Updated: 9/15/2021

Suprascapular Neuropathy

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https://upload.orthobullets.com/topic/3063/images/suprascapular notch cyst.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
https://upload.orthobullets.com/topic/3063/images/clinical image, infraspinatus atrophy.jpg
  • Summary
    • 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).
    • Diagnosis can be suspected clincally with weakness and atrophy of the infraspinatous or supraspinatous and confirmed with MRI studies showing cysts in the suprascapular notch or spinoglenoid notch.
    • Treatment of suprascapular nerve compression at the suprascapular notch requires decompression of a cyst when present. Treatment of a spinoglenoid cyst requires either decompression or repair of an associated labral lesion (if present).
  • Etology
    • Pathophysiology
      • suprascapular notch entrapment
        • weakness of both supraspinatus and infraspinatus
    • Associated conditions
      • SLAP tears
  • 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 cyst
      • 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
      • 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 cyst
      • 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
        • labral repair with or without arthroscopic cyst decompression
          • 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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Questions (23)
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(SBQ16SM.4) A 27-year-old volleyball player complains of worsening right posterolateral shoulder pain and weakness for the past 4 weeks. She denies any injury to the shoulder. Her examination reveals 5/5 muscle strength with shoulder elevation, abduction and internal rotation. She is found to have weakness in external rotation with the elbow at the side and gross inspection is remarkable for mild atrophy along the posterior scapula. She has an unremarkable lift-off test. Which nerve and corresponding site of compression is most likely responsible?

QID: 211150
1

Suprascapular nerve and Suprascapular notch

12%

(166/1419)

2

Axillary nerve and Quadrilateral space

4%

(59/1419)

3

Suprascapular nerve and Spinoglenoid notch

81%

(1150/1419)

4

Upper subscapular nerve and Spinoglenoid notch

2%

(35/1419)

5

Radial nerve and Triangular interval

0%

(1/1419)

L 2 A

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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?

QID: 4677
FIGURES:
1

Subscapular nerve

6%

(291/4861)

2

Axillary nerve

3%

(163/4861)

3

Musculocutaneous nerve

1%

(71/4861)

4

Suprascapular nerve

88%

(4289/4861)

5

Long thoracic nerve

0%

(24/4861)

L 2 B

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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?

QID: 4384
FIGURES:
1

Suprascapular nerve entrapment at the suprascapular notch

12%

(730/6329)

2

Suprascapular nerve entrapment at the spinoglenoid notch

83%

(5230/6329)

3

Axillary nerve entrapment in the posterior triangle

2%

(144/6329)

4

Axillary nerve entrapment in the axillary pouch

1%

(53/6329)

5

Axillary nerve entrapment at near inferior neck of glenoid

2%

(106/6329)

L 2 A

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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?

QID: 3602
1

Cranial nerve XI palsy

1%

(30/4384)

2

Spinoglenoid notch cyst

78%

(3398/4384)

3

Axillary nerve palsy

1%

(59/4384)

4

Suprascapular notch cyst

19%

(833/4384)

5

Parsonage-Turner Syndrome

1%

(47/4384)

L 2 B

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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?

QID: 3261
FIGURES:
1

Suprascapular notch

7%

(176/2492)

2

Spinoglenoid notch

80%

(1998/2492)

3

Quadrangular space

5%

(127/2492)

4

Subscapular recess

6%

(153/2492)

5

Triangular interval

1%

(26/2492)

L 1 B

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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?

QID: 8751
FIGURES:
1

Positive impingement sign

11%

(53/476)

2

Positive apprehension

14%

(68/476)

3

Positive active compression

12%

(56/476)

4

Weakness of external rotation

52%

(248/476)

5

Weakness of abduction

10%

(49/476)

L 4 D

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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

QID: 8713
FIGURES:
1

aspiration and steroid injection.

14%

(57/411)

2

rest.

4%

(16/411)

3

acromioplasty.

1%

(5/411)

4

arthroscopic repair and decompression.

73%

(298/411)

5

rehabilitation.

8%

(34/411)

L 3 E

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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?

QID: 1436
FIGURES:
1

Refrain from weightlifting for a minimum of 6 weeks

5%

(103/2223)

2

Physical therapy with rotator cuff strengthening

8%

(170/2223)

3

Suprascapular cyst decompression

6%

(143/2223)

4

Infraspinatus rotator cuff repair and acromioplasty

4%

(80/2223)

5

Spinoglenoid cyst decompression with posterior labral repair

77%

(1717/2223)

L 2 B

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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?

QID: 768
1

Deltoid

0%

(5/2168)

2

Supraspinatus

5%

(100/2168)

3

Supraspinatus and infraspinatus

85%

(1840/2168)

4

Infraspinatus

10%

(210/2168)

5

Teres minor

0%

(10/2168)

L 1 A

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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?

QID: 1017
FIGURES:
1

Adduction

1%

(19/2380)

2

Internal rotation

1%

(35/2380)

3

Abduction and external rotation

54%

(1281/2380)

4

Abduction

12%

(278/2380)

5

External rotation

31%

(744/2380)

L 2 D

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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:

QID: 52
FIGURES:
1

Axillary nerve at the triangular space

0%

(2/832)

2

Suprascapular nerve in the suprascapular notch

10%

(80/832)

3

Axillary nerve in the quadrangular space

2%

(14/832)

4

Suprascapular nerve in the spinoglenoid notch

88%

(728/832)

5

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

1%

(5/832)

L 1 A

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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?

QID: 1088
FIGURES:
1

Weakness in forward elevation

4%

(39/1019)

2

Weakness in internal rotation

11%

(108/1019)

3

Weakness in external rotation

80%

(819/1019)

4

Positive impingement maneuver

4%

(36/1019)

5

Scapular winging

1%

(11/1019)

L 2 A

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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?

QID: 1232
1

Partial articular sided tear of the infraspinatus

4%

(97/2445)

2

Partial articular sided tear of the supraspinatus

1%

(33/2445)

3

Full thickness tear of the infraspinatus

5%

(120/2445)

4

Inferior labral tear with quadrangular space cyst

3%

(63/2445)

5

SLAP tear and spinoglenoid notch cyst

87%

(2116/2445)

L 1 C

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