Clinical evaluation and treatment of spinoglenoid notch ganglion cysts

Spontaneous resolution of spinoglenoid ganglion cyst: a case series

BACKGROUND

Spontaneous resolution of a spinoglenoid notch ganglion cyst (SGC) without surgical treatment has been rarely reported; however, we have encountered this phenomenon occasionally. Therefore, we aimed to describe a case series of consecutive patients with SGC in whom it spontaneously resolved without surgical treatment.

METHODS

We retrospectively reviewed 12 patients with magnetic resonance imaging (MRI)-confirmed SGC in whom it resolved without surgical treatment between January 2011 and March 2023. We included patients without abnormally increased signal intensity or muscle atrophy due to denervation from suprascapular neuropathy on MRI. Resolution of the SGC was confirmed via MRI or ultrasound at the follow-up visit, and suprascapular neuropathy was assessed using electromyography and nerve conduction studies when needed. For functional assessments, the visual analog scale for pain and active range of motion of the shoulder were used to compare pre and postresolution follow-ups.

RESULTS

Eleven men and 1 woman with a median age of 54.0 years (interquartile range [IQR] 37.0-65.3) were included in this study. The SGCs resolved spontaneously at a median of 13.2 months with an IQR of 8.2-23.0 after initial evaluation using MRI. The SGCs were multiloculated cysts with superior labrum anterior and posterior II-IX lesions, with a median diameter of 2.5 cm (IQR 2.0-2.8). The median visual analog scale for pain (pre-resolution 5.0 [IQR 4.0-7.0] vs postresolution 1.0 [IQR 0.0-1.0], P = .002) and internal rotation at the back (preresolution 8.0 [IQR 7.0-10.3] vs postresolution 7.5 [IQR 7.0-8.0], P = .034) were significantly improved after the resolution.

CONCLUSIONS

Surgical treatment may not be necessary in all cases of SGC. Nonsurgical treatment may be a viable option in the absence of suprascapular nerve involvement or superior labrum anterior and posterior-related physical findings.

The correlation of the spinoglenoid ganglion cyst size with the electrophysiological alterations of suprascapular nerve and the rotator cuff muscle power

BACKGROUND

Although various treatment options are available for spinoglenoid cyst, including conservative and surgical methods, there is no standard guideline for its surgical decompression. Thus, the purpose of the study was to correlate the size of the spinoglenoid notch ganglion cyst (GC) as revealed by magnetic resonance imaging (MRI) with electrophysiological alterations, muscle power, and pain severity, and to estimate a cut-off value of cyst size to perform a decompression.

METHODS

Between January 2010 and January 2018, the patients with a GC at the spinoglenoid notch diagnosed on MRI, and who had a minimum follow-up of 2 years after the decompression were included. Maximum cyst diameter as measured on MRI was used for comparison. Electromyography (EMG) and nerve conduction velocity (NCV) studies were performed before the surgery. Peak torque deficit (PTD) percentage compared to opposite shoulder was calculated preoperatively and at 1 year after surgery. Pain severity was estimated using visual analogue scale (VAS) preoperatively.

RESULTS

Ten (50%) of 20 patients with GC > 2.2 cm and 1 (5.9%) of 17 patients with GC < 2.2 cm showed EMG/NCV abnormalities (p = 0.019). There was a correlation between the cyst size and the positive EMG/NCV findings (Correlation coefficient (CC) = 0.535, p < 0.001). The preoperative peak torque deficit on the external rotation was correlated with the positive EMG/NCV findings (CC = 0.373, p = 0.021). The PTD was improved significantly at 1 year postoperatively in patients with a GC size >2.2 cm (p = 0.029). The cyst size was not related to the preoperative pain VAS and muscle power.

CONCLUSIONS

The spinoglenoid cyst size >2.2 cm, but not pain severity or muscle power, correlates with the positive finding of EMG for compressive suprascapular neuropathy. The GC size >2.2 cm can be a reference to decide the need of decompression surgery.

LEVEL OF EVIDENCE

IV, case series.

Suprascapular nerve entrapment caused by a large hematoma of the scapula: a case report

BACKGROUND

Suprascapular nerve entrapment is a rare disorder that is frequently misdiagnosed as another disease. The suprascapular nerve is commonly entrapped at the following two sites: the suprascapular and spinoglenoid notches. Nerve entrapment at the spinoglenoid notch causes infraspinatus muscle weakness and atrophy. Patients present with posterior shoulder pain and weakness. Magnetic resonance imaging is used to confirm the diagnosis of a spinoglenoid cyst and nerve compression. Open or arthroscopic aspiration or decompression is indicated for patients with cysts in whom conservative treatment has failed and those with cysts associated with suprascapular nerve compression.

