1. Anatomy Case Correlate
“Shoulder Pain”

2. 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

3. Physical Exam Normal motion Pain with lifting beyond 90 degrees
Abduction 4+/5 and painful
External rotation 4/5
Infraspinatus atrophy

4. Differential Rotator cuff Cervical spine Instability Nerve entrapment
Labral tear
Arthritis

5. Differential Inflammatory Tumor Infection Fracture Adhesive Capsulitis
Intrathoracic
Biceps

6. 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

8. Rotator Cuff Disease Inflammatory Degeneration Partial Tearing
Full Thickness Tearing
Tears predictably begin in supraspinatus
Part of normal aging process

9. Instability Static restraints Dynamic restraints (musculature)
Osseous architecture
Capsuloligamentous restraints
Dynamic restraints (musculature)

10. Shoulder Instability Dislocation Subluxation More difficult diagnosis
Suspect in younger patient with chronic post-traumatic shoulder pain, with or without history of instabilty

11. AC JOINT Traumatic event (separation)
Arthritis (post-traumatic versus degenerative)
Well localized pain, superior shoulder

12. Labral Tear Variable anatomy
SLAP lesion (superior, labrum, anterior and posterior)
Most common in repetitive overhead athletes

14. 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

16. Approaching the Problem
But, infraspinatus atrophy and external rotation weakness
Massive rotator cuff tear
Suprascapular neuropathy

17. 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

18. Further Work-up X-rays normal
Electrodiagnostic studies  injury to suprascapular nerve at spinoglenoid notch  isolated denervation of infraspinatus
Ganglion cyst?

20. Diagnosis
Suprascapular neuropathy right shoulder secondary to ganglion cyst with possible superior labral tear at spinoglenoid notch

21. Treatment Right shoulder arthroscopy
Labral debridement, arthroscopic decompression of the cyst
Post op rehab, return to play at 6 weeks with full strength

22. 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