Diagnostic Injections About the Shoulder

Edward McFarland, MD; Johnathan Bernard, MD, MPH; Eric Dein, MD; Alex Johnson, MD


J Am Acad Orthop Surg. 2017;25(12):799-807. 

In This Article

Suprascapular Nerve Abnormality

Presentation and Evaluation

Suprascapular nerve entrapment has various causes, including traction and compressive injuries. Traction on the suprascapular nerve is believed to cause symptoms in those who play volleyball or overhead ball-throwing sports, such as baseball and team handball. Compressive injuries are typically associated with a synovial or ganglion cyst.

The pain of suprascapular nerve entrapment is usually dull, achy, and diffuse and is not localized to the pathology causing the pain. The most common site of nerve injury is at the spinoglenoid notch and involves only the infraspinatus branch of the suprascapular nerve. However, the patient should be examined carefully because entrapment of the nerve at the scapular notch can involve both the suprascapularis and the infraspinatus muscles. When there is any doubt about the location of the nerve injury, electromyography can be used to confirm the diagnosis.

The most important step in examining a patient with shoulder pain is to have the patient undress to expose the supraspinatus fossa, the infraspinatus fossa, and the border of the scapula. Visualization of atrophy of the supraspinatus and infraspinatus fossae confirms the diagnosis of suprascapular nerve entrapment in most cases. Evaluation of the shoulder for scapular dyskinesis or scapular winging should also be part of the examination to rule out other nerve involvement.

Technique Summary

In patients with negative electromyography results, injection of anesthetic into the region of the suprascapular nerve may help delineate the source of the pain[40] (Figure 8). Injection of the suprascapular notch can be either unguided or guided with ultrasonography or fluoroscopy. Unguided injections are feasible; however, ultrasonography or fluoroscopic guidance is used in most patients to aid in reaching the suprascapular notch because nerve injury and vascular puncture can occur (Figure 9).

Figure 8.

Illustration of the posterior view of the shoulder showing the technique for injection of the suprascapular nerve. (Copyright Louis Okafor, MD, Baltimore, MD.)

Figure 9.

A, Photograph of the posterior aspect of a shoulder demonstrating an ultrasonography-guided suprascapular nerve injection. B, Axial T1-weighted MRI of the shoulder showing the suprascapular nerve at the spinoglenoid notch (red arrow). (Copyright Uma Srikumaran, MD, Baltimore, MD.)