Suprascapular Neuropathy in Collegiate Baseball Player
A right handed 20 year old male baseball pitcher sought evaluation for right posterior shoulder pain from the athletic training staff in Spring 2010, at the start of his second season of Division-I competitive baseball. At the time, the closing pitcher had completed 29 innings of play in the first three weeks of the competitive season. Upon initial evaluation, the patient primarily complained of sharp pain in his posterior right shoulder during throwing, particularly upon ball release. Pain symptoms generally persisted for several days, up to one week. He also described an inability to throw further than 20-30 feet and increased pain in the posterior shoulder after throwing. He reported rehabilitating intermittently for the past one and a half years for diffuse and intermittent right shoulder pain.\nThe athletic trainer (AT) assessed for labral pathology, joint instability, shoulder dyskinesis, swelling and deformity, of which all findings were negative ().\nThe evaluation revealed decreased right shoulder infraspinatus strength (MMT: 4/5) with bilateral comparison. After the initial evaluation, the AT withheld the patient from sport participation, required rest and managed discomfort with conservative treatment. The AT aimed to decrease pain, improve range of motion, increase strength, complete functional and sport-specific activities, and return to play. Treatments occurred for two weeks with no change, so the AT referred the patient to an orthopedic specialist.\nThe orthopedic physician's initial evaluation yielded negative results for right shoulder impingement, apprehension, instability, and labral pathology. The physician's exam again revealed infraspinatus weakness resulting in orders for magnetic resonance imaging (MRI) and electromyography (EMG) analyses to examine soft tissue and nerve involvement. The diagnostic imaging revealed nothing remarkable. One week after orthopedist evaluation (three weeks from initial evaluation) an MR arthrogram with intraarticular contrast of the patient's right shoulder identified only a minor lesion affecting the posterior labrum ().\nAfter ruling out several pathologies with the physical exam and diagnostic imaging (after three weeks since initial evaluation), the physician ordered an electrodiagnostic study. The test indicated right suprascapular neuropathy at the suprascapular notch with supraspinatus and infraspinatus involvement, evidence of mild ongoing denervation and mild chronic neuropathic changes of the suprascapular nerve with absence of right cervical radiculopathy or brachial plexopathy. Approximately five weeks post initial evaluation, the patient underwent right suprascapular nerve release and extensive debridement of the glenoid labrum and bursa. The surgeon predicted a 3 to 5 month recovery.\nSurgical intervention detected significant superficial fraying of the entire posterior labrum, which was debrided to create a smooth and stable surface (). Analysis of the subacromial bursa indicated significant fibrosis of the bursa thus a need for a partial bursectomy. The transverse scapular ligament was transected to release the suprascapular nerve in the suprascapular notch.\nPost surgically, the physician referred the patient for physical rehabilitation to relieve pain, increase function, increase strength, and increase range of motion. Two weeks following surgery (seven weeks post initial evaluation with the AT), the patient demonstrated decreased shoulder range of motion and strength, with significant decreases in internal rotation and visible atrophy of the right infraspinatus as a consequence of immobilization. The patient underwent physical rehabilitation with ATs and PTs for 22 weeks (). Rehabilitation followed a standard progression from pain management and strengthening to sport specific exercises through therapeutic interventions, exercise and manual therapy.\nThe athlete returned to live throwing and simulated games without any complaints or deficits in performance. Time to return to sport without restrictions from date of surgery totaled approximately seven months. The patient has since returned to competitive collegiate baseball pitching without issues related to pain, fatigue, pitching velocity, or pitch control.