy
]
Etiology:
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Repetitive motion
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Tumors
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Ganglion cysts
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Traction injury
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Direct trauma
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Injury at spinoglenoid notch
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Volleyball
players
]
Baseball players and other
overhead athletes
Suprascapular Neuropathy
]
Injury at the suprascapular notch
]
“sling effect” with hyperabduction
of shoulder
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↑ shoulder ROM correlated with
SScap n. entrapment in sx. Volleyball players
]
Eccentric Infraspin contraction
during spike in VB players
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Creates tension in n. as it passes
around spinoglenoid notch
]
↑ pressure on n. at confluence of
Infra and Supra at notch w/ ABER
Suprascapular Neuropathy
]
Ganglion Cyst
]
Spinoglenoid notch
]
Usually associated with labral
tear
]
Suprascap notch
Suprascapular Neuropathy
]
Presenting c/o
]
Deep dull posterior shoulder pain
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Exacerbated by overhead activities
]
Pain more likely with lesion at
sscap notch
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May present with painless weakness
]
+/- numbness postlat shoulder
]
+/- mechanical symptoms
Suprascapular Neuropathy
]
PE: rule out neck, brachial
plexopathy
]
Look for atrophy
]
↓ ER and abduction strength
]
Cross body adduction test (tension
sscap)
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Palpate sscap notch
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Diagnostic tests:
]
Plain films—stryker notch view can
see sscap notch
]
Electrodiagnostics can confirm
diagnosis
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NCV’s: ↑ motor latencies
]
EMG’s: fibrillations, sharp waves,
decreased amplitudes and polyphasics
Suprascapular Neuropathy
]
MRI:
]
Soft tissue anatomy
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Reliable way of space occupying
lesions
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Muscle changes with nerve damage
Suprascapular Neuropathy
]
Treatment:
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Non-operative: some authors
suggest minimum of 6 mos trial with PT, overhead sport limitation
]
Caveat: muscle atrophy and
weakness is often irreversible
]
Cuff, deltoid strength, scapular
retraction and posture
Suprascapular Neuropathy
]
Indications for surgery:
]
Most recommend + neurodiagnostic studies,
]
although signif % of those without still improve
]
Failure of non-op means
Suprascapular Neuropathy
]
Operative treatment
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Decompression of SScap notch
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Open posterior approach, reflect
trap, reflect sspin, release transverse ligament, remove space occ lesions if
present
]
Decompression of SG notch
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open posterior approach, split
deltoid, reflect infraspinatus off spine of scap, debride vascular fibrous
tissue in notch around nerve and remove space occ lesions if present.
Suprascapular Neuropathy
]
Cyst with labral tear
]
Decompress cyst arthroscopically
or open and then repair labrum
Suprascapular Neuropathy
]
Overall:
]
72% improved
]
Compressive lesions do much better
with surgery
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81% improved with surgery overall
Case Study
]
VB player treated with 1 month
rehab.
]
Pain improved somewhat
]
Still weak
]
Opted for operative intervention
Case study
Case study
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Currently six months post op and
rehabbing
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No complaints but not back to
volleyball activities yet
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Plan return to sport this fall as
tolerated if ready
Case 2
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45 yo male h/o 3 years “deep” shoulder pain
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Underwent “injection” a 2 years ago that made sx better for 6
months, but pain returned
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Occasional popping in shoulder
]
Works as farmer
Case 2
]
Full ROM
]
Mild infra atrophy and mild ER weakness
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++ O’Brien’s
]
+ Apprehensionà pain
MRI done outside
Case 2
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Diagnosed with SLAP tear and
paralabral cyst occupying spinoglenoid region
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Indicated for surgery
Case 2
Case 2
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Returned for 1 year f/u
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Now asx and without pain
]
Back to full activities
]
Still slight ER weakness
Thank you