Updated: 7/6/2019

Suprascapular Neuropathy

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https://upload.orthobullets.com/topic/3063/images/suprascapular notch cyst.jpg
https://upload.orthobullets.com/topic/3063/images/anatomy.jpg
https://upload.orthobullets.com/topic/3063/images/clinical image, infraspinatus atrophy smaller.jpg
https://upload.orthobullets.com/topic/3063/images/spinoglenoid notch cystplain.jpg
Introduction
  • Can be caused by
    • suprascapular notch entrapment
      • weakness of both supraspinatus and infraspinatus 
    • spinoglenoid notch entrapment
      • weakness of infraspinatus only   
Anatomy
  • Suprascapular nerve (C5,C6) 
    • emerges off superior trunk (C5,C6) of brachial plexus  
    • travels across posterior triangle of neck to scapula
    • innervates 
      • supraspinatus 
      • infraspinatus 
  • Suprascapular ligament
    • arises from medial base of coracoid and overlies suprascapular notch
      • suprascapular artery runs above
      • suprascapular nerve runs below
  • Spinoglenoid ligament
    • arises near spinoglenoid notch
      • overlies distal suprascapular nerve 
Suprascapular notch entrapment
  • Introduction
    • proximal compression of suprascapular nerve in the suprascapular notch 
      • leads to weakness of both supraspinatus and infraspinatus
  • Pathoanatomy
    • compression can be from
      • ganglion cyst (often associated with labral tears)
      • transverse scapular ligament entrapment
      • fracture callus
  • Presentation
    • symptoms
      • deep, diffuse, posterolateral shoulder pain
    • physical exam
      • pain with palpation of suprascapular notch
      • weakness of supraspinatus
        • weakness seen with shoulder abduction to 90 degree, 30 degrees forward flexion, and with internal rotation (Jobe test positive) 
      • weakness of infraspinatus
        • weakness to external rotation with elbow at side
      • atrophy along the posterior scapula 
  • Evaluation
    • MRI
      • important to identify a compressive mass with associated cys
    • EMG/NCV
      • diagnostic
  • Treatment
    • nonoperative
      • activity modification and organized shoulder rehab program 
        • indications
          • no structural lesion seen on MRI
        • technique
          • rehab should be performed for a minimum of 6 months
    • operative
      • surgical nerve decompression at suprascapular notch 
        • indications
          • structural lesion seen on MRI (cyst)
          • failure of extended nonoperative management (~ 1 year)
Spinoglenoid notch entrapment
  • Introduction
    • distal compression of suprascapular nerve 
      • affects infraspinatus only     
    • Pathoanatomy
      • compression can be due to
        • posterior labral tears causing a cyst  
        • spinoglenoid ligament
        • spinoglenoid notch ganglion 
        • traction injury (seen in 45% of volley ball players) 
        • transglenoid fixation
          • lies 1.5cm medial to glenoid labrum
  • Presentation
    • symptoms
      • deep, diffuse, posterolateral shoulder pain
    • physical exam
      • infraspinatus weakness  
        • weakness to external rotation with elbow at side
      • infraspinatus atrophy along the posterior scapula 
      • supraspinatus strength is normal
  • Evaluation
    • MRI
      • important to identify posterior labral lesions with associated cys
    • EMG/NCV
      • diagnostic
  • Treatment
    • nonoperative
      • activity modification and organized shoulder rehab program 
        • indications
          • no structural lesion seen on MRI
        • technique
          • posterior shoulder capsule stretching
    • operative
      • arthroscopic cyst decompression and labral repair
        • indications
          • labral lesion with associated cyst seen on MRI
      • spinoglenoid ligament release with nerve decompression 
        • indications
          • no structural lesion seen on MRI and failure of extended nonoperative management (~ 1 year)
        • technique
          • posterior approach commonly utilized
          • decompress nerve in spinoglenoid notch
 

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Technique Guides (2)
Questions (18)
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(OBQ13.42) Figure A and B are MRI images of a 42-year-old male with symptoms of right shoulder neuropathy. If this patient has an abnormality detected on EMG and nerve conduction testing, which of the following nerves is most likely to be involved? Review Topic

QID: 4677
FIGURES:
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1

Subscapular nerve

6%

(249/4054)

2

Axillary nerve

3%

(135/4054)

3

Musculocutaneous nerve

2%

(61/4054)

4

Suprascapular nerve

88%

(3569/4054)

5

Long thoracic nerve

1%

(21/4054)

L 2

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(OBQ12.24) A 22-year-old right-handed semi-professional baseball player complains of right shoulder pain and progressive weakness. He denies any traumatic events. His exam is noted to have a normal "empty can" and "belly press" tests. Resisted external rotation with the arm at the side does exhibit weakness. His MRI images are shown in figure A and B. What is the most likely cause of his symptoms? Review Topic

QID: 4384
FIGURES:
Type in at least one full word to see suggestions list
1

Suprascapular nerve entrapment at the suprascapular notch

11%

(613/5354)

2

Suprascapular nerve entrapment at the spinoglenoid notch

83%

(4423/5354)

3

Axillary nerve entrapment in the posterior triangle

2%

(118/5354)

4

Axillary nerve entrapment in the axillary pouch

1%

(45/5354)

5

Axillary nerve entrapment at near inferior neck of glenoid

2%

(93/5354)

L 2

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(OBQ11.179) A 44-year-old male presents with a 2 month history of posterior shoulder pain. He is noted to have normal forward flexion and abduction strength and isolated weakness on shoulder external rotation. He has slight atrophy of his periscapular area. He has no numbness or paraesthesias. Which pathology would best explain his symptoms? Review Topic

