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Suprascapular nerve syndrome
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Suprascapular nerve syndrome - June 28, 2005 3:06:00 AM
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KAK
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One of my co-workers set up an inservice at a local medical school. We did an anatomy review of the shoulder. It was a ton of fun (OK maybe I need a life) and fascinating. The Doctor reviewing with us made a point which got me wondering…
He pointed out that the suprascapular nerve is NORMALLY immobile in the suprascapular notch and that sometimes it is even fused with the periostium as it descends deep to the subscapularis. He brought out the point that the notch is close to the axis of rotation of the scapula so as to lessen the stress on it.
I was aware of the Suprascapular Nerve Syndrome, but saw it in a new light.
I thought about the instability issues overhead athletes have. I’ve always considered the weakness of the supraspinatus and infraspinatus as secondary- sort of inhibition due to the inflammatory response brought on by microtrauma.
With this new (to me) info on the suprascapular nerve, I wondered if sometimes the impingement sequel starts with the nerve. What if there is slight traction to the nerve which causes a mild neuropraxia? This in turn would cause mild rotator cuff weakness leading to poor mechanics and the sequel begins.
I wonder how often a mild case of suprascapular nerve syndrome is completely missed clinically? Any thoughts?
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Re: Suprascapular nerve syndrome - June 28, 2005 3:12:00 AM
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KAK
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I should have said "deep to the infraspinatus", not subscapularis.
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Re: Suprascapular nerve syndrome - June 28, 2005 6:27:00 AM
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JLS_PT_OCS
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KAK-
Good point. There are many people (see [URL=http://www.noigroup.com)]www.noigroup.com)[/URL] who are looking at "Orthopedics" in new ways, learning to see the involvement of nerves in everyday conditions we have treated with interventions traditionally aimed solely at other tissues. Some, like Barrett, Diane, Nari, and others have been aware of this for some time, but I am just beginning to see this better.
Shacklock's "Clinical Neurodynamics" is arriving soon, and I hope to learn more.
Here's a followup question to your post. If you suspected this mild entrapment neuropathy, how might you approach it?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Suprascapular nerve syndrome - July 2, 2005 2:39:00 AM
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KAK
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Jason,
Thank you for the link!
Re treatment:
1) My first thought is resting from the activity which causes the traction. If it was a traumatic injury, then time is our best modality.
2) Of course there is the surgical approach for a release.
3) I’m not sure about neural gliding. Maybe someone can help me out here. If the nerve is normally immobile in the notch or fused with the periostium, I’m not sure how neural glides would help. There is naturally no nerve mobility and no amount of gliding is going to change that. I’m not up to snuff (yet) with this work and the theories behind it. To me, in this case, the glides would put a nerve injured by stretching on stretch. This doesn’t make sense. Are the gentle glides to improve circulation to the nerve? But even then, wouldn’t a stretch compress and compromise circulation momentarily? Is this what is meant by milking the nerve?
4) If it is an overuse injury-take a look at their mechanics.
5) Strengthen the rotator cuff.
I’d welcome any input.
Another follow up question:
What would lead us to suspect this injury and how would we differentially diagnose?
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Re: Suprascapular nerve syndrome - July 2, 2005 3:14:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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KAK,
How about approaching it as I suggested at the course?
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Suprascapular nerve syndrome - July 2, 2005 1:42:00 PM
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Jon Newman
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Hi KAK,
According to Shacklock, in his book Clinical Neurodynamics, he states
[QUOTE] For the nervous system to move normally, it must successfully execute three primary mechanical functions; withstand tension, slide in its container, and be compressible. Ultimately, all mechanical events in the nervous system stem from these three functions such that the more complex mechanical events that occur during human movement are merely combinations of tension, sliding and compression [/QUOTE]Thus the problem may be one of inability to withstand compression or tension in the nerved instead of sliding.
However, while the nerve as a whole may be adhered or constrained at points it is likely the epineurium which is adhered. See [URL=http://science.nhmccd.edu/biol/nervous/nerve.htm]this link[/URL] for a refresher.