CASE PRESENTATION

Herein, we describe the case of a 49-year-old man with suprascapular nerve entrapment caused by a large cyst, namely, a hematoma, in the superior scapular and spinoglenoid notches. Open surgical decompression of the suprascapular nerve was performed owing to an intact rotator cuff and glenoid labrum.

CONCLUSION

Posterior shoulder pain promptly resolved without complications.

Clinical Outcomes Following Arthroscopic Decompression and Repair versus Repair Alone in Patients with a Concomitant Spinoglenoid Cyst and SLAP Lesion: A Systematic Review

(1) Background: Patients with a superior-labrum-from-anterior-to-posterior (SLAP) tear associated with a spinoglenoid ganglion cyst have undergone various procedures. The purpose of this study is to evaluate clinical outcomes following arthroscopic treatment in patients with a concomitant spinoglenoid ganglion cyst and SLAP lesion. (2) Methods: This study followed PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, utilizing the PubMed, EMBASE, Cochrane Library, and Scopus databases. The keywords included shoulder, SLAP, labral tear, spinoglenoid notch, paralabral cyst, arthroscopy, and treatment. (3) Results: A total of 14 articles (206 patients) were included. Repair alone was administered in 114 patients (Group R), and 92 patients underwent additional cyst decompression (Group RD). Both groups showed excellent and similar clinical scores. The rate of the complete resorption of the cyst was 95.5% in Group RD, and 92.2% in Group R. The complication rate was 3.5% in Group RD, and 11.4% in Group R. The reoperation rate was 0% in Group RD, and 5.3% in Group R. (4) Conclusion: Reliable clinical outcomes without serious complications were obtained from the use of both procedures. The decompression of the cyst is a safe method that will alleviate pressure on the suprascapular nerve.

Spinoglenoid Notch Ganglion Cyst: A Case Report

Suprascapular nerve dysfunction caused by ganglion cysts is a rare condition that can cause significant pain and weakness in the shoulder. The suprascapular nerve is a branch of the brachial plexus that innervates the supraspinatus and infraspinatus muscles. It is most commonly compressed at the suprascapular notch or the spinoglenoid notch. A 40-year-old male presented with a two-year history of left shoulder pain that was aggravated by overhead activities. Physical examination revealed mild tenderness along the infraspinatus with noticeable atrophy, full range of motion, and mild external rotation weakness. MRI was obtained and confirmed the suspected diagnosis of suprascapular nerve dysfunction caused by a ganglion cyst at the spinoglenoid notch. The patient was initially treated conservatively with physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs), but after completing nine months of conservative management, he showed no improvement. The patient elected to undergo open ganglion cyst excision and decompression of the spinoglenoid notch. Postoperatively, the patient's pain resolved gradually and he regained the full power of external rotation. The patient was followed for one year postoperatively and was satisfied with the outcome with a full range of motion, full power, and a complete return to his baseline level of activity. In conclusion, this case report demonstrates the successful treatment of suprascapular nerve dysfunction caused by a ganglion cyst at the spinoglenoid notch with open ganglion cyst excision and decompression. This procedure is a safe and effective treatment option for patients with this condition who have failed to respond to conservative treatment and emphasizes and signifies the role of eliciting a detailed patient history, conducting a thorough radiographic examination including MRI scans, and planning optimum surgical interventions.

Suprascapular Nerve Compression Secondary to a Spinoglenoid Ganglion Cyst: A Case Report

Suprascapular nerve entrapment is an uncommon entity; it is usually missed as a differential diagnosis of shoulder pain, especially since the main presentation of this condition in patients is usually non-specific shoulder pain. It is often only considered when the patient presents with weakness and denervation of the supraspinatus and infraspinatus muscles. Diagnosis of spinoglenoid ganglion cysts is usually considered after other causes have been ruled out. They are usually detected on magnetic resonance imaging (MRI); however, this could be delayed and happens only after suprascapular nerve compression has already occurred and the patient's muscles have atrophied leading to limitations in their function. Treatment of spinoglenoid ganglion cysts should be tailored to each individual patient. Numerous treatment options are available and can range from conservative management to open decompression. The aim of our study was to highlight the clinical presentation of this condition by describing a case that we have diagnosed and managed at our center. We report a 29-year-old male who presented with dysfunctional left shoulder pain. The patient was diagnosed with a spinoglenoid ganglion cyst, which was treated successfully with open excision. The patient's condition improved following the procedure with a successful return to his daily activities.

