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Editorial Commentary: Suprascapular Neuropathy in Overhead Athletes: To Release or Not to Release?

      Abstract

      A growing body of evidence has demonstrated that repetitive overhead athletes with shoulder pathology often have associated infraspinatus atrophy and suprascapular neuropathy. Although decompression of the suprascapular nerve has not been shown to clearly impact outcomes in the general population, release of the nerve in overhead athletes with documented evidence of impingement may improve outcomes in this high-demand population.
      A growing body of evidence has demonstrated that repetitive overhead athletes with shoulder pathology often have associated infraspinatus atrophy and suprascapular neuropathy (SSN). In this month's issue, Tsikouris, Bolia, Vlaserou, Angelis, Odantzis, and Psychigios from Greece attempt to answer the question of whether suprascapular nerve release influences outcomes in their article “Shoulder Arthroscopy With Versus Without Suprascapular Nerve Release: Clinical Outcomes and Return to Sports Rate in Overhead Athletes.”
      • Tsikouris G.D.
      • Bolia I.
      • Vlaserou P.
      • Angelis K.
      • Odantzis N.
      • Psychigios V.
      Shoulder arthroscopy with versus without suprascapular nerve release: Clinical outcomes and return to sports rate in elite overhead athletes.
      The authors performed a retrospective review of elite overhead athletes with intra-articular shoulder pathology and clinical evidence of SSN, which was confirmed by electrodiagnostic studies followed by ultrasound-guided injection at the suprascapular notch. Fifty-six athletes were identified over a 7-year period, 35 of whom underwent arthroscopic SSN release in addition to treatment of intra-articular pathology and 21 of whom underwent treatment of intra-articular pathology alone. Although both groups improved and met the patient-acceptable symptom state value for the Constant score, the group with SSN had greater improvements in both the University of California, Los Angeles score (33 vs 28; P = .01) and Constant score (91 vs 82; P < .001) and had a higher rate of return to play (97 vs 84%; P < .005). The authors concluded that in elite overhead athletes with combined SSN pathology and intra-articular pathology, SSN release leads to superior clinical outcomes compared with treatment of the intra-articular pathology alone.
      The management of SSN in association with concomitant shoulder pathology is controversial. Costouros et al.
      • Costouros J.G.
      • Porramatikul M.
      • Lie D.T.
      • Warner J.J.
      Reversal of suprascapular neuropathy following arthroscopic repair of massive supraspinatus and infraspinatus rotator cuff tears.
      reported reversal of SSN by repair of a massive rotator tear alone in 6 patients with documented preoperative SSN. Kim et al.
      • Kim D.H.
      • Murovic J.A.
      • Tiel R.L.
      • Kline D.G.
      Management and outcomes of 42 surgical suprascapular nerve injuries and entrapments.
      reported no difference between SLAP repair alone and SLAP repair with spinoglenoid cyst decompression in patients with SLAP tears and spinoglenoid cysts. However, neither of these studies represented an isolated population of overhead athletes as in the study by Tsikouris et al.
      • Tsikouris G.D.
      • Bolia I.
      • Vlaserou P.
      • Angelis K.
      • Odantzis N.
      • Psychigios V.
      Shoulder arthroscopy with versus without suprascapular nerve release: Clinical outcomes and return to sports rate in elite overhead athletes.
      In recent years, it has been recognized that overhead athletes have a high incidence of infraspinatus atrophy. Lajtai et al.
      • Lajtai G.
      • Pfirrmann C.W.
      • Aitzetmuller G.
      • Pirkl C.
      • Gerber C.
      • Jost B.
      The shoulders of professional beach volleyball players: High prevalence of infraspinatus muscle atrophy.
      reported that 30% of professional volleyball players had infraspinatus atrophy. Interestingly, the Constant score was lower in those with atrophy (P < .0001), yet the difference was only 6 points (87 vs 93). Likewise, there were small differences in external rotation strength (8.2 vs 9.5 kg; P < .001). Young et al.
      • Young S.W.
      • Dakic J.
      • Stroia K.
      • Nguyen M.L.
      • Harris A.H.
      • Safran M.R.
      High incidence of infraspinatus muscle atrophy in elite professional female tennis players.
      noted that 52% of professional tennis players had infraspinatus atrophy, but that this did not appear to affect performance, based on player rankings. Finally, in a separate study, Lajtai et al.
      • Lajtai G.
      • Wieser K.
      • Ofner M.
      • Raimann G.
      • Aitzetmuller G.
      • Jost B.
      Electromyography and nerve conduction velocity for the evaluation of the infraspinatus muscle and the suprascapular nerve in professional beach volleyball players.
