Leider JD, Derise OC, Bourdreaux KA, et al.

Treatment of suprascapular nerve

entrapment syndrome. Orthopedic Reviews. 2021;13(1). doi:10.52965/001c.25554

Reviews

Treatment of suprascapular nerve entrapment syndrome

a
Joseph D. Leider, BS 1, Olivia C. Derise, BS 2, Kyle A. Bourdreaux, BS 2, Gregor J. Dierks, BS 2, Christopher Lee, MD 3 ,
Giustino Varrassi, MD, Ph.D., FIPP 4, William F. Sherman, MD, MBA 5, Alan D. Kaye, MD, Ph.D 6
1 Georgetown University School of Medicine, Washington DC, 2 Louisiana State University Health Sciences Center, New Orleans, 3 Department of
Internal Medicine, Creighton University School Of Medicine—Phoenix Regional Campus, Phoenix, AZ, 4 Paolo Procacci Foundation, Via Tacito 7, Rome,
Italy, 5 Department of Orthopaedic Surgery, Tulane Medical Center, New Orleans, LA, 6 Department of Anesthesiology, Louisiana State University
Shreveport, LA
Keywords: arthroscopic, nerve entrapment, suprascapular nerve entrapment
https://doi.org/10.52965/001c.25554

Orthopedic Reviews
Vol. 13, Issue 1, 2021

Suprascapular nerve entrapment syndrome (SNES) is an often-overlooked etiology of

shoulder pain and weakness. Treatment varies depending on the location and etiology of
entrapment, which can be described as compressive or traction lesions. In some cases,
treating the primary cause of impingement (ie. rotator cuff tear, ganglion cyst, etc.) is
sufficient to relieve pressure on the nerve. In other cases where impingement is caused by
dynamic microtrauma (as seen in overhead athletes and laborers), treatment is often
more conservative. Conservative first-line therapy includes rehabilitation programs,
nonsteroidal anti-inflammatory drugs, and lifestyle modification. Physical therapy is
targeted at strengthening the rotator cuff muscles, trapezius, levator scapulae,
rhomboids, serratus anterior, and deltoid muscle(s). If non-operative treatment fails to
relieve suprascapular neuropathy, minimally invasive treatment options exist, such as
suprascapular nerve injection, neurostimulation, cryoneurolysis, and pulsed
radiofrequency. 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. Often patients can be treated
with non-invasive measures alone; however, injuries refractory to conservative treatment
may require either arthroscopic or open surgery, particularly if the patient has an
identifiable and reversible cause of nerve compression. Indications for invasive treatment
include, but are not limited to, refractory to non-operative treatment, have a
space-occupying lesion, or show severe signs and symptoms of muscle atrophy. Open
decompression has fallen out of favor due to the advantages inherent in the less invasive
arthroscopic approach.

INTRODUCTION jury at many locations along its path.6 The SN is particu-

larly susceptible to entrapment at the suprascapular notch
Suprascapular nerve entrapment syndrome (SNES) is an of- and the spinoglenoid notch.7 Etiologies of SNES can be de-
ten-overlooked etiology of shoulder pain and weakness. Al- scribed as compressive or traction lesions. Traction lesions
though rare in the general population, SNES increases sig- occur in the setting of ligament tension, hypertrophy, or
nificantly in high-risk populations.1–3 The suprascapular calcification due to rotator cuff tears, overuse in overhead
nerve (SN) originates from the superior trunk of the athletes or overhead laborers.6–8 Traction injuries can also
brachial plexus, where it passes deep to the trapezius to- be exacerbated or directly caused by anatomical variants
ward the scapula to innervate the supraspinatus and in- of the suprascapular notch, spinoglenoid notch, and ac-
fraspinatus muscles. It carries motor nerve fibers to these companying ligaments.9,10 Compression injuries occur via
muscles and sensory nerve fibers from several structures in mass effect, most commonly from ganglion cysts, soft tissue
the posterolateral shoulder.1,4,5 The SN is vulnerable to in- masses, vascular abnormalities, and malignancies.11 They

a Corresponding Author
Christopher Lee, MD
St. Joseph Hospital & Medical Center
Department of Internal Medicine
500 West Thomas Rd
Phoenix, AZ 85013
[email protected]
 Treatment of suprascapular nerve entrapment syndrome