Comparisons between treatment of isolated posterosuperior paralabral cysts and simultaneous treatment of cysts combined with associated shoulder pathologies: arthroscopic treatment of posterosuperior paralabral cysts

INTRODUCTION

The purpose of this study is to report the radiologic and clinical outcomes of arthroscopic intervention for isolated posterosuperior paralabral cysts and simultaneous treatment of cysts combined with associated shoulder pathologies.

MATERIALS AND METHODS

From March 2008 through December 2016, 70 cases (48 males and 22 females) operated on for symptomatic posterosuperior paralabral cysts were included. Mean age was 45 (range 18-69). These patients were classified into two groups depending on if they had accompanying lesions: Group I (isolated group, 27 patients) and Group II (concomitant group, 43 patients). Arthroscopic cyst decompression with a labral repair or posterior capsulotomy for patients without labral tear were performed. All concomitant pathologies were also operated simultaneously. Follow-up MRI were performed at postoperative 6 months and clinical outcomes were evaluated during the follow-up.

RESULTS

Arthroscopic all intra-articular cyst decompression and labral repair was performed on 67 patients. In three patients, posterior capsulotomy without labral repair was performed for cyst removal. For 43 patients with concomitant lesions, 31 rotator cuff repairs, three SLAP repairs along with biceps tenodesis, two distal clavicle resections due to A-C joint arthritis, one calcific deposit removal, four Bankart repairs, and two acromioplasties were performed. The follow-up MRI showed complete cyst resorption except for two patients. The mean VAS, ASES, UCLA, SST and CS scores significantly improved at the last follow-up. Although both groups showed significantly improved range of motion after the surgery, improvement of ROM in Group II lagged at early periods of the rehabilitation.

CONCLUSIONS

Arthroscopic labral repair with all intra-articular cysts decompression or simple posterior capsulotomy were both effective treatment modalities. If paralabral cysts were associated with other shoulder lesions, simultaneous treatment of combined lesions could be performed for the improved clinical outcomes at final follow-up with expected lag in the early rehabilitation period.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Trial, Treatment Study.

Two paleopathological cases suggestive of paralabral cysts of the shoulder

OBJECTIVE

To undertake differential diagnosis of scapular bone defects found in two medieval skeletons buried in different necropoles of Friuli Venezia Giulia (Italy) and to evaluate the clinical significance of paralabral cysts in the context of shoulder pathology.

MATERIALS

Individual JoT36 is an adult male exhumed from a necropolis belonging to a rural agricultural settlement dated to the 10th to 11th century A.D. Individual CIVT58 is an adult male from a Langobard necropolis dated to 630-670 A.D.

METHODS

Macroscopic examination of the skeletons was performed using standard osteological methods and review of pertinent clinical literature to assist differential diagnosis.

RESULTS

Between the glenoid cavity and the spinoglenoid notch of the right scapula of JoT36 there is a multilocular circular defect adjacent to the glenoid rim. On the neck of the left scapula of CIVT58, immediately above the spinoglenoid notch, there is a unilocular circular depression. In both cases, the cortical bone appears smooth without any evidence of erosion or sclerosis.

CONCLUSIONS

Skeletal findings and historical/archaeological contexts of both cases are compatible with the diagnosis of paralabral cysts.

SIGNIFICANCE

Paralabral cysts are relatively frequently observed in clinical settings but very few examples have been documented in paleopathological literature. This study seeks to improve recognition and interpretation of this pathology in historical/archaeological contexts.

LIMITATIONS

Findings from a case report can neither generate epidemiological information nor be generalized.

SUGGESTIONS FOR FURTHER RESEARCH

Identification of new cases may add valuable information about lifestyles and related shoulder pathologies in ancient times.

Trans-Rotator Cuff Approach for Spinoglenoid Cysts: Tips and Traps

In this study, we introduce an arthroscopic technique for posterior-superior capsular fenestration and spinoglenoid cyst resection completely via a trans-rotator cuff approach. This approach can provide a full field of view and allow evaluation of the scope of the cyst under direct vision, which reduces the risk of recurrence and injury to the suprascapular neurovascular bundle.