This does not mean that the neural core cannot move and I THINK that this is what is important in sliding/gliding but I'm uncertain. Here a pdf that speaks to that effect
[URL=http://www.ecmjournal.org/journal/supplements/vol004supp02/pdf/v004supp02a42.pdf]core/sheath interface[/URL]
As far as knowing the characteristics of helpful movement and where this movement is being generated from in order to help the nervous system's predicament is my interpretation of what Barrett's course is about.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Suprascapular nerve syndrome - July 2, 2005 3:48:00 PM
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Barrett
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Jon,
Yes, that is what I try to teach. I'm told it's entertaining but my success at getting others to understand and follow through is unknown. I suspect it's slight at best.
I'm wondering about this patient's breathing pattern, the resting posture of the ipsolateral hip and which ways they want to move instinctively.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Suprascapular nerve syndrome - July 2, 2005 4:48:00 PM
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dragonfire
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From: usa
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jon,
great links! thank you.
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Re: Suprascapular nerve syndrome - July 3, 2005 3:00:00 AM
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SJBird55
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From: Michigan
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It is so weird to see everyone jumping on the "nerve" bandwagon. Just because someone hurts doesn't automatically mean you can fix it, no matter what your approach.
If the patient had definite atrophy and you thought the suprascapular nerve may be involved, I don't know, but I believe alerting the physician and recommending an EMG or an MRI just might be more appropriate. Granted, I am speaking from experience, but the time I had a patient with definite suprascapular involvement - the family physician and I were looking at an anatomy book... the physician came over and observed what I saw.... I took the stance that I wanted to know the integrity of the nerve before I did anything. The guy was in his 30's and did overhead work all day. I would have never solved his problems - he had some kind of fibrous tumor right there by the notch that was impinging in the nerve. (Couldn't feel it or see it....) He had surgery and was perfectly fine afterwards (didn't need any PT).
What if... what if that guy I saw were treated with neurodynamics or whatever manual stuff.... what if he did have some symptoms relief... but what if he came back to you 6 weeks later with the same symptoms? Do you treat it the same way because "it works" or do you pause and think?
I believe that we have a spectrum of sorts to the care we provide.... yes, addressing the nerves with neurodynamics or whatever is on that spectrum... but in my opinion, if clinicians move their approaches so that neurodynamic approaches completely dominate, their approach becomes just as imbalanced as the clinicians that only look at patients from a biomechanical perspective. Personally, I think that knowing what to do, when to do it and with what patient is the key to success. All patients may not necessarily need all the "whats" of what we do...
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Re: Suprascapular nerve syndrome - July 3, 2005 4:40:00 AM
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Jon Newman
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Hi SJ,
I don't think anyone is advocating a PT only approach to this but if the MD sent the patient to PT they are likely trying a conservative route first. Clearly pain serves a protective function. If the patient's pain is appropriately addressed and the pain remains or is constantly recurring then the condition is simply not amenable to PT.
That said, I think what KAK is looking for is what would be appropriate conservative care. Since KAK framed her question as a nerve problem, one would be smart to look to the 'nerve bandwagon' for solutions. Is there another bandwagon you would have her look to?
KAK asks,
[QUOTE]What would lead us to suspect this injury and how would we differentially diagnose?
[/QUOTE]There are numerous case studies and other research available on suprascapular nerve palsy upon searching your favorite source of journal articles.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Suprascapular nerve syndrome - July 3, 2005 4:44:00 AM
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Barrett
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We all know that treatment does not end when the patient leaves the therapist's presence. Appropriate resolution of an abnormal neurodynamic emerges most effectively from the patient's active movement, not the therapist's coercion of their tissues. Virtually everybody working with, researching and treating this sort of problem agrees with this. Where we diverge is seen in what we think that movement ought to look like and how it is to be facilitated. But no less an authority than Patrick Wall contends that resolution follows an instinctive movement, not one that is volitional. I agree.
In my experience, if the patient continues to "dose" the system with corrective movement (and thus with blood) relief will endure. Of course, rare, relevant pathology is something for which we must maintain some vigilance. But most of the time if the problem recurs you'll usually find that the patient has not been following through and/or life has offered them too much strain to their sensitized tissue. That being the case, the problem becomes more sociologic than therapeutic, given the ergonomic, financial and societal pressures that now are seen to perpetuate it.