may also result from direct shoulder trauma and iatrogenic increase tension on the SN at the suprascapular notch sub-
complications.1 stantially and spinoglenoid notch as ruptured muscles re-
The presentation of SNES is characterized by impairment tract medially.7 Paradoxically, some rare events of SNES
of sensory and motor innervations to the shoulder.6,10 have also been attributed to rotator cuff repair surgeries.6
Those who are symptomatic may present with weakness Cadaveric studies have determined that significant (1-3cm)
as well as posterolateral shoulder pain. Symptoms depend lateral translation of the rotator cuff during repair can in-
largely on the lesion’s location, as distal injuries result in crease tension on the SN.6,13,15
isolated symptoms of the infraspinatus muscle.10,12 Muscu- Following tears of the labrum, synovial fluid can leak into
lar atrophy of the supraspinatus and/or infraspinatus tends the surrounding tissue forming paralabral ganglion cysts.1,6
to differentiate SNES from similarly presenting patholo- These cysts are formed by a one-way valve mechanism,
gies.1,7 which allows them to grow in size and compress nearby
Vague symptomatology and various etiologies make structures such as the SN.6 SNES from ganglion cysts most
SNES a challenging diagnosis. Once considered a diagnosis often occurs at the spinoglenoid notch; however, ganglion
of exclusion, SNES can now be confirmed with a thorough cysts can compress the SN at both the spinoglenoid notch
history, advanced imaging, and nerve conduction tests.7,13 or the suprascapular notch depending on the primary labral
MRI is the most valuable imaging study as it allows direct injury and size of the cyst.4,11
visualization of both the SN and underlying pathologies
such as rotator cuff tears and compressive masses.7,9 It also ANATOMICAL VARIATIONS IN SUPRASCAPULAR NOTCH
allows the physician to assess supraspinatus and infra-
spinatus muscle atrophy qualitatively.9 Despite the many After branching from the superior trunk of the brachial
advantages of MRI, the diagnostic gold standard for SNES plexus, the SN dives into the shoulder and passes through
remains electromyography (EMG) and nerve conduction ve- the suprascapular notch. The scapula forms the osseous
locity (NCV) studies, allowing for localization of the nerve portion of the notch. At the same time, the fibrous segment
lesion.1,10 is created by the superior transverse scapular ligament
Treatment of SNES varies depending on the location and (STSL), which forms the superior border of the foramen.
etiology of entrapment. In some cases, treating the primary Both the bony notch and the STSL have recognized anatom-
cause of impingement (i.e., rotator cuff tear, ganglion cyst, ical variants affecting the incidence of entrapment at the
etc.) is necessary to relieve pressure on the nerve.6,10 In- suprascapular notch.11
juries refractory to conservative treatment may require ei- The suprascapular notch can be classified into six
ther arthroscopic or open surgery.7,11,13,14 anatomical types.1,11 These include Type I (wide depres-
sion), Type II (wide blunted V shape), Type III (symmetric
U shape), Type IV (small V shape), Type V (partial ossified
RISK FACTORS
STSL), and Type VI (fully ossified STSL).1,17,18 A cadaveric
OCCUPATIONAL/ATHLETICS study of 104 scapulae concluded the ossified, Type VI, the
suprascapular notch was a risk factor for developing SN im-
The relationship between overhead activities and SNES has pingement.19 The study determined that 10-20% of individ-
been well documented in the literature.13 Sports such as uals with a Type VI suprascapular notch had gross impinge-
volleyball, tennis, and swimming increase the risk of dy- ment.1
namic entrapment caused by repetitive compression and The shape of the suprascapular notch can be character-
subsequent swelling, fibrosis, and demyelination of the ized as either U or V-shaped. Based on 616 CT scans of
SN.13 The sling effect describes how certain maneuvers in- the scapula, Polguj et al. determined the difference between
crease stress on the SN at the spinoglenoid ligament.13,14 depth and superior transverse diameter of the suprascapu-
Protraction and retraction of the scapula during the throw- lar notch was a notable risk factor for developing SNES.11
ing motion puts significant pressure on the SN.1 Cadaveric Thus, deep and narrow V-shaped notches increase the risk
studies have demonstrated that shoulder adduction and in- of SNES.1,11
ternal rotation increase tension at the inferior portion of As described by Labetowicz et al., there are 3 morpho-
the spinoglenoid ligament, directly superior to the SN.3,13 logic variants to the STSL.11 These include a fan-shaped lig-
This motion, often seen in volleyball spikes and overhead ament (prevalence = 54.6%), band-shaped ligament (preva-
serves, is thought to cause cumulative microtrauma and lence = 41.9%), and a bifid ligament (prevalence =
neuropathy of the SN.1,7,8,11,15 Around 33% of volleyball 3.5%).1,7,11,14 Of these, the fan-shaped variant was shown
players suffer from SNES at some point in their careers.13 to produce the smallest area within the suprascapular notch
The greatest tension in the suprascapular ligament is seen and is thought to increase the risk of entrapment.12,20
during abduction and full rotation of the arm, which is a
motion common to many overhead sports.7,12 Some re- VASCULAR ABNORMALITIES
searchers have also suggested that SNES can be caused by
microemboli formation secondary to repeated compression It is common for the suprascapular vein to accompany the
trauma that damages the vasonervorum.4,13,16 SN in the suprascapular notch.20 Although usually asymp-
tomatic, when the vein becomes congested, the risk for de-
PRIMARY SHOULDER INJURIES veloping SNES increases as the engorged vein limits space
for the SN to pass through the suprascapular notch.1
Rotator cuff and labrum injuries are potential causes of The suprascapular artery has also been documented
SNES.1,7,13 Massive rotator cuff tears have been shown to

