A 17-year-old right-hand dominant high school female volleyball player presents to an outpatient physical therapy clinic with complaints of diffuse right posterior shoulder pain and weakness. Weakness is most prominent with shoulder external rotation. She reports gradual weakness and pain over the last month and notes that her shoulder blades no longer look symmetrical. She denies a single specific mechanism of injury. Past medical history is unremarkable for systemic complaints, previous surgeries, or previous shoulder injuries. Impairments revealed on initial physical therapy examination include supraspinatus and infraspinatus weakness and decreased active shoulder external rotation and abduction. Passive horizontal shoulder adduction reproduces the patient's pain with a muscle guarding end feel.
What are the most appropriate physical therapy interventions?
What is her rehabilitation prognosis?
What are the examination priorities?
What examination signs may be associated with the suspected diagnosis?
- ATROPHY: Wasting or loss of muscle tissue
- ENTRAPMENT: Direct pressure on a single nerve due to intrinsic (e.g., bony abnormalities) and/or extrinsic factors (e.g., repetitive overhead activities)
- GANGLION CYST: Abnormal fluid-filled sac-like structure surrounding a joint or covering a tendon
- SUPRASCAPULAR NEUROPATHY: Damage to the suprascapular nerve that results in decreased sensation and strength of the structures innervated by the suprascapular nerve
Describe examination findings that would lead to a suspected diagnosis of suprascapular neuropathy or a suprascapular nerve entrapment.
Identify mechanisms of entrapment of the suprascapular nerve.
Discuss the differential diagnosis process to differentiate between rotator cuff pathology and suprascapular neuropathy.
Identify differential diagnoses for a suprascapular neuropathy.
Identify diagnostic tests for suprascapular neuropathy.
Describe physical therapy interventions to address impairments present in a patient with a suprascapular neuropathy.
PT considerations during management of the individual with muscle weakness, scapular dyskinesia, and posture impairments due to suprascapular neuropathy:
- General physical therapy plan of care/goals: Increase muscle strength; increase muscular flexibility; restore normal joint and soft tissue mechanics
- Physical therapy interventions: Muscular strengthening, scapular stabilization, soft tissue and/or joint mobilization
- Precautions during physical therapy: Monitor patient's physiological response to treatment
- Complications interfering with physical therapy: Repetitive overhead activities required for recreational or occupational activities; noncompliance with home exercise program and activity modification
The suprascapular nerve is derived from the C5 and C6 nerve roots1-8 and has a variable contribution from C4.3-5,9 The suprascapular nerve innervates the infraspinatus and supraspinatus muscles1,3,5,10-12 and provides sensory fibers to the coracoacromial ligament, acromioclavicular and glenohumeral joints,3-5,8,10-13 subacromial bursa,10 the scapula,8 and shoulder joint capsule.1,6,8,13,14 It is estimated that 15% of individuals have a cutaneous branch of the suprascapular nerve supplying sensation to the lateral arm.4,5,10,15
To understand injuries to the suprascapular nerve, a review of the anatomical course of the nerve is helpful. The suprascapular nerve ...