We know that sensitized nervous tissue can conduct normally, thus revealing nothing pathologic (Sunderland's "irritative nerve lesion") while at the same time producing profound symtomotology. When any part of the body is mechanically stressed the nervous tissue is the first to complain, it being by far the most sensitive. Why not consider it first?
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Suprascapular nerve syndrome - July 3, 2005 5:24:00 AM
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SJBird55
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To not consider the nervous tissue is erroneous. To only consider the nervous tissue is just as erroneous.
Jon, I'm not meaning to pick a fight or go against any of the learning occurring at this site. But, that saying dealing with only having a hammer in one's toolbox kind of makes everything look like a nail seems appropriate at the moment.
Barrett, Wall may believe an instinctive movement, but have you read Moseley? Moseley tends to look very centrally within the brain. He'd potentially think more along the lines of education and volitional movements. Are the tissues truly "sensitized" or is the brain just perceiving harm/danger when there truly isn't any harm/danger and the person believes that the pain = danger and perpetuates the whole thing through their fear?
Moseley GL. Related Articles, Links
Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain.
Aust J Physiother. 2005;51(1):49-52.
PMID: 15748125 [PubMed - indexed for MEDLINE]
Clin J Pain. 2004 Sep-Oct;20(5):324-30. Related Articles, Links
A randomized controlled trial of intensive neurophysiology education in chronic low back pain.
Moseley GL, Nicholas MK, Hodges PW.
University of Queensland, Brisbane, Australia. l.moseley@mailbox.uq.edu.au
Aust J Physiother. 2005;51(1):49-52. Related Articles, Links
Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain.
Moseley GL.
Department of Physiotherapy, Royal Brisbane and Women's Hospital & The University of Queensland, Brisbane, Australia. l.moseley@fhs.usyd.edu.au
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Re: Suprascapular nerve syndrome - July 3, 2005 5:58:00 AM
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Diane
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SJ, ..just so that potential divisions aren't artifically sharpened, I just want to throw in that I've been to hear Moseley speak three times.. I can assure you he doesn't leave anything out. Any emphasis he places on central processing (as opposed to PNS) is as far as I can tell, to make up for the fact that there is still such a great deal of catagorical (Cartesian) thinking shot through our profession, not because he is trying to overturn the canoe to the right instead of the left.
I've personally "gone over to the dark side" of considering nervous system tissue first in cases of pain, (i.e., NOT joints, NOT muscles), whether it is PNS or brain or patient's sense of self. I do that because of the statement I read in Butler's book long ago, "The brain is the greediest bodily organ in terms of fuel consumption. It will burn about 10 times as much oxygen and glucose as the other body systems at rest. Although only 2 and a half per cent of body weight it will take about 20 percent of oxygen consumption. And as we know if it runs out of oxygen neurones will die very rapidly. It helps to establish how alive the brain is. Take the greediness a step farther - the central nervous system is always searching and seeking and trying to reward itself. This takes a lot of energy." Other than gate considerations, I don't divide the nervous system into PNS and CNS when I treat.
Now, about the suprascapular nerve being tethered to the scapula, I'm sure that it's the tunnel that is attached, and that the nerve can slide a bit inside it, like tendons do inside tendon sheaths, maybe not to the same extent..
If the suprascapular nerve is entrapped, maybe swollen inside the sheath or tunnel, it can be refreshed by UNloading the musculature (e.g. prone lying with the arm hanging down off the side of the plinth, head turned or left face down, whichever works best in the moment), taking the arm out about 45 degrees, forward (or backward, whichever works better) about 45 degrees, and turning it slightly into external rotation. One hand can palpate over the "cranky spot" and feel when it relaxes/stops feeling tender. Hold the patient's arm in that position until everything has finished doing what it needs to do, about 2 minutes. The nerve will have been moved a bit off the square it was on. It will have been "refreshed", some microcirculation improving its mood, some drainage away of stuff that was irritating it. Neurodynamic treatment can be very small but very effective. The nerve probably doesn't slide longitudinally with this sort of approach, it probably gets rotated slightly this way or that. Whatever. Motion is lotion, and a change is as good as a rest for nerves.
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Re: Suprascapular nerve syndrome - July 3, 2005 9:57:00 AM
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KAK
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I appreciate and enjoy the discussion.