Orthopedic Reviews 2
 Treatment of suprascapular nerve entrapment syndrome

passing through this notch as well.12 Additionally, a rare amining the superior border of the patient shoulders from
abnormality can also occur where all three structures behind, noting any bilateral asymmetry.7 Infraspinatus at-
(suprascapular vein, suprascapular artery, and SN) pass un- rophy can be best assessed while looking down at the
der the STSL.1 Crowding of the notch in this situation in- scapula with the patient seated closely in front of the physi-
creases the risk of developing SNES.6 cian.
The patient can present with point tenderness at the
PRESENTATION suprascapular or spinoglenoid notch, depending on the lo-
cation of the injury. 6,12,13 Those with lesions in the supras-
capular notch may experience tenderness to palpation over
The onset of symptoms in SNES typically arises insidi-
the supraspinatus muscles in the supraspinatus fossa, com-
ously.6 Studies have shown that only 40% of patients could
pared to those with spinoglenoid entrapment, which may
recall a traumatic event to the shoulder.2,5,13,14 Clinical
endorse tenderness deep and posterior to the acromioclav-
presentation depends on the location and etiology of SN
icular joint.6
entrapment.1,6 Dynamic nerve injuries, seen in overhead
Making a diagnosis on a physical exam alone can be chal-
athletes and laborers, can occur at both the suprascapular
lenging because SNES is closely related to injuries of the
notch and the spinoglenoid notch.1,2,5,15 Injury at the
brachial plexus and rotator cuff. One physical exam maneu-
suprascapular notch can present dull, aching, or burning
ver to help diagnose SNES at the suprascapular notch is the
pain in the posterolateral shoulder that may radiate to the
suprascapular nerve stretch.6,12 This is performed by having
neck or ipsilateral upper extremity.5,14 Pain may also be ex-
the patient turn their head to face their unaffected shoul-
acerbated with overhead shoulder movements.4
der, followed by gentle traction to the affected shoulder.
Denervation of the supraspinatus and infraspinatus
Pain in the posterolateral shoulder is indicative of a positive
causes weakness in shoulder abduction and external rota-
test.21 The empty can test and infraspinatus test may also
tion, respectively.1,12,13 Weakness may present variably as
be positive, but non-specific tests represent many forms of
the teres minor and serratus anterior muscles compensate
supraspinatus injury.21
for infraspinatus muscle weakness.15 Due to this compen-
The physical exam maneuver used to assess spinoglenoid
sation, it is critical to inspect the supraspinatus and infra-
notch entrapment is the cross-arm adduction test.12 This
spinatus for signs of atrophy, as it may be the only present-
test is performed by crossing the patient’s extended arm
ing clinical exam finding.1,10
medially across the chest.22 A positive test will elicit shoul-
Entrapments at the spinoglenoid notch are often caused
der pain.22 Of note, this test will also be positive in
by dynamic traction injuries or ganglion cysts. However,
acromioclavicular joint arthritis.20
larger ganglion cysts can entrap the SN at both the supras-
capular notch and the spinoglenoid notch. At the spinog-
IMAGING
lenoid notch, the SN only contains motor nerve fibers to
the infraspinatus muscle.10 Therefore, entrapments at the
Ultrasound, X-ray, CT, and MRI have strengths and weak-
spinoglenoid notch cause isolated infraspinatus weakness
nesses in assessing scapular nerve entrapment. Ultrasound
and atrophy.7,10,12,15 The extent of weakness depends on
is widely considered the first-line imaging study to evaluate
the severity of the nerve entrapment, as well as the degree
peripheral neuropathies because they are clinically effica-
of compensation from the teres minor.6,12 Because sensory
cious and non-invasive.20,22 Furthermore, ultrasound can
nerve fibers join the SN proximal to the spinoglenoid notch.
be used to follow a patient’s recovery by assessing muscle
Severe shoulder pain is a far less common presentation in
texture at regular intervals following treatment.20 Ultra-
these injuries compared to suprascapular notch entrap-
sound is a specifically useful modality for evaluating fluid-
ment.7
filled masses such as ganglion cysts and engorged supras-
capular veins.23 The SN itself may also be directly visualized
DIAGNOSIS by ultrasound.22 Vascular abnormalities about the supras-
PHYSICAL EXAM capular notch can be visualized using ultrasound with a
doppler.8 This modality is useful in diagnosing SNES caused
Diagnosing SNES includes a history and physical exam fol- by engorged veins or an anatomical defect where the
lowed by shoulder imaging studies. A thorough history and suprascapular artery accompanies the nerve in the supras-
physical exam is critical for assessing possible risk factors capular notch.8 In cases where the suprascapular notch is
while simultaneously ruling out other similar pathologies completely ossified, MRI is needed to determine if an artery
such as cervical radiculopathy, cervical disk disease, and or vein is accompanying the SN.12 MRI is also superior to
various rotator cuff injuries.15 A physical exam of the shoul- ultrasound when assessing soft tissue lesions and ganglion
der should assess the range of motion, changes in sensa- cysts.6
tion, point tenderness, atrophy, and weakness. When sus- The usefulness of ultrasound varies widely based on op-
pecting SNES, the strength of abduction and external erator experience and lesion depth.23 To decrease the depth
rotation should be investigated closely.6 Due to the subjec- of the posterior fossa, have the patient put their hand from
tive nature of grading muscle weakness, using a handheld the affected side on their contralateral shoulder.6,23 Despite
dynamometer to assess rotator cuff weakness objectively is the high prevalence of SNES in overhead athletes and the
prefered.6 diagnostic utility of ultrasound, there is currently no indi-
Physical exams should include an inspection of the cation for ultrasound as a screening tool.6
shoulder. Supraspinatus atrophy is best appreciated by ex- Helpful X-ray imaging planes include AP, scapular, lat-