Entrapment Neuropathies of the Shoulder

Entrapment neuropathies of the shoulder most commonly involve the suprascapular or axillary nerves, and they primarily affect the younger, athletic patient population. The extremes of shoulder mobility required for competitive overhead athletes, particularly in the position of abduction and external rotation, place this cohort at particular risk. Anatomically, the suprascapular nerve is most prone to entrapment at the level of the suprascapular or spinoglenoid notch; the axillary nerve is most prone to entrapment as it traverses the confines of the quadrilateral space.Radiographs should be ordered as a primary imaging study to evaluate for obvious pathology occurring along the course of the nerves or for pathology predisposing the patient to nerve injury. Magnetic resonance imaging plays a role in not only identifying any mass-compressing lesion along the course of the nerve, but also in identifying muscle signal changes typical for denervation and/or fatty atrophy in the distribution of the involved nerve.

Diagnostic and therapeutic value of ultrasonography in the detection of paralabral ganglion cysts with a curved array transducer: A case report

BACKGROUND

Paralabral cysts are a rare cause of shoulder pain. Linear ultrasound transducers are often used for musculoskeletal evaluation and intervention. However, the use of linear transducer is limited when the target structure is located deep and blocked by bony barriers, as is the case of paralabral ganglion cysts.

OBJECTIVE

This case report aims to describe a beneficial role of using a convex transducer on the evaluation and ultrasonography-guided intervention of paralabral cysts below the acromion.

CASE DESCRIPTION

Two patients visiting the outpatient clinic of Physical Medicine and Rehabilitation complained of severe pain during shoulder movement. Ultrasound scans with linear transducer detected rotator cuff lesions. Shoulder magnetic resonance imaging was done because of the persistent pain despite therapeutic interventions for the rotator cuff lesion, and confirmed paralabral cysts. Although a linear array transducer could not visualize the cystic lesion but could only perform suprascapular nerve block and intra-articular injection, the use of a convex array transducer improved the visualization of the cystic lesion which we treated using ultrasound-guided aspiration and intra-cystic injection. Visual analog scale and Shoulder Pain and Disability Index were checked to assess the treatment effect of each intervention. The intra-cystic injection with aspiration and intra-articular injection showed minimal to moderate improvement of pain score.

CONCLUSION

In pain related to shoulder movement, especially pain that continues despite appropriate treatment for rotator cuff lesions, ultrasound diagnosis of paralabral ganglion cysts using convex transducers will improve the diagnostic value and accuracy of intervention.

Endoscopic/arthroscopic decompression of the suprascapular nerve at the spinoglenoid notch: indications and surgical technique

Suprascapular nerve compression at the spinoglenoid notch can lead to posterior shoulder pain, muscle weakness, and longstanding muscle atrophy of the infraspinatus. Although rare, it is most commonly seen in overhead athletes and laborers who perform repetitive overhead activities. Early diagnosis requires a thorough history and physical examination including imaging, diagnostic injections, and electromyography to avoid a missed diagnosis. While a course of nonoperative treatment is most often prescribed, early surgical intervention may be prudent to avoid irreversible damage especially if a space occupying lesion is present. This article will describe the history, physical examination findings, diagnostic workup, and our surgical technique for arthroscopic decompression of the suprascapular nerve at the spinoglenoid notch through a simple posterior approach avoiding the subacromial space.

Open Surgical Decompression for Large Multiloculated Spinoglenoid Notch Ganglion Cyst With Suprascapular Nerve Neuropathy

Suprascapular nerve entrapment at the spinoglenoid notch causes infraspinatus weakness and wasting. Patients present with shoulder pain and weakness. The spinoglenoid notch cyst is the reason for suprascapular nerve compression. Magnetic resonance imaging (MRI) confirms the diagnosis of spinoglenoid cyst and its nerve compression. Also, MRI rules out other differential diagnosis causing shoulder pain and weakness. One of the treatment modalities for small and asymptomatic cyst is conservative, which has produced acceptable results and functional outcome. Open or arthroscopic aspiration or decompression is indicated for patients with single small cysts where conservative treatment failed, and cyst associated with suprascapular nerve compression. We report a 32-year-old dancer with a large multiloculated multiple spinoglenoid cysts compressing the suprascapular nerve causing infraspinatus wasting and shoulder dysfunction. We performed an open surgical decompression of the suprascapular nerve and excised multiple ganglions. The patient improved significantly and regained his shoulder function and muscle wasting at two-year follow-up.

