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Suprascapular neuropathy in collegiate baseball player.

BACKGROUND

Treatment, rehabilitation, and return to activity criteria for those with suprascapular neuropathy (SSN) are variable [1-18] creating elusive guidelines for achieving optimal outcomes (Table 1).

SSN has traditionally served as a diagnosis of exclusion [3,14], occurring when the suprascapular nerve is compressed at the suprascapular or spinoglenoid notch [19]. The prevalence of SSN is unknown and most estimates are based on case study articles in elite athletes not a representation of the general population [1-18]. SSN occurs between 12% to 33% and 8% to 100% in the athletic population with massive rotator cuff tears [15]. Beyond the extreme rotator cuff pathologies, SSN has been associated with infraspinatus paralysis, which results in humeral head depression and altered mechanics. These concomitant may create diffuse symptoms thus complicating diagnosis [1-18].

To prevent chronic supraspinatus and infraspinatus atrophy, clinicians should make an accurate diagnosis of SSN [12]. SSN can be treated operatively or conservatively, yet the time to return varies significantly beyond the two approaches: operative--3 months [13] conservative--6 months [8]. Treatment and rehabilitation protocols are largely individualized and a standardized protocol has yet to be articulated in the literature. The purpose of this case study is to introduce a unique case involving a baseball pitcher with posterior shoulder pain who presented with uncharacteristic symptoms and underwent supra scapular nerve decompression with success.

CASE PRESENTATION

A right handed 20 year old male baseball pitcher sought evaluation for right posterior shoulder pain from the athletic training staff in Spring 2010, at the start of his second season of Division-I competitive baseball. At the time, the closing pitcher had completed 29 innings of play in the first three weeks of the competitive season. Upon initial evaluation, the patient primarily complained of sharp pain in his posterior right shoulder during throwing, particularly upon ball release. Pain symptoms generally persisted for several days, up to one week. He also described an inability to throw further than 20-30 feet and increased pain in the posterior shoulder after throwing. He reported rehabilitating intermittently for the past one and a half years for diffuse and intermittent right shoulder pain.

The athletic trainer (AT) assessed for labral pathology, joint instability, shoulder dyskinesis, swelling and deformity, of which all findings were negative (Table 2).

The evaluation revealed decreased right shoulder infraspinatus strength (MMT: 4/5) with bilateral comparison. After the initial evaluation, the AT withheld the patient from sport participation, required rest and managed discomfort with conservative treatment. The AT aimed to decrease pain, improve range of motion, increase strength, complete functional and sport-specific activities, and return to play. Treatments occurred for two weeks with no change, so the AT referred the patient to an orthopedic specialist.

The orthopedic physician's initial evaluation yielded negative results for right shoulder impingement, apprehension, instability, and labral pathology. The physician's exam again revealed infraspinatus weakness resulting in orders for magnetic resonance imaging (MRI) and electromyography (EMG) analyses to examine soft tissue and nerve involvement. The diagnostic imaging revealed nothing remarkable. One week after orthopedist evaluation (three weeks from initial evaluation) an MR arthrogram with intraarticular contrast of the patient's right shoulder identified only a minor lesion affecting the posterior labrum (Table 3).

After ruling out several pathologies with the physical exam and diagnostic imaging (after three weeks since initial evaluation), the physician ordered an electrodiagnostic study. The test indicated right suprascapular neuropathy at the suprascapular notch with supraspinatus and infraspinatus involvement, evidence of mild ongoing denervation and mild chronic neuropathic changes of the suprascapular nerve with absence of right cervical radiculopathy or brachial plexopathy. Approximately five weeks post initial evaluation, the patient underwent right suprascapular nerve release and extensive debridement of the glenoid labrum and bursa. The surgeon predicted a 3 to 5 month recovery.

Surgical intervention detected significant superficial fraying of the entire posterior labrum, which was debrided to create a smooth and stable surface (Table 4). Analysis of the subacromial bursa indicated significant fibrosis of the bursa thus a need for a partial bursectomy. The transverse scapular ligament was transected to release the suprascapular nerve in the suprascapular notch.