Orthopedic Reviews 3
 Treatment of suprascapular nerve entrapment syndrome

eral, and stryker. The stryker view is obtained by taking the value is limited by the uncertainty of the precise location
image with the patient’s hand on their head with the X-ray and depth of the injection.15 No studies have determined
beam angled 10 degrees caudally.9 This image helps assess the sensitivity and specificity of this test.15
bony abnormalities of the suprascapular notch.9 Assessing
the anatomical type of the suprascapular notch is partic- ANATOMY
ularly important before surgery because the release of an
entrapped nerve in a completely ossified (Type VI) supras-
The suprascapular nerve (SN) is a derivative of the upper
capular notch can vary of a fibro-osseous foramen. If an
trunk of the brachial plexus formed by the ventral rami of
X-ray cannot visualize the suprascapular notch, CT can be
C5 and C6 nerve roots that provides both motor and sen-
used for higher resolution assessment.9
sory innervation to parts of the upper body.2 Beginning in
MRI is supported in the literature as the ideal imaging
the posterior triangle of the neck, it courses down the dorsal
modality for analyzing nerves and lesions of the nervous
aspect of the scapula through the suprascapular notch and
system.12 MRI can visualize vascular and bony abnormal-
beneath the superior transverse scapular, or suprascapular
ities, as well as soft tissue lesions and ganglion cysts.7,8
ligament. It then enters the supraspinous fossa, where it
Sotereanos et al. states that MRI has a sensitivity and speci-
provides motor and sensory innervation to the supraspina-
ficity of 95% in diagnosing ganglion cysts.7,12 Bony struc-
tus. After twisting around the lateral spine of the scapula,
tures of the scapula are also well visualized using MRI. No-
it finds the infraspinous fossa through an opening called
tably, the suprascapular notch and spinoglenoid notch plus
the spinoglenoid notch, thus supplying motor innervation
their accompanying ligaments, the STSL and spinoglenoid
to the infraspinatus muscle. The suprascapular artery and
ligament.6,10 A cohort of 60 patients with SNES was com-
vein run alongside the nerve, but the vessels usually travel
pared to 47 healthy patients using MRI and determined
above the suprascapular ligament instead. The SN provides
spinoglenoid notch distension was significantly enlarged
somatosensory innervation to the acromioclavicular and
in patients with SNES compared to the control group (p
glenohumeral joints also.3
< 0.01). They determined that using a spinoglenoid notch
As the nerve travels, various sites of impingement have
distension value of 7 mm as a cutoff for diagnosing SNES
been identified. Before the SN enters the notch, it may ex-
represented a sensitivity of 74% and a specificity of 78%.10
perience tension from heavy shoulder weight on the supra-
The same study used MRI to classify fatty atrophy of the
clavicular area. Soft tissue tumors or scar tissue from clavic-
supraspinatus and infraspinatus muscles with qualitative
ular fractures have also caused entrapment before entering
Goutallier scores.7,15 As a result, Katsuura et al. found a