QID: 3602
Type in at least one full word to see suggestions list
1

Cranial nerve XI palsy

1%

(26/3781)

2

Spinoglenoid notch cyst

78%

(2947/3781)

3

Axillary nerve palsy

1%

(50/3781)

4

Suprascapular notch cyst

19%

(703/3781)

5

Parsonage-Turner Syndrome

1%

(39/3781)

L 2

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(OBQ10.168) A 29-year-old male volleyball player presents with a one year history of right shoulder weakness and deep aching pain. He denies any history of trauma or prior shoulder problems. A clinical photograph and representative sagittal MRI image are shown in Figures A and B respectively. He is diagnosed with a ganglion cyst of the shoulder. Based on the images provided, where is the cyst located? Review Topic

QID: 3261
FIGURES:
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1

Suprascapular notch

6%

(127/2016)

2

Spinoglenoid notch

82%

(1662/2016)

3

Quadrangular space

5%

(93/2016)

4

Subscapular recess

5%

(105/2016)

5

Triangular interval

1%

(17/2016)

L 1

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(SAE07SM.89) A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding? Review Topic

QID: 8751
FIGURES:
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1

Positive impingement sign

9%

(15/169)

2

Positive apprehension

17%

(29/169)

3

Positive active compression

12%

(21/169)

4

Weakness of external rotation

52%

(88/169)

5

Weakness of abduction

9%

(16/169)

L 4

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(SAE07SM.51) A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of Review Topic

QID: 8713
FIGURES:
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1

aspiration and steroid injection.

12%

(7/58)

2

rest.

5%

(3/58)

3

acromioplasty.

2%

(1/58)

4

arthroscopic repair and decompression.

67%

(39/58)

5

rehabilitation.

12%

(7/58)

L 3

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(SBQ07SM.51) A 34-year-old competitive weightlifter presents with increasing pain during bench pressing. Despite modifications in his workout, he is unable to compete. His physical exam demonstrates weakness in external rotation. Radiographs are unremarkable. His MRI findings are seen in Figure A. Treatment should include which of the following? Review Topic

QID: 1436
FIGURES:
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1

Refrain from weightlifting for a minimum of 6 weeks

5%

(78/1584)

2

Physical therapy with rotator cuff strengthening

7%

(117/1584)

3

Suprascapular cyst decompression

6%

(91/1584)

4

Infraspinatus rotator cuff repair and acromioplasty

3%

(51/1584)

5

Spinoglenoid cyst decompression with posterior labral repair

78%

(1239/1584)

L 2

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(OBQ07.107) A patient with shoulder pain and weakness has an MRI showing a cyst in the suprascapular notch. Which of the following muscles is most likely to show weakness? Review Topic

QID: 768
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1

Deltoid

0%

(4/1894)

2

Supraspinatus

4%

(79/1894)

3

Supraspinatus and infraspinatus

86%

(1629/1894)

4

Infraspinatus

9%

(172/1894)

5

Teres minor

0%

(7/1894)

L 1

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(OBQ05.131) A 24-year-old avid volleyball player has noted gradual onset of shoulder fatigue and weakness limiting his game. Radiographs done by his primary care physician were normal and he has failed to improve with 6 weeks of physical therapy. Given the MRI image shown in Figure A, this patients physical exam may reveal weakness with which of the following actions? Review Topic

QID: 1017
FIGURES:
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1

Adduction

1%

(13/1906)

2

Internal rotation

1%

(27/1906)

3

Abduction and external rotation

54%

(1021/1906)

4

Abduction

11%

(212/1906)

5

External rotation

32%

(614/1906)

L 2

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(OBQ05.15) A 21-year-old collegiate volleyball player is noted to have weakness in external rotation and isolated atrophy of the infraspinatus on physical examination as seen in Figure A. An axial MRI image is shown in Figure B. This clinical condition is most likely caused by compression of the: Review Topic

QID: 52
FIGURES:
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1

Axillary nerve at the triangular space

0%

(1/494)

2

Suprascapular nerve in the suprascapular notch

9%

(44/494)

3

Axillary nerve in the quadrangular space

1%

(7/494)

4

Suprascapular nerve in the spinoglenoid notch

88%

(436/494)

5

Long thoracic nerve anterior to the scalenus and the first rib and posterior to the clavicle

1%

(4/494)

L 1

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(OBQ05.202) A patient is scheduled to undergo arthroscopy for a SLAP tear of his shoulder. Based on the sagittal images of the right shoulder MRI shown in Figure A, what additional physical exam finding is the patient likely to display? Review Topic

QID: 1088
FIGURES:
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1

Weakness in forward elevation

4%

(28/754)

2

Weakness in internal rotation

9%

(69/754)

3

Weakness in external rotation

82%

(622/754)

4

Positive impingement maneuver

3%

(20/754)

5

Scapular winging

1%

(11/754)

L 2

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(OBQ04.127) A 25-year-old volleyball player has recurrent right shoulder pain. On exam she has right shoulder weakness to external rotation with her arm at her side and atrophy below the scapular spine. There is no external rotation lag sign. Jobe drop arm and hornblower's tests are negative. The O'Brien's active compression test is positive. What will most likely be found on MRI of her shoulder? Review Topic

QID: 1232
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1

Partial articular sided tear of the infraspinatus

4%

(82/2090)

2

Partial articular sided tear of the supraspinatus

1%

(29/2090)

3

Full thickness tear of the infraspinatus

5%

(104/2090)

4

Inferior labral tear with quadrangular space cyst

2%

(49/2090)

5

SLAP tear and spinoglenoid notch cyst

87%

(1812/2090)

L 1

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