Success would be reliant on a selective sensory ablation. Kurt E, van Eijk T, Henssen D, Arnts I, Steegers M. Neuromodulation of the suprascapular nerve. J Shoulder Elbow Surg. Georgetown University School of Medicine, Washington DC, 2 7. National Library of Medicine Cross-body adduction and internal rotation may increase pain. Shoulder Arthroscopy Positioning: Lateral Decubitus Versus Beach Chair. If non-operative treatment fails to provide relief of suprascapular neuropathy, minimally invasive treatment options exist. 11. One physical exam maneuver to help diagnose SNES at the suprascapular notch is the suprascapular nerve stretch.6,12 This is performed by having the patient turn their head to face their unaffected shoulder, followed by gentle traction to the affected shoulder. Symptoms include pain and paresthesia in the ulnar nerve dermatome, especially in the fourth and fifth digits of the hand.17,18,35 This is exacerbated by repetitive elbow flexion, which compresses the area of the cubital tunnel. Other findings may include cramping, decreased grip strength, or paresthesia in the first three digits.22, Pronator and anterior interosseous nerve syndromes are the two most common compression neuropathies of the median nerve occurring around the elbow.22 Pronator syndrome occurs with compression of the median nerve between the two heads of the pronator teres (Figure 3)42 or under the proximal edge of the flexor digitorum superficialis (see a video about pronator syndrome). Thus, symptoms of poor external rotation of the shoulder may not be present. Once considered a diagnosis of exclusion, SNES can now be confirmed with a thorough history, advanced imaging, and nerve conduction tests.7,13 MRI is the most valuable imaging study as it allows direct visualization of both the SN and underlying pathologies such as rotator cuff tears and compressive masses.7,9 It also allows the physician to assess supraspinatus and infraspinatus muscle atrophy qualitatively.9 Despite the many advantages of MRI, the diagnostic gold standard for SNES remains electromyography (EMG) and nerve conduction velocity (NCV) studies, allowing for localization of the nerve lesion.1,10, Treatment of SNES varies depending on the location and etiology of entrapment. 30. 28. 29 Despite the . This is known as radial neuropathy, or sometimes Saturday night palsy.17 Compression also occurs at the axilla, as it passes through the triceps brachii lateral head.41 The nerve innervates the extensors of the wrist and fingers, causing wrist and finger drop. Suprascapular nerve block is indicated for relief of acute shoulder pain e.g., after shoulder surgery and is more effective when combined with blockade of the axillary nerve. Shupeck M, Onofrio BM. Treatment varies depending on the location and etiology of entrapment, which can be described as compressive or traction lesions. Ilfeld BM, Finneran JJ, Gabriel RA, et al. This is caused by compensatory actions of the extensor carpi radialis longus, which is not innervated by the posterior interosseous nerve.30 These findings are usually from compression by space-occupying lesions (most commonly lipoma) or synovitis of the elbow.30. Spinal Accessory Nerve. The stryker view is obtained by taking the image with the patients hand on their head with the X-ray beam angled 10 degrees caudally.9 This image helps assess bony abnormalities of the suprascapular notch.9 Assessing the anatomical type of the suprascapular notch is particularly important before surgery because the release of an entrapped nerve in a completely ossified (Type VI) suprascapular notch can vary of a fibro-osseous foramen. Rotator cuff injury can present similarly; therefore, magnetic resonance imaging, ultrasonography, or electrodiagnostic studies are usually appropriate to determine the specific etiology if initial radiography is inconclusive.18,33, Radial Nerve. Since this can now be done percutaneously, it allows for much broader use of this therapy, which was once only done with complete surgical exposure of the nerve.14 Until current advancements, cryotherapy was reserved for treating postoperative pain rather than as its treatment modality.15 Using cryotherapy on the SN is an area of focus currently. Kim SH, Kim SJ, Sung CH, Koh YG, Kim YC, Park YS. Local anesthetic injections have shown to be helpful in the diagnosis of SNES and can aid in localizing the point of entrapment.15 Although relief of SN pain post-injection can support the diagnosis of SNES at that site. Suprascapular nerve | Radiology Reference Article | Radiopaedia.org The axillary nerve is vulnerable