the notch. The nerve can also be compressed by anatomic
significant proliferation of fatty atrophy in those suffering
variants of the bony structure of the suprascapular notch,
from SNES vs. control (p < 0.01). These findings further but-
especially since the nerve takes a tortuous route through
tress the use of MRI as an imaging modality for assessing
it. When the SN is in the supraspinous fossa, inflamed tis-
muscular atrophy in SNES.6,7,15
sue from the supraspinatus muscle through excessive use
can also cause impingement. Ganglion cysts may protrude
NERVE CONDUCTION VELOCITY AND
in the infraspinous fossa, thereby compressing the SN after
ELECTROMYOGRAPHY
innervating the supraspinatus, thereby only causing atro-
phy of the infraspinatus. The SN courses through numerous
NCV and EMG studies are considered the gold standard for
bony landmarks and takes a labyrinth of a route to reach
diagnosing SNES.7 These tests should be considered when
its final destination, an impingement in various locations a
MRI, ultrasound, and physical exam do not yield a diag-
possible occurrence.4
nosis.6,10 Moen et al. concluded NCV and EMG are useful
in confirming the diagnosis of suprascapular neuropathy in
patients with and without symptoms, physical exam find- PATHOPHYSIOLOGY
ings, or positive imaging (sensitivity = 74%, specificity =
91%).15 Furthermore, Moen et al. claim NCV and EMG are Although uncommon, suprascapular nerve compression is a
useful modalities for monitoring a patient’s recovery fol- possible cause of shoulder numbness, weakness, pain, and
lowing treatment.15 SNES leads to demyelination of the dysfunction. Due to its difficult course through bony and
nerve, causing characteristic NCV and EMG findings such small landmarks, many points along its path can serve as
as denervation potentials, fibrillations, sharp waves, and sites of compression, especially the suprascapular notch
prolonged motor latencies.15 It is also common to see de- and spinoglenoid notch. It also can experience traction with
creased nerve conduction velocity between Erb’s point and the transverse scapular ligament. Sports that require a great
the supraspinatus or infraspinatus.15 Even with negative deal of repetitive overhead arm movement are most com-
NCV, EMG, and imaging, if high clinical suspicion of SNES monly involved, such as volleyball, tennis, heavy weightlift-
remains, the diagnosis should not be ruled out. ing, baseball, and football, to name a few. This trauma can
be a direct force or indirectly through damage to the vas-
LOCAL ANESTHETIC cular supply to the nerve. Due to variations of the supras-
capular notch, transverse scapular ligament, and shape of
Local anesthetic injections have shown to be helpful in the the scapula itself, some patients may be more susceptible to
diagnosis of SNES and can aid in localizing the point of en- this type of injury. Iatrogenic injuries, especially after rota-
trapment.15 Although relief of SN pain post-injection can tor cuff, clavicle, and posterior shoulder repair.5 After ex-
support the diagnosis of SNES at that site. Its diagnostic cluding more common causes of shoulder dysfunction, clin-

Orthopedic Reviews 4
 Treatment of suprascapular nerve entrapment syndrome

ical findings, and magnetic resonance imaging may lead to agnosis as well as relief. Using anesthetic medications with
suspicion of an SN injury.6 steroids such as bupivacaine and methylprednisolone ac-
The SN contributes to 70% of the shoulder joint’s sensory etate can be useful in managing neuropathy.11 Most injec-
innervation.7 Therefore, SN injury typically presents as tions are performed at the area of the suprascapular notch,
weakness of abduction and external rotation of the shoulder with an ultrasound-guided probe to assist in capturing the
and a diffusely dull ache of the posterior and lateral shoul- nerve instead of the vascular structures nearby. It is noted
der. One may mistake this for a rotator cuff or spinal issue. that locating the superior transverse ligament is extremely
Radiation to the lateral arm, neck, or anterior thorax has useful in identifying the location of the SN. This procedure
also been observed. It is noted that injuries at the location is typically done with the patient positioned either prone
of the suprascapular notch tend to be more severe in pre- with the arm draped over the side of the table or upright
sentation than the spinoglenoid notch pathologies. Since with the ipsilateral hand on the contralateral shoulder. The
the nerve has already supplied innervation to the transducer should be placed parallel to the scapular spine
supraspinatus when it reaches the spinoglenoid notch, the above the suprascapular notch.12 This treatment approach
only muscle involved is the infraspinatus. Thus, symptoms can be beneficial in delaying surgery until necessary or ap-
of poor external rotation of the shoulder may not be pre- propriate, as well as simply providing short-term or imme-
sent. Injecting a local anesthetic into the suprascapular diate relief of shoulder pain.
notch can serve as a diagnostic and a therapeutic test to If SN blocks do not provide therapeutic relief, another
identify the cause of pain.8 method would include neurostimulation. Neurostimulation
is a well-known treatment option for chronic pain from
CONSERVATIVE MANAGEMENT nerve damage in various parts of the body.13 Percutaneous
neurostimulation is now being studied as a possible modal-
ity for treating shoulder pain, specifically since there is not
Since many SN neuropathies result from excessive repeti-
much literature on the topic. There is potential for this
tive overhead arm movements, putting those activities to a
technique to provide non-opioid pain relief as a therapeutic
halt is beneficial to rest the shoulder and nerve and prevent
option.13 The procedure is conducted with the patient lying
further injury. Without clear evidence of a fracture, space-
prone and arms laid in whichever fashion the scapula ex-
occupying lesion, or immediate need for surgery, non-op-
hibits a flat surface. Generally, a small incision is made
erative treatment including a rehabilitation program, nons-
slightly lateral to the spinous process, where an introducer
teroidal anti-inflammatory drugs, and lifestyle modification
needle is guided to the location of the suprascapular notch.
is first-line therapy.9 Physical therapy is targeted at
A nerve stimulator device, such as a single quad lead, is
strengthening the rotator cuff muscles, trapezius, levator
then guided through the introducer to the notch, where the
scapulae, rhomboids, serratus anterior, and deltoid mus-
SN is found. Trial stimulation is done during surgery to en-
cle(s).8 Scapular movements, such as elevation, pronation,
sure adequate attachment and correct placement. The rest
retraction, and depression, are also heavily assessed and
of the stimulator can be attached to different body areas,
fortified. A weak or unstable scapula can cause SN impinge-
such as the thorax and buttocks. The device does not move
ment as it passes through the suprascapular notch, so
and the system controls are easily accessible.11
strengthening these muscles can aid in the resolution of
Cryoneurolysis is another treatment modality used to
symptoms and future damage.8
provide analgesia until a nerve can “revive.” This is
Indications for invasive treatment include, but are not
achieved through applying exceptionally cold temperatures
limited to, refractory to non-operative treatment, have a
to the nerve, thus temporarily ablating it and causing Wal-
space-occupying lesion, or show severe signs and symptoms
lerian degeneration. Nitrous oxide or carbon dioxide are
of muscle atrophy. Timing is extremely important, as the
highly pressurized gases that can become extremely cold,
period between onset of symptoms to when the patient pre-
so they are typically used in this application. Specialized
sents can provide a rough estimate of muscle atrophy and
probes are utilized so that no gas enters and remains in
denervation. This can be useful when deciding whether it
the patient’s body. Regeneration of the nerve typically takes
is best to treat nonoperatively or if a more invasive tech-
weeks to months, providing a significant amount of anal-
nique is warranted. A rotator cuff tear leading to secondary
gesia during this time. Since this can now be done percu-
SN entrapment is common; therefore, treating the problem
taneously, it allows for much broader use of this therapy,
at hand is more appropriate than an isolated nerve decom-
which was once only done with complete surgical exposure
pression.9 It is important to consider the possible long-term
of the nerve.14 Until current advancements, cryotherapy
effects of choosing a conservative approach rather than im-
was reserved for treating postoperative pain rather than as
mediate decompression. Further nerve damage can cause
its treatment modality.15 Using cryotherapy on the SN is
extensive muscle atrophy and weakness that may not be
an area of focus currently. However, damage to the motor
reversible, so non-operative treatment should be closely
nerves with this technique would lead to muscle weakness
monitored to ensure that surgery is not indicated.10
and atrophy of the supraspinatus and infraspinatus. Success
would be reliant on a selective sensory ablation. More re-
MINIMALLY INVASIVE TREATMENTS search on this area is necessary.
Pulsed radiofrequency is another method used to control
If non-operative treatment fails to provide relief of supras- pain caused by suprascapular neuropathy, providing a long-
capular neuropathy, minimally invasive treatment options acting analgesic effect. It is accomplished by applying short
exist. SN injections can be used to provide an immediate di- high-voltage bursts of current then allowing heat diffusion

Orthopedic Reviews 5
 Treatment of suprascapular nerve entrapment syndrome

with longer, silent phases.7 This ultimately leads to re- ment modality for suprascapular nerve entrapment.25 In
versible cell damage, causing nerve fibers to ironically one review, researchers found that out of 269 operations, 2
“freeze”.16 Unlike continuous radiofrequency, which causes reported complications – superficial infection and adhesive
extensive damage to neighboring structures, pulsed ra- capsulitis.26 The few large retrospective analyses of arthro-
diofrequency allows for a finer use with less destruction to scopic decompression outcomes show that most patients
the surrounding areas. Since the SN is very small and takes included in the study parameters have a statistically signif-
a winding route through the scapula, precisely stimulat- icant improvement in various outcome measures, including
ing the nerve in the most efficacious location poses a great a range of motion, shoulder pain, and strength.26–29
challenge to this therapy.17 The addition of ultrasonogra- The following arthroscopic decompression surgical de-
phy has greatly advanced this approach; however, patients scription will be based on the beach-chair position. The pa-
may still report pain after the procedure. Endoscopy allows tient will be placed supine on the operating table, with the
the nerve to be seen clearly, but with that comes a more back at 60 to 90 degrees, head secured, and the operative
invasive process. Pulsed radiofrequency has been gaining arm resting on a padded Mayo stand or in an arm-position-
popularity in treating chronic shoulder pain, especially with ing device.30 Often, traction is placed on the arm to distract
the guidance of ultrasonography. Studies are being con- the humeral head from the acromion and better visualize
ducted to evaluate its efficacy, which may show promise for the transverse scapular notch.18,31
the future. Various combinations and durations of frequen- The modern arthroscopic approach utilizes multiple por-
cies and currents have been applied to discover the best ap- tals – a posterior portal, a lateral subacromial portal, an
proach through these experiments. anterolateral portal, the Neviaser portal, and an SN por-
Chronic shoulder pain has plagued numerous patients tal.18 The posterior portal is used to achieve diagnostic
throughout the world, and each person is unique in regards arthroscopy and intraarticular inspection.29 This portal is
to their shoulder anatomy, physiology, pain response, and placed 1cm medial and 2cm inferior to the posterolateral
pathology. Multiple treatment modalities are often used corner of the acromion.32 After initial arthroscopy is com-
synergistically due to these variations since only one thera- plete. The arthroscope is then moved to the lateral sub-
peutic option does not seem successful for all cases. Unfor- acromial portal. A shaver is typically placed in the antero-
tunately, it is common to find patients that have undergone lateral portal to perform a bursectomy and visualize the
extensive treatment, rehabilitation, and several procedures coracoacromial ligament better.2,32 After identifying the
that proceed to have pain that decreases their quality of life. coracoacromial ligament, it is traced to its base to identify
Although minimally invasive techniques are typically tried the coracoclavicular ligaments, which are then traced to the
before operative treatments, some patients may ultimately base of the coracoid process. After identifying the base of
need surgery to relieve their shoulder pain. the coracoid process, a blunt trocar is placed via the SSN
portal, which is located between the spine of the scapula
SURGICAL TECHNIQUES 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
Surgery is an important consideration in patients with
help protect the SSN and suprascapular vessels (SSVs) when
suprascapular entrapment. Often patients can be treated
transecting the TSL. After the TSL, SSN, and SSVs are well
with non-invasive measures alone. However, surgery be-
visualized and protected, scissors are advanced through the
comes the primary treatment modality when those fail, par-
Neviaser portal and the TSL is transected.18 The SSN should
ticularly if the patient has an identifiable and reversible
be mobilized gently to verify decompression.
nerve compression cause.10 In general, there are two
modalities to treat SNES – arthroscopic decompression and
OPEN DECOMPRESSION
open decompression. Regardless of modality, the goal of the
surgery is to remove any associated compressive lesions or
There are two approaches to the open decompression pro-
areas. Open decompression has fallen out of favor due to
cedure, an anterior and a posterior approach.34 In general,
the advantages inherent in the less invasive arthroscopic
as with the arthroscopic approaches, the open decompres-
approach. These advantages include optimal visualization
sion procedures are well tolerated and have excellent re-
of the SN and associated structures and do not require
sults regarding patient recovery of strength and reduction
transaction of the trapezius at its insertion point.18 There
in pain.34–36
is debate whether it is best to correct the surrounding tears
The posterior approach requires a prone or lateral decu-
or damage in addition to the SSN pathology or if it is best
bitus position.36 An incision is made 2 cm superior to the
to treat the underlying structural damage to treat the SSN
spine of the scapula, and the trapezius fibers are split in a
pathology indirectly.1,19–21 Ultimately, it is left to the sur-
parallel fashion. Using the supraspinatus muscle as a guide,
geon’s discretion and causation of the compression.
the suprascapular foramen is located via palpation of the
superior border of the scapula. Subsequently, the SSV’s are
ARTHROSCOPIC DECOMPRESSION
identified and protected, and the TSL is transected, typi-
cally allowing the SSN to displace out of the suprascapular
Patients are first placed in either the beach-chair position
notch.36
or lateral decubitus position. Currently, there is no defin-
If utilizing the anterior approach, the patient will be
itive “best” position, and it is up to the surgeon based on
placed supine on the operating bed facing the contralateral
their experience and training.22–24 Arthroscopic decom-
side with the operative arm in slight abduction.35 The inci-
pression surgery is considered a safe and effective treat-

Orthopedic Reviews 6
 Treatment of suprascapular nerve entrapment syndrome

sion is started along with the sternocleidomastoid muscle,

about 1/3 of the way up from its insertion, and it is contin-
CONFLICT OF INTEREST
ued inferiorly, parallel with the clavicle. After a distance of
about 2/3 of the clavicle has been reached, the incision is The authors have no conflicts of interest to disclose.
extended posteriorly to the spine of the scapula, perpendic-
ular to the clavicle.37 The origin of the SSN on the upper FUNDING STATEMENT
trunk of the brachial plexus can be found under the poste-
rior belly of the omohyoid. After identifying the SSN in the No funding was received for the completion of this manu-
cervical triangle, it is dissected along its length to the TSL, script.
at which point the SSVs are protected, and the TSL is tran-
sected.37 Submitted: June 30, 2021 EST, Accepted: July 03, 2021 EST

Orthopedic Reviews 7
 Treatment of suprascapular nerve entrapment syndrome

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