Post surgically, the physician referred the patient for physical rehabilitation to relieve pain, increase function, increase strength, and increase range of motion. Two weeks following surgery (seven weeks post initial evaluation with the AT), the patient demonstrated decreased shoulder range of motion and strength, with significant decreases in internal rotation and visible atrophy of the right infraspinatus as a consequence of immobilization. The patient underwent physical rehabilitation with ATs and PTs for 22 weeks (Table 5). Rehabilitation followed a standard progression from pain management and strengthening to sport specific exercises through therapeutic interventions, exercise and manual therapy.

The athlete returned to live throwing and simulated games without any complaints or deficits in performance. Time to return to sport without restrictions from date of surgery totaled approximately seven months. The patient has since returned to competitive collegiate baseball pitching without issues related to pain, fatigue, pitching velocity, or pitch control.

DISCUSSION

Neuropathies affecting the suprascapular nerve are typically the result of traction or compression from repetitive overhead activities, rotator cuff tears, displaced labral tears in conjunction with cysts, and space-occupying lesions at the suprascapular or spinoglenoid notch [4,6,7,12,14,15,20]. Uniquely, our patient demonstrated an absence of the concomitant pathologies usually associated with the neuropathy: he lacked a displaced labral tear, SLAP lesion, cystic changes around the labrum, or a retracted distal rotator cuff tendon. Individuals usually present with pain and weakness in the posterior, lateral, and superior aspect of the shoulder [14,15], atrophy and weakness of the infraspinatus and supraspinatus muscles [15]. Yet some individuals may be altogether asymptomatic [14]. Our patient, presented with some of the common pathogenesis, but specifically pain was narrowed, versus more global, in the posterior shoulder with infraspinatus weakness. Our athlete was unique, most significantly because of the lack of a debilitating labral tear. Although the patient's symptoms had a debilitating affect on performance, only superficial fraying was revealed during the surgical intervention.

The decision to conduct surgery on this athlete was based on neurological symptoms present in early stages, minor concurrent posterior labral pathology, and infraspinatus atrophy. Typically, a conservative non-operative approach focusing on infraspinatus strengthening and range of motion is implemented for six to nine months or until the patient is able to reach 80% shoulder strength upon bilateral comparison [7,12,15,21]. In this case, the patient underwent supervised (and consistent) conservative treatment for approximately one month prior to surgical intervention. Cases of SSN in and of themselves are not necessarily unique, and therefore different approaches to manage of SSN exist, yet they are not standardized in the literature (Table 1). Surgical management of SSN injury is generally indicated when conservative treatment has failed to resolve issues after six months, or obvious indications exist [7,12,15,21]. Our patient did not incur the typical 6 month conservative treatment and the decision to conduct surgery was based simply on infraspinatus atrophy, decreased ROM, and decreased nerve conduction velocity, which is unique to the literature.

Our patient underwent arthroscopic decompression, but not the more common open technique where the upper trapezius is dissected [6,12,14,15]. The open decompression technique is invasive and requires a long recovery time [6,12,14,15]. Arthroscopic management is less invasive, requires less recovery time and allows for repair of concurrent shoulder pathology (usually the rotator cuff tear or labral defect) [6,12,14,15], and was therefore the preferred choice for our patient. During surgical intervention, the suprascapular nerve is generally released in one of two places, the spinoglenoid notch or the suprascapular notch [6,14,15]. Release at the spinoglenoid notch is indicated when the patient presents with a SLAP lesion and cystic changes exist requiring aspiration to relieve the impingement of the suprascapular nerve [12,15,21]. Our patient received a suprascapular nerve release at the suprascapular notch because these associated conditions were not present. Release at the suprascapular notch is accomplished through an anterior portal hole, guiding the shaver past the coracoid process then superiorly to release the transverse suprascapular ligament as it spans the notch [6,7]. According to the surgical report, the posterior labrum was thoroughly debrided prior to the resection of the suprascapular ligament. Our athlete demonstrated characteristics of posterior impingement, which is atypical in other patients, but should be considered among overhead throwing athletes.

Post surgically the patient underwent supervised rehabilitation sessions for approximately five months prior to the initiation of a throwing progression and simulated game throwing (total time=7 months). A detailed time to return to full sport participation post surgically in baseball pitchers is variable in the literature (Table 1). Previous literature regarding conservative treatment in three different athletes indicated great variability in time to full recovery [9] Timelines varied from a few short weeks up to 30 months [9]. Case reports among general population patients have detailed full recovery from arthroscopic repair in three to six months [7,12,15]. Reports focused on elite volleyball players and other overhead athletes showed complete recovery in six to eight months [13,21,22]. The return to participation in this study was 7 months, which is consistent with previous cases.

CONCLUSION

In most cases of SSN, several months of conservative treatment precede any surgical intervention. Although our patient complained of generalized shoulder pain for up to one year prior to this debilitating injury, only a brief period (1 month) of conservative treatment preceded the surgical intervention. The physician pursued an aggressive diagnostic study, followed by an arthroscopic surgical intervention, which likely aided in the speedy recovery of our patient. The treatment plan our athlete followed is not consistent with the current literature [7,12,15,22], yet the election of surgical treatment in conjunction with thorough physical rehabilitation, returned the athlete to full sport participation by the subsequent baseball season. Current literature lacks a standardized method for surgical intervention and conservative treatment. The current case indicates that early surgical intervention may decrease recovery time and increase return to participation in an athletic population.

Conflict of interests: None

REFERENCES

[1] Alomar AZ, Powell T, Burman ML. Isolated supraspinatus muscle atrophy and fatty infiltration associated with recurrent anterior shoulder instability: A case report and review of the literature. Int J Shoulder Surg 2011;5:81-4.

[2] Boykin RE, Friedman DJ, Higgins LD, Warner JJ. Suprascapular neuropathy. J Bone Joint Surg 2010;92:2348-64.

[3] Boykin RE, Friedman DJ, Zimmer ZR et al. Suprascapular neuropathy in a shoulder referral practice. J Shoulder Elb Surg 2011;20: 983-8.

[4] Economides CP, Christodoulou L, Kyriakides T, Soteriades ES. An unusual case of suprascapular nerve neuropathy: A case report. J Med Case Rep 2011;5:419.

[5] Fabre T, Piton C, Leclouerec G, et al. Entrapment of the suprascapular nerve. J Bone Joint Surg 1999;81:414-9.

[6] Lafosse L, Piper K, Lanz U. Arthroscopic suprascapular nerve release: indications and technique. J Shoulder Elb Surg 2011;20:S913.

[7] Lee BC, Yegappan M, Thiagarajan P. Suprascapular nerve neuropathy secondary to spinoglenoid notch ganglion cyst: Case reports and review of literature. Ann Acad Med 2007;36:1032-5.

[8] Ligh CA, Schulman BL, Safran MR. Case reports: Unusual cause of shoulder pain in a collegiate baseball player. Clin Orthop Relat R 2009;467:2744-8.

[9] Liveson JA, Bronson MJ, Pollack MA. Suprascapular nerve lesions at the spinoglenoid notch: Report of three cases and review of the literature. J Neurol NeurosurPs 1991;54:241-3.

[10] Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Phys 2010;81:147-55.

[11] Piasecki DP, Romeo AA, Bach BR, Jr., Nicholson GP. Suprascapular neuropathy. J Am Acad Orthop Surg 2009;17:665-76.

[12] Romeo AA, Ghodadra NS, Salata MJ, Provencher MT. Arthroscopic suprascapular nerve decompression: indications and surgical technique. J Shoulder Elb Surg 2010;19:118-23.

[13] Sandow MJ, Ilic J. Suprascapular nerve rotator cuff compression syndrome in volleyball players. J Shoulder Elb Surg 1998;7:516-21.

[14] Sergides NN, Nikolopoulos DD, Boukoros E, Papagiannopoulos G. Arthroscopic decompression of an entrapped suprascapular nerve due to an ossified superior transverse scapular ligament: a case report. Cases J 2009;2:8200.

[15] Shah AA, Butler RB, Sung SY, et al. Clinical outcomes of suprascapular nerve decompression. J Shoulder Elb Surg 2011;20:975-82.

[16] Stergioulas A, Stergioula M, Aarskog R et al. Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Am J Sport Med 2008;36:881-7.

[17] Walsworth MK, Mills JT 3rd, Michener LA. Diagnosing suprascapular neuropathy in patients with shoulder dysfunction: a report of 5 cases. Phys Ther 2004;84:359-72.

[18] Witvrouw E, Cools A, Lysens R et al. Suprascapular neuropathy in volleyball players. Br J Sport Med 2000;34:174- 80.

[19] Economides CP, Christodoulou L, Kyriakides T, Soteriades ES. An unusual case of suprascapular nerve neuropathy: a case report. J Med Case Rep 2011;5:419.

[20] Boykin RE, Friedman DJ, Higgins LD, Warner JJP. Suprascapular Neuropathy. J Bone Joint Surg 2010;92A:2348-64.

[21] Cummins CA, Schneider DS. Peripheral nerve injuries in baseball players. Phys Med Rehabil Clin N Am Feb 2009;20:175-93.

[22] Toth C. Peripheral nerve injuries attributable to sport and recreation. Phys Med Rehabil Clin N Am 2009;20:77-100.

Niemann, Andrew J. (ABCDEG), MS, ATC; Juzeszyn, Laura S. (ABCDEG), BS, ATC; Kahanov, Leamor (ACEG), EdD, ATC; Eberman, Lindsey E. (CEG), PhD, ATC

Authors' Affiliation:

Department of Applied Medicine and Rehabilitation, Indiana State University, USA

* Authors' Contribution

(A) Concept / Design

(B) Acquisition of Data

(C) Data Analysis / Interpretation

(D) Manuscript Preparation

(E) Critical Revision of the Manuscript

(F) Funds Collection

(G) Approval of the Article

* Corresponding Author;

Address: Indiana State Unversity, Department of Applied Medicine and Rehabilitation, Terre Haute IN, 47809, USA

E-mail: aniemann@sycamores.indstate.edu

Received: Apr 28, 2012

Accepted: Sep 16, 2012

Available Online: Oct 10, 2012
Table 1: Current Literature-Case Studies

Author               Suprascapular Nerve          Surgery
                   Palsy Signs and Symptoms

Sergides et      Pain/6 months, weakness in     Arthroscopy
al 2009 [14]     abduction and ER, difficult
                 to lift objects, atrophy of
                 supraspinatus and
                 infraspinatus, MMT 3/5
                 supraspinatus and
                 infraspinatus

Lee et           Posterior shoulder pain,       Arthroscopic
al 2007 [7]      difficult to perform           decompression of
                 overhead activities            cyst

Lee et           Vague shoulder pain            Open decompression
al 2007 [7]      exacerbated with overhead      and excision of cyst
                 activities

Walsworth        Difficult to carry luggage     Release of superior
2004 [17]        and perform overhead           transverse scapular
                 activities, supraspinatus      ligament
                 and infraspinatus atrophy,
                 painful arc, MMT
                 infraspinatus 2-5, MMT

                 supraspinatus 3-5, Hawkins-
                 Kennedy Test +, Neer
                 Impingement Test +

Sandow &         Posterior shoulder pain,       Spinoglenoid
Ilic 1998 [13]   wasting of infraspinatus,      Notchplasty
                 weak ER

Ligh et al       Posterior shoulder pain at     Arthroscopic labral
2009 [8]         midpoint of throwing motion,   debridement,
                 could not throw more than 50   decompression of
                 ft. without pain,              suprascapular nerve
                 Impingement sign +, mild
                 infraspinatus atrophy, ER in
                 adduction weakness, pain
                 with ER and abduction

