Anatomy

Case Correlate

Shoulder Pain
 History
22 year old male, professional hockey
player
6 week history of right shoulder pain
No recent trauma
Training heavily in the off-season
Upper arm pain, increased with overhead
activity, lifting
 Physical Exam
Normal motion
Pain with lifting beyond 90 degrees
Abduction 4+/5 and painful
External rotation 4/5
Infraspinatus atrophy
 Differential
Rotator cuff
Cervical spine
Instability
Nerve entrapment
Labral tear
Arthritis
 Differential
Inflammatory
Tumor
Infection
Fracture
Adhesive Capsulitis
Intrathoracic
Biceps
 Rotator Cuff Impingement
Dynamic pinching of the supraspinatus
tendon between the humeral head and
undersurface of acromion
Force couple between deltoid and rotator
cuff musculature
 Rotator Cuff Disease
Inflammatory
Degeneration
Partial Tearing
Full Thickness Tearing
Tears predictably begin in supraspinatus
Part of normal aging process
 Instability
Static restraints
Osseous architecture
Capsuloligamentous restraints
Dynamic restraints (musculature)
 Shoulder Instability
Dislocation
Subluxation
More difficult diagnosis
Suspect in younger patient with chronic post-
traumatic shoulder pain, with or without history
of instabilty
 AC JOINT
Traumatic event (separation)
Arthritis (post-traumatic versus
degenerative)
Well localized pain, superior shoulder
 Labral Tear
Variable anatomy
SLAP lesion (superior, labrum, anterior and
posterior)
Most common in repetitive overhead
athletes
 Approaching the Problem
Subjective complaints cuff tendinitis
Abduction pain cuff tendinitis
No history of instability
Pain not localized to AC joint
No repetitive overhead sports
 Approaching the Problem
But, infraspinatus atrophy and external
rotation weakness
Massive rotator cuff tear
Suprascapular neuropathy
 Suprascapular Nerve
Origin: C5 root or upper trunk of brachial
plexus
Suprascapular notch, beneath transverse
scapular ligament
Innervates supraspinatus
Winds around spine of scapula
Innervates infraspinatus
 Further Work-up
X-rays normal
Electrodiagnostic studies injury to
suprascapular nerve at spinoglenoid notch
isolated denervation of infraspinatus
Ganglion cyst?
 Diagnosis
Suprascapular neuropathy right shoulder
secondary to ganglion cyst with possible
superior labral tear at spinoglenoid notch
 Treatment
Right shoulder arthroscopy
Labral debridement, arthroscopic
decompression of the cyst
Post op rehab, return to play at 6 weeks
with full strength
 Suprascapular Neuropathy
It all starts with the anatomy
Careful history + careful exam usually
results in diagnosis
Imaging studies, when necessary, support
what you suspect from above