Jon-
Thanks for the great links; you truly are the “Link Master”! I agree that it is most likely the epineurium which is fused with the periostium. I’m thinking that even the tethering of the epineurium might leave the nerve a little more vulnerable to injury than a nerve where the tunnel is free to move as well. However, it also helps me see how movement with in the tunnel might be effective. You are right that I was looking to the “nerve bandwagon” for input. Initially, I was wondering if it was a plausible scenario and Jason asked what to do about it.
Diane-
Your illustration of “rotating” the nerve is very enlightening to me. In my mind I was imagining the nerve being injured from excessive longitudinal forces (a stretch injury from repetitive overhead use). I have a hard time conceptualizing how adding additional longitudinal forces could help the situation. The rotation makes sense- “rest” and increased circulation from a change in position/forces. Yet, did I understand correctly that you may have been implying that longitudinal forces might have been also effective? Obviously I have much catching up to do in this area.
Barrett-
I think I’m starting to get it. You are saying we don’t have to think about which way to move the nerve for improved circulation because the body knows instinctively how to move to accomplish this.
I didn’t originally consider your treatment because I understood you to say that it’s not for injuries which require healing. I was looking at the possibility of a mild nerve injury, leading to mild transient weakness, not necessarily a chronic pain issue.
I’ve thought more than once that a two day course may do better justice to your approach. Although, considering some of the “pleasant” students you encounter maybe one is enough for you! ;)
SJ,
In my original post, I wasn’t thinking about a gross entrapment of the nerve with obvious atrophy. I agree that this needs further work up. I guess I was just hypothesizing (from the cadaver lab) that a mild irritation of this particular nerve (set up by it’s anatomy) might play an infrequent, but maybe unrecognized part in shoulder pathology for overhead athletes.
Thanks all!
Kathy
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Re: Suprascapular nerve syndrome - July 3, 2005 10:56:00 AM
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Diane
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Kathy,
[QUOTE]Yet, did I understand correctly that you may have been implying that longitudinal forces might have been also effective? [/QUOTE]Maybe, if there was a way to take the nerve the other way through the tunnel... Actually the way I described sort of does that; if the neck is still, and turned to the same side, the nerve is de-tensioned. Then lifting up the relaxed arm may help it de-tension further, even slide proximally. At least, in my head I can see that happening. I'm sure there are no studies on that..
My sense of nerve tunnel treatment is to scrunch it end to end, sort of like those little Chinese finger trap toys, that soften and let go of your finger only if you push your finger further into it; when you try to pull your finger out, it tightens harder.
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Re: Suprascapular nerve syndrome - July 3, 2005 11:12:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Kathy,
Some might consider this a small thing and wonder why I bring it up, but, having said that, I don't ever say that "the body" knows what to do. I say repeatedly that our instinct to move, which resides in the brain, and, more specifically, the unconscious, knows. It is that knowledge that is translated to movement once the conscious mind permits it.
Our unconscious mind is the genius here and its strategy for correction of intricate and unique mechanical deformation is what I watch my patients do every day. I've been watching this now for 25 years.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Suprascapular nerve syndrome - July 3, 2005 11:49:00 AM
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srcase
Posts: 551
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From: Michigan
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Kathy,
I saw a patient with suprascapular nerve palsy once as a student. Mechanism of injury was a fall onto the scapula and possible fracture (?). The patient had appreciable atrophy of the infraspinatus, and we tried to regain strength with NMES using active shoulder ER with the arm at 90 degrees abduction (supported on the table). It seemed to help a little, but as I recall, he didn't make as much improvement as we'd hoped.
Along your original line of thought, have you ever noticed that patients with rotator cuff lesions or tendonitis commonly have severe tenderness superficial to and around the suprascapular notch? I notice this in some patients with supraspinatus tendinitis when trying to do cross-friction massage at the supraspinous fossa close to the acromion. Normally, CFM seems to decrease the pain if there is increased tissue tension/bogginess to begin with and it "numbs" out after 2-4 minutes of treatment. But, in some patients, no real increase in tone is felt, but the area is very tender and does not change with CFM. I then, wonder to myself if they have suprascapular nerve involvement. Then I think, I probably shouldn't be rubbing on it! Just an interesting observation.
I like Diane's ideas of slackening the nerve and allowing it to unload.
Sarah
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