Author               Treatment/Outcome

Sergides et      Returned to daily
al 2009 [14]     activities 3 months post-
                 op

Lee et           No pain at month 4; cyst
al 2007 [7]      resolution at month 3

Lee et           Complete resolution at
al 2007 [7]      month 6

Walsworth        Minimal decrease in pain
2004 [17]        and strength improvement,
                 unable to return to full
                 activities due to pain
                 and weakness

Sandow &         Average RTP-3 months
Ilic 1998 [13]

Ligh et al       Participated in 6 month
2009 [8]         rehabilitation program,
                 able to compete
                 successfully the
                 following season

Table 2: Objective Findings upon initial evaluation by athletic
trainer

Observation or Test                      Result

Observation                    No deformity, swelling  or
                                     discoloration

AROM/ PROM                          110[degrees] Arc

Manual Muscle Testing           5/5 throughout, External
                              Rotation 4/5 upon bilateral
                                       comparison

Scapulothoracic Rhythm                  Normal

Biceps Load I and II                    Negative

Internal Rotation                       Negative
Lag Sign

External Rotation                       Negative
Lag Sign

Kim Test                                Negative

Jerk Test                               Negative

Anterior Apprehension Test         Positive for pain

External Rotation                       Negative
Apprehension Test

Relocation Test                         Negative

Surprise Test                           Negative

Observation or Test                Comment          Possible Diagnosis

Observation

AROM/ PROM                   Pain with external        RC pathology
                                  rotation             (specific to
                                                    external rotators)

Manual Muscle Testing                                  RC pathology
                                                       (specific to
                                                    external rotators)

Scapulothoracic Rhythm

Biceps Load I and II              Pain and           Superior labral
                              apprehension in           pathology
                              external rotation
                                 positioning

Internal Rotation
Lag Sign

External Rotation
Lag Sign

Kim Test

Jerk Test

Anterior Apprehension Test                           Inconclusive (no
                                                      apprehension)
External Rotation
Apprehension Test

Relocation Test

Surprise Test

Table 3: Magnetic resonance arthrogram with intraarticular
contrast findings

Injury                        MR-Arthrogram Findings

Rotator Cuff Tendons                  Intact
Biceps Tendon                         Intact
Coracoclavicular ligaments            Intact
Acromioclavicular ligaments           Intact
Hill-Sachs lesion                     Absent
Glenoid Labrum                Minor posterior lesion
Bennet lesion                         Absent

Table 4: Post-Operative Diagnoses

Right supracapular neoropathy
Posterior glenoid labral tear, absence of flap tears or displacement
Extensive subacromial bursa fibrosis, bursectomy

Table 5: Rehabilitation Progression

Rehabilitation Phase     Treatment Goal            Intervention

Early Acute Phase                                   Game Ready
                       Decrease pain and            Cryocuff
                       inflammation                 BioWave

Late Acute Phase                                    PROM
                       Increase ROM                 AROM
                                                    Pendulum
                                                    exercises

Subacute Phase                                      Game Ready
                       Pain management              Cryocuff
                                                    BioWave
                       Regain ROM                   AROM

                       Increase Strength            Isometric
                                                    exercises
                                                    (RC and scapular
                                                    stabilizers)

Proliferation/         Pain management              BioWave
regeneration phase

                                                    Stretching
                       Regain ROM and strength      Strengthening (RC
                                                    and scapular
                                                    stabilizers)

                                                    Agility exercises
                       Improve coordination         Sport-specific
                                                    activities
                                                    Interval throwing
                                                    program

Remodel/               Regain sport-                Interval throwing
maturation phase       specific function            program
                                                    Mount progression
                                                    throwing program
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Article Details
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Title Annotation:CASE REPORT
Author:Niemann, Andrew J.; Juzeszyn, Laura S.; Kahanov, Leamor; Eberman, Lindsey E.
Publication:Asian Journal of Sports Medicine (AsJSM)
Article Type:Clinical report
Geographic Code:1USA
Date:Mar 1, 2013
Words:2868
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