Suprascapular Neuropathy Secondary to Compressive Paralabral Cyst at the Spinoglenoid Notch

A 53-yr-old right-hand dominant elite-level cross-country skier was referred with insidious atraumatic right shoulder fatigue during training. Physical examination demonstrated focal infraspinatus wasting with weakness graded 4/5 for external rotation. Needle electromyography revealed denervating potentials and polyphasic motor units in infraspinatus, sparing supraspinatus, in keeping with subacute suprascapular neuropathy localizing to the spinoglenoid notch. Point-of-care ultrasound demonstrated a well-circumscribed, anechoic cyst at the spinoglenoid notch adjacent to the glenoid labrum (Fig. 1). In addition, asymmetric atrophy and patchy hyperechogenicity were observed in the Infraspinatus muscle, in keeping with denervation.1 A subsequent magnetic resonance imaging confirmed a paralabral cyst secondary to labral tear, compressing on the suprascapular nerve. Ultrasound-guided aspiration was offered owing to the progressive nature of the patient’s symptoms (Fig. 2).FIGURE 1: Paralabral cyst at the spinoglenoid notch. Arrow, cyst; star, labrum. D indicates deltoid; I, infraspinatus; G, glenoid; HH, humeral head.FIGURE 2: Patient, probe, and needle positioning for posterior glenohumeral joint, labrum, and paralabral cyst visualization and access.The patient was positioned in the left lateral decubitus position with the shoulder in neutral rotation. The curvilinear probe was used to identify the cyst, and a 16-gauge, 1.5-in needle was directed with the in-plane technique commonly described for posterior glenohumeral injections in the literature.2 Approximately 5 mL of straw-colored fluid was aspirated. After complete cyst aspiration, 40 mg of Depo-medrol diluted in 2 mL of 1% lidocaine was injected into the cyst. The procedure was well tolerated, with no complications. At a 3-mo follow-up appointment, the patient reported 95% recovery of his shoulder external rotation power after reinstituting a strengthening program directed by physiotherapy. On examination, the infraspinatus bulk had improved, and he had full power in external rotation. Because of clinical improvement, repeat electromyography and ultrasound were not undertaken. The patient was advised to return to sport without any restrictions and follow-up as needed. Suprascapular nerve palsy is a rare cause of shoulder pain and weakness.3 The suprascapular nerve is a mixed motor and sensory nerve that arises from the C5 and C6 nerve roots and branches from the upper trunk of the brachial plexus.3 Although the most common site of entrapment occurs at the suprascapular notch deep to the transverse scapular ligament, entrapment at the spinoglenoid notch is well described in the literature, resulting in isolated external rotation weakness.3 In this case report, the breadth of physiatric care is demonstrated, with multiple subdisciplines of physiatry aligning to diagnose and manage the patient in a cost-effective and minimally invasive fashion.

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