as it passes around the humerus and through the quadrilateral space of the posterior shoulder. The suprascapular nerve is a mixed motor and sensory nerve arising from the upper trunk of the brachial plexus with contributions primarily from the anterior primary rami of the C5 and C6 nerve roots. The cross-arm adduction test causes tension on the suprascapular nerve and may be a provocative test in reproducing symptoms. rotator cuff tear, ganglion cyst, etc.) Multiple treatment modalities are often used synergistically due to these variations since only one therapeutic option does not seem successful for all cases. Peripheral Nerve Stimulation for Chronic Shoulder Pain Due to Rotator It receives nerve fibers that originate in the nerve roots C5 & C6 [ & sometimes C4]. official website and that any information you provide is encrypted Multiple treatment modalities are often used synergistically due to variations in shoulder anatomy, physiology, pain response, and pathology as a sole therapeutic option does not seem successful for all cases. It is accomplished by applying short high-voltage bursts of current then allowing heat diffusion with longer, silent phases.7 This ultimately leads to reversible cell damage, causing nerve fibers to ironically freeze.16 Unlike continuous radiofrequency, which causes extensive damage to neighboring structures, pulsed radiofrequency allows for a finer use with less destruction to the surrounding areas. 36. [28] and nerve conduction tests. The modern arthroscopic approach utilizes multiple portals a posterior portal, a lateral subacromial portal, an anterolateral portal, the Neviaser portal, and an SN portal.18 The posterior portal is used to achieve diagnostic arthroscopy and intraarticular inspection.29 This portal is placed 1cm medial and 2cm inferior to the posterolateral corner of the acromion.32 After initial arthroscopy is complete. Peripheral Nerve Entrapment and Injury in the Upper Extremity The clinical and electrophysiologic techniques of diagnosis can be easily learned. Sjdn GO, Movin T, Gntner P, Ingelman-Sundberg H. Spinoglenoid bone cyst causing suprascapular nerve compression. Iatrogenic injuries, especially after rotator cuff, clavicle, and posterior shoulder repair.5 After excluding more common causes of shoulder dysfunction, clinical findings, and magnetic resonance imaging may lead to suspicion of an SN injury.6, The SN contributes to 70% of the shoulder joints sensory innervation.7 Therefore, SN injury typically presents as weakness of abduction and external rotation of the shoulder and a diffusely dull ache of the posterior and lateral shoulder. Prolonged latency, decreased amplitude, fibrillation potentials, and positive sharp waves in the nerve conduction study are indicative of suprascapular nerve compression and denervation. Neurapraxia is injury that damages the myelin sheath but not the axon. Careers, Unable to load your collection due to an error. Iatrogenic nerve injuries in shoulder surgery. There are no protocols for physiotherapy management of suprascapular nerve palsy. Regardless of modality, the goal of the surgery is to remove any associated compressive lesions or areas. The suprascapular nerve is the only branch of the upper trunk (C5 and C6) of the brachial plexus, supplying the supraspinatus and infraspinatus muscles and sensation to the acromioclavicular and glenohumeral joints. Search dates: September/October 2019; February 26, 2020; May 2, 2020; August 2020; and January 2, 2021. The long thoracic nerve is vulnerable to traction injury at its nerve roots located at the middle scalene.20 Other mechanisms of injury include direct blows to the nerve as it exits the pectoralis muscle at the fourth or fifth rib, repetitive stretching (e.g., throwing a baseball, serving a volleyball), or iatrogenic damage (e.g., during a radical mastectomy).20,21 Injury to this nerve is the most common cause of scapular winging.20,21. Physical examination findings should be used in combination with electrodiagnostic studies to increase the accuracy of a carpal tunnel syndrome diagnosis before surgical intervention. Momaya AM, Kwapisz A, Choate WS, et al. The suprascapular nerve is a mixed nerve of the upper limb. The pronator syndrome test is performed by resisting the patient's pronation starting with the elbow in neutral and moving into extension (see a video demonstrating the pronator syndrome test). 2. Epidemiology data on entrapment neuropathies are sparse. SABRINA SILVER, DO, CHRISTOPHER C. LEDFORD, MD, KENDALL J. VOGEL, DO, AND JAMES J. ARNOLD, DO. When the SN is in the supraspinous fossa, inflamed tissue from the supraspinatus muscle through excessive use can also cause impingement. There are two approaches to the open decompression procedure, an anterior and a posterior approach.34 In general, as with the arthroscopic approaches, the open decompression procedures are well tolerated and have excellent results regarding patient recovery of strength and reduction in pain.3436, The posterior approach requires a prone or lateral decubitus position.36 An incision is made 2 cm superior to the spine of the scapula, and the trapezius fibers are split in a parallel fashion. 1979 Mar;19(3):203-6. Suprascapular neuropathy after distal clavicle excision. After identifying the base of the coracoid process, a blunt trocar is placed via the SSN portal, which is located between the spine of the scapula and the clavicle, about 7 cm medial to the most lateral border of the acromion.32,33 The blunt trocar is used to mobilize tissue to visualize the TSL better and ultimately help protect the SSN and suprascapular vessels (SSVs) when transecting the TSL. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559151/. It is seen in 80% of cases. Al-Redouan A, Holding K, Kachlik D. Suprascapular canal: Anatomical and topographical description and its clinical implication in entrapment syndrome. Anterior coracoscapular ligament and suprascapular nerve entrapment. When refering to evidence in academic writing, you should always try to reference the primary (original) source. 5. As a library, NLM provides access to scientific literature. Its nerve roots are C5 and C6. Shoulder arthroscopy: A modified approach. The .gov means its official. 7,9 It also allows the physician . [2-6] It is also performed as a diagnostic . Suprascapular neuropathy is compression of the suprascapular nerve that most commonly occurs at the suprascapular notch or spinoglenoid notch by a mass (i.e cyst). Although minimally invasive techniques are typically tried before operative treatments, some patients may ultimately need surgery to relieve their shoulder pain. This trauma can be a direct force or indirectly through damage to the vascular supply to the nerve. Effects of ultrasound-guided suprascapular nerve pulsed radiofrequency on chronic shoulder pain. Suprascapular nerve: Weakness in shoulder flexion, abduction, external rotation . [7], Non-steroidal anti-inflammatory drugs and anaesthetic injections (nerve block) are used to conservatively manage the pain. 25. Acta Orthop Scand. The suprascapular nerve stretch test (Fig. Gross anatomy Origin Federal government websites often end in .gov or .mil. The site is secure. Trial stimulation is done during surgery to ensure adequate attachment and correct placement. 2011 Mar;20(2 Suppl):S9-13. Using the supraspinatus muscle as a guide, the suprascapular foramen is located via palpation of the superior border of the scapula. YNR 7. pd. Various physical examination tests such as Apley Scratch test, Neer's test, and Hawkins test can evaluate the origin of the shoulder pain and differentiate rotator cuff injuries from other causes of shoulder pain. A Comparison of the Lateral Decubitus and Beach-chair Positions for Shoulder Surgery. Suprascapular Neuropathy - Shoulder & Elbow - Orthobullets Without clear evidence of a fracture, space-occupying lesion, or immediate need for surgery, non-operative treatment including a rehabilitation program, nonsteroidal anti-inflammatory drugs, and lifestyle modification is first-line therapy.9 Physical therapy is targeted at strengthening the rotator cuff muscles, trapezius, levator scapulae, rhomboids, serratus anterior, and deltoid muscle(s).8 Scapular movements, such as elevation, pronation, retraction, and depression, are also heavily assessed and fortified. Pain is exacerbated by extending the elbow, pronating the forearm, and flexing the wrist.30, Posterior interosseous nerve syndrome results in motor-only weakness. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Int Orthop. Treatment of a spinoglenoid cyst requires either decompression or repair of an associated labral lesion (if present). It then enters the supraspinous fossa, where it provides motor and sensory innervation to the supraspinatus. The suprascapular nerve can be identified under ultrasound, and can be used to screen for parascapular ganglia or masses. After identifying the SSN in the cervical triangle, it is dissected along its length to the TSL, at which point the SSVs are protected, and the TSL is transected.37. Ultrasound-Guided Peripheral Nerve Procedures. Clinical outcomes of suprascapular nerve decompression: a systematic review. Shoulder Arthroscopy in the Beach Chair Position. Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation. CT, MRI, and diagnostic ultrasound can help localize the site of injury. Clin Anat. is necessary to relieve pressure on the nerve.6,10 Injuries refractory to conservative treatment may require either arthroscopic or open surgery.7,11,13,14, The relationship between overhead activities and SNES has been well documented in the literature.13 Sports such as volleyball, tennis, and swimming increase the risk of dynamic entrapment caused by repetitive compression and subsequent swelling, fibrosis, and demyelination of the SN.13 The sling effect describes how certain maneuvers increase stress on the SN at the spinoglenoid ligament.13,14 Protraction and retraction of the scapula during the throwing motion puts significant pressure on the SN.1 Cadaveric studies have demonstrated that shoulder adduction and internal rotation increase tension at the inferior portion of the spinoglenoid ligament, directly superior to the SN.3,13 This motion, often seen in volleyball spikes and overhead serves, is thought to cause cumulative microtrauma and neuropathy of the SN.1,7,8,11,15 Around 33% of volleyball players suffer from SNES at some point in their careers.13 The greatest tension in the suprascapular ligament is seen during abduction and full rotation of the arm, which is a motion common to many overhead sports.7,12 Some researchers have also suggested that SNES can be caused by microemboli formation secondary to repeated compression trauma that damages the vasonervorum.4,13,16, Rotator cuff and labrum injuries are potential causes of SNES.1,7,13 Massive rotator cuff tears have been shown to increase tension on the SN at the suprascapular notch substantially and spinoglenoid notch as ruptured muscles retract medially.7 Paradoxically, some rare events of SNES have also been attributed to rotator cuff repair surgeries.6 Cadaveric studies have determined that significant (1-3cm) lateral translation of the rotator cuff during repair can increase tension on the SN.6,13,15, Following tears of the labrum, synovial fluid can leak into the surrounding tissue forming paralabral ganglion cysts.1,6 These cysts are formed by a one-way valve mechanism, which allows them to grow in size and compress nearby structures such as the SN.6 SNES from ganglion cysts most often occurs at the spinoglenoid notch; however, ganglion cysts can compress the SN at both the spinoglenoid notch or the suprascapular notch depending on the primary labral injury and size of the cyst.4,11, After branching from the superior trunk of the brachial plexus, the SN dives into the shoulder and passes through the suprascapular notch. The transducer should be placed parallel to the scapular spine above the suprascapular notch.12 This treatment approach can be beneficial in delaying surgery until necessary or appropriate, as well as simply providing short-term or immediate relief of shoulder pain. Most nerve injuries seen by family physicians will involve neurapraxia, resulting from entrapment along the anatomic course of the nerve. Regeneration of the nerve typically takes weeks to months, providing a significant amount of analgesia during this time. [2], Compression neuropathy resulting from nerve entrapment is the most common cause of suprascapular nerve palsy. It is also useful for the diagnosis and treatment of chronic shoulder pain secondary to bursitis, arthritis, degenerative joint and rotator cuff disease. The spinal accessory nerve is vulnerable to injury in the posterior triangle of the neck from direct trauma or iatrogenic damage. 26. Gabriel RA, Ilfeld BM. Suprascapular Nerve Neurodynamic Test - YouTube Physical exams should include an inspection of the shoulder. The opinions and assertions contained herein are the private views of the authors and are not to be construed as the official policy or position of the U.S. Air Force, the Department of Defense, or the U.S. government. Specialized probes are utilized so that no gas enters and remains in the patients body. Li X, Eichinger JK, Hartshorn T, Zhou H, Matzkin EG, Warner JP. Following a first episode, return to play is acceptable when there is complete resolution of symptoms and cervical spine injury has been excluded.32,39 Persistent or recurrent stingers prompt additional evaluation for cervical stenosis or other bony abnormalities.32. Are you sure you want to trigger topic in your Anconeus AI algorithm? found a significant proliferation of fatty atrophy in those suffering from SNES vs.control (p < 0.01). Suprascapular neuropathy is compression of the suprascapular nerve that most commonly occurs at the suprascapular notch or spinoglenoid notch by a mass (i.e cyst). When suspecting SNES, the strength of abduction and external rotation should be investigated closely.6 Due to the subjective nature of grading muscle weakness, using a handheld dynamometer to assess rotator cuff weakness objectively is prefered.6. Injecting a local anesthetic into the suprascapular notch can serve as a diagnostic and a therapeutic test to identify the cause of pain.8, Since many SN neuropathies result from excessive repetitive overhead arm movements, putting those activities to a halt is beneficial to rest the shoulder and nerve and prevent further injury. Axonotmesis extends damage to the axon but preserves the connective tissue framework. 5) has been described in order to reproduce the posterior shoulder pain associated with compression of the nerve at the suprascapular notch. Subsequently, the SSVs are identified and protected, and the TSL is transected, typically allowing the SSN to displace out of the suprascapular notch.36, If utilizing the anterior approach, the patient will be placed supine on the operating bed facing the contralateral side with the operative arm in slight abduction.35 The incision is started along with the sternocleidomastoid muscle, about 1/3 of the way up from its insertion, and it is continued inferiorly, parallel with the clavicle. [10], Nerve conduction studies and electromyography is considered to be the gold standard for the diagnosis of suprascapular nerve palsy. Lafosse L, Tomasi A, Corbett S, Baier G, Willems K, Gobezie R. Arthroscopic Release of Suprascapular Nerve Entrapment at the Suprascapular Notch: Technique and Preliminary Results. Diagnosing Suprascapular Neuropathy in Patients With Shoulder 34. 24. Romeo AA, Ghodadra NS, Salata MJ, Provencher MT. At the wrist, the superficial radial nerve is susceptible to injury by compression because it runs superficially to the flexor retinaculum. Patients may have point tenderness over the ulnar nerve and a positive Tinel sign.35 Late findings are motor weakness of finger and thumb abduction.35, Median Nerve. Bethesda, MD 20894, Web Policies Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Although historically considered a diagnosis of exclusion, suprascapular neuropathy may be more common than once believed, as more recent reports are describing the condition as a cause of substantial pain and weakness in patients with and without concomitant shoulder pathology. Corresponding Author Christopher Lee, MD St.Joseph Hospital & Medical Center Department of Internal Medicine 500 West Thomas Rd Phoenix, AZ 85013 Chrislee0621@gmail.com. Elzinga KE, Curran MWT, Morhart MJ, Chan KM, Olson JL. The primary clinical finding is pain in the proximal volar forearm. In the upper extremity, the brachial plexus branches into five peripheral nerves, three of which are commonly entrapped at the shoulder, elbow, and wrist. There is potential for this technique to provide non-opioid pain relief as a therapeutic option.13 The procedure is conducted with the patient lying prone and arms laid in whichever fashion the scapula exhibits a flat surface. Treatment of suprascapular nerve compression at the suprascapular notch requires decompression of a cyst when present. Injury to the suprascapular nerve associated with anterior dislocation of the shoulder: case report and review of the literature. The lateral trunk of the suprascapular nerve also could be ablated (which may spare supraspinatus function but compromise infraspinatus function) midway between the suprascapular notch and spinoglenoid notch in the supraspinous fossa. sharing sensitive information, make sure youre on a federal Suprascapular Nerve Palsy - Physiopedia Pain might radiate down the upper limb or to the neck. 9. Pain in the posterolateral shoulder is indicative of a positive test.21 The empty can test and infraspinatus test may also be positive, but non-specific tests represent many forms of supraspinatus injury.21, The physical exam maneuver used to assess spinoglenoid notch entrapment is the cross-arm adduction test.12 This test is performed by crossing the patients extended arm medially across the chest.22 A positive test will elicit shoulder pain.22 Of note, this test will also be positive in acromioclavicular joint arthritis.20, Ultrasound, X-ray, CT, and MRI have strengths and weaknesses in assessing scapular nerve entrapment. Suprascapular nerve palsy is a relatively uncommon cause of shoulder pain and dysfunction, but can lead to significant disability. Suprascapular nerve entrapment: Damage to the suprascapular nerve in your shoulder. At the wrist, the median nerve travels under the transverse carpal ligament (i.e., carpal tunnel syndrome), which has been reviewed previously in American Family Physician.1 Symptoms include pain in the wrist and hand, numbness and tingling in the first three digits, and weak grip strength. 27. Neurostimulation is a well-known treatment option for chronic pain from nerve damage in various parts of the body.13 Percutaneous neurostimulation is now being studied as a possible modality for treating shoulder pain, specifically since there is not much literature on the topic. Kostretzis L, Theodoroudis I, Boutsiadis A, Papadakis N, Papadopoulos P. Suprascapular Nerve Pathology: A Review of the Literature. Suprascapular Nerve Block - Physiopedia If an exam indicates a potential nerve problem, you may receive one or more of these diagnostic tests: Electromyography (EMG) and nerve conduction study to measure the transmission of nerve signals to muscles. 1978 Aug;49(4):338-40. In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and include patient education, physical therapy, and activity modification. Almost 40% of cases present with associated trauma to the shoulder. The indications include adhesive capsulitis, frozen shoulder, rotator cuff tear, and degenerative or inflammatory glenohumeral arthritis. government site. Sports-specific activity modification is advised for overhead athletes to prevent repetitive trauma. Full range of motion should be maintained at the shoulder to prevent adhesive capsulitis. It is susceptible to stretching injuries related to overhead activities at the suprascapular and spinoglenoid notches.33 It can also be entrapped by glenoid labral cysts that extend from the capsule with labral injury.33 Symptoms of suprascapular nerve entrapment include shoulder pain and shoulder abduction and forward flexion weakness. This procedure is typically done with the patient positioned either prone with the arm draped over the side of the table or upright with the ipsilateral hand on the contralateral shoulder. Due to its difficult course through bony and small landmarks, many points along its path can serve as sites of compression, especially the suprascapular notch and spinoglenoid notch. A Comparison of Risk Between the Lateral Decubitus and the Beach-Chair Position When Establishing an Anteroinferior Shoulder Portal: A Cadaveric Study. Examination findings include loss of finger extension (finger drop) but preserved wrist extension with radial deviation of the wrist. 10. In: StatPearls [Internet]. The https:// ensures that you are connecting to the Treatment of Labral Tears with Associated Spinoglenoid Cysts without Cyst Decompression. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. Introduction The suprascapular nerve is a mixed nerve of the upper limb. The test is usually easier in sitting or standing. indirect features of entrapment via features of muscle atrophy or acute denervation 3. supraspinatus and infraspinatus muscles: compression at the suprascapular notch. The extent of the injury can range from mild neurapraxia, in which the nerve experiences mild ischemia caused by compression, to severe neurotmesis, in which the nerve has full-thickness damage and full recovery may not occur. For a detailed description of nerve injury rehabilitation in general, visit this page on Physiopedia. It arises from the upper portion of the brachial plexus, which is a network of nerves that stretches across your check from your neck down to your armpit. Supraspinatus - Physiopedia Sporadically, it may have roots from C4 as well. Notably, the suprascapular notch and spinoglenoid notch plus their accompanying ligaments, the STSL and spinoglenoid ligament.6,10 A cohort of 60 patients with SNES was compared to 47 healthy patients using MRI and determined spinoglenoid notch distension was significantly enlarged in patients with SNES compared to the control group (p < 0.01). Suprascapular Nerve - Origin, Course, Function - Mobile Physio If the pain at the shoulder worsens with this manoeuvre, the test is positive. Gosk J, Urban M, Rutowski R. Entrapment of the suprascapular nerve: anatomy, etiology, diagnosis, treatment. Suprascapular nerve injury is experiencing an increase in clinical significance due to its role in shoulder pain and upper limb weakness. Here, the patient is asked to laterally rotate the head away from the affected shoulder and retract the neck. Author disclosure: No relevant financial affiliations.