      performed electrodiagnostic studies on 35 professional beach volleyball players and found that 34% had infraspinatus atrophy, all of whom had evidence of SSN on electrodiagnostic studies. These studies demonstrate that overhead athletes are prone to SSN through repetitive overhead movement.
      This leaves us with the question of how do the findings of Tsikouris et al.
      • Tsikouris G.D.
      • Bolia I.
      • Vlaserou P.
      • Angelis K.
      • Odantzis N.
      • Psychigios V.
      Shoulder arthroscopy with versus without suprascapular nerve release: Clinical outcomes and return to sports rate in elite overhead athletes.
      impact our clinical practice? First, it is interesting to note that 56 of the 87 overhead athletes (64%) presenting with shoulder pain during the study period met the inclusion criteria of documented SSN pathology. Does this high rate of SSN represent the distribution of a tertiary referral practice, or is this a case of recognition? I am certain that most of us do not see 8 cases a year of SSN in overhead athletes (56 cases over 7 years). Nonetheless, the study forces us to ask ourselves: “Is it seeing us, and we are seeing it?” It is well known that electrodiagnostic studies do not identify every case of SSN.
      • Freehill M.T.
      • Shi L.L.
      • Tompson J.D.
      • Warner J.J.
      Suprascapular neuropathy: Diagnosis and management.
      We need a combined approach of history, examination, and diagnostic evaluation, but the first step is raising our awareness of the condition.
      Second, we must consider the magnitude of clinical impact. Although Tsikouris et al.
      • Tsikouris G.D.
      • Bolia I.
      • Vlaserou P.
      • Angelis K.
      • Odantzis N.
      • Psychigios V.
      Shoulder arthroscopy with versus without suprascapular nerve release: Clinical outcomes and return to sports rate in elite overhead athletes.
      noted a statistical difference between the groups, the magnitude of difference was small, and 100% of the patients met the patient-acceptable symptom state criteria for acceptable treatment. On one hand, we could conclude that the differences are not clinically relevant; however, on the other hand, we must recognize that magnitude of differences are only as good as the sensitivity of our clinical outcome measures. The Constant score in particular has only a small position of the overall score dedicated to strength, and the activity section is likely insufficiently sensitive for an elite athlete population. In a population in which differences are measured in split seconds, our current measurement techniques are imprecise. Therefore, I would argue that the small difference in Constant scores between the groups is likely relevant.
      Finally, we must consider our surgical technique. Unfortunately, here Tsikouris et al.
      • Tsikouris G.D.
      • Bolia I.
      • Vlaserou P.
      • Angelis K.
      • Odantzis N.
      • Psychigios V.
      Shoulder arthroscopy with versus without suprascapular nerve release: Clinical outcomes and return to sports rate in elite overhead athletes.
      fail to provide clear guidelines. Approximately one-third of the patients underwent decompression at the suprascapular notch, one-third underwent decompression at the spinoglenoid notch, and one-third had decompression at both locations. We are left wondering which location to choose and needing to assess the risks of the procedure. Whereas the reported rate of complications of suprascapular nerve release is <1%, most studies have been performed at high-level centers.
      • Momaya A.M.
      • Kwapisz A.
      • Choate W.S.
      • et al.
      Clinical outcomes of suprascapular nerve decompression: A systematic review.
      Having the opportunity to instruct in many cadaveric learning environments, I have observed that orthopedic surgeons are often inexperienced in performing release of the suprascapular nerve. As we continue to seek to treat our patients better, we must improve our skills and ask ourselves if we can personally do the best for the patient or if referral is required.
      In summary, Tsikouris et al.
      • Tsikouris G.D.
      • Bolia I.
      • Vlaserou P.
      • Angelis K.
      • Odantzis N.
      • Psychigios V.
      Shoulder arthroscopy with versus without suprascapular nerve release: Clinical outcomes and return to sports rate in elite overhead athletes.
      have again raised our awareness of SSN and suggested that outcomes are improved when the nerve is decompressed in overhead athletes with electrodiagnostic evidence of SSN. However, further studies are needed to corroborate these findings with more sensitive outcome measures in high-demand overhead populations.

      Supplementary Data

      References

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