Anatomical Variations of the Suprascapular Notch and its Importance in Suprascapular Entrapment Neuropathy

Background: Anatomical knowledge about the suprascapular notch is very important in understanding the risk of suprascapular nerve entrapment syndrome. Suprascapular nerve injuries have become commonly recognized as a cause of shoulder pain and dysfunction. This study aimed to describe the morphometrical influence of the suprascapular notch on the course of the suprascapular nerve. Method: A total of 138 dry human scapulae of both sides of the unknown sex were used. Four measurements were defined and collected for every suprascapular notch: maximum depth (MD), superior transverse diameter (STD), middle transverse diameter (MTD), and total circumferential diameter (TCD). Result: In the present study we found different shapes of suprascapular notches. Out of 138 scapulae, 67 (48.55%) had U-shaped notch, 29 (21.01%) V-shaped notch and 14 (10.14%) J-shaped notch. Nine (6.52%) scapulae had incomplete notch. Two (1.44%) scapulae had large double foramen. Six (4.34%) scapulae had complete suprascapular notch. In seven (5.07%) scapulae, the notch was absent. Interestingly, in two (1.44%) scapulae, we found a W-shaped notch. This observation was unique and not reported anywhere in the literature before. Conclusion: Anatomical knowledge about the morphology of the suprascapular notch is of extreme importance for clinicians, radiologists, neurosurgeons, and orthopedic surgeons in making a proper diagnosis and for planning the surgical procedures of the shoulder region.

Ultrasound-Guided Intralesional Methylene Blue Injection for the Arthroscopic Decompression of Spinoglenoid Notch Cyst Causing Suprascapular Neuropathy

Symptomatic spinoglenoid ganglion cyst is a rare cause of shoulder pain and disability. Surgical treatment, which may be considered after failed nonoperative treatment, includes open or arthroscopic cyst debridement. Arthroscopic treatment is less invasive and has the advantage of addressing intraarticular pathologies; however, exposure of the cyst may be deemed difficult. Furthermore, the suprascapular nerve is susceptible to iatrogenic injury owing to its close proximity to the posterior glenoid rim. The purpose of this article is to present our technique for arthroscopic spinoglenoid cyst decompression after preoperative ultrasound-guided methylene blue injection.

The Evaluation and Management of Suprascapular Neuropathy

Suprascapular neuropathy is a potential source of shoulder pain and functional limitation that can present secondary to various etiologies including entrapment or compression. Cystic lesions arising from a labral or capsular tear can compress the nerve along its course over the scapula. Nerve traction is theorized to arise from chronic overhead athletics or due to a retracted rotator cuff tear. The diagnosis of suprascapular neuropathy is based on a combination of a detailed history, a comprehensive physical examination, imaging, and electrodiagnostic studies. Although the anatomic course and variations in bony constraint are well understood, the role of surgical treatment in cases of suprascapular neuropathy is less clear. Recent reviews on the topic have shed light on the outcomes after the treatment of suprascapular neuropathy because of compression, showing that surgical release can improve return to play in well-indicated patients. The incidence of compressive neuropathy is quite high in the overhead athletic cohort, but most patients do not show clinically relevant deficiencies in function. Surgical release is therefore not routinely recommended unless patients with pain or deficits in strength fail appropriate nonsurgical treatment.

A spinoglenoid cyst compressing on the suprascapular nerve causing supraspinatus and infraspinatus muscle weakness: A case report

INTRODUCTION

Spinoglenoid cysts are a rare cause of suprascapular neuropathy of compressive etiology in which the patient may present with shoulder pain and muscle hypotrophy. MRIs are the imaging modality of choice showing location, size, and extent of the lesion for preoperative assessment. Currently, surgical intervention is the preferred approach for the management of a spinoglenoid cyst with arthroscopy being favored over the open technique.

CASE PRESENTATION

A 25-year-old male patient presenting with right posterior shoulder pain and decreased range of motion associated with the development of progressive weakness of the supraspinatus and infraspinatus muscles. Right shoulder MRI showed a posterior tear of the glenoid labrum and a spinoglenoid ganglion cyst. Preoperative electroneuromyography was suggestive of a suprascapular nerve impairment.

FOLLOW-UP

Six months postoperatively, the patient has regained full range of motion of his right shoulder with no residue signs of muscle hypotrophy.

CONCLUSION

Spinoglenoid cysts can cause compressive neuropathy with associated pain and muscle hypotrophy. MRI and EMG can help in establishing the diagnosis and in the pre-operative assessment. Surgical intervention with arthroscopy is currently the technique preferred by most surgeons.

Current concepts review: peripheral neuropathies of the shoulder in the young athlete

Peripheral neuropathies of the shoulder and upper extremity are uncommon injuries that may affect the young athletic population. When present, they can result in significant pain and functional impairment. The cause of peripheral neuropathy in young athletes may be an acute, traumatic injury such as a shoulder dislocation or a direct blow to the shoulder girdle. Alternatively, repetitive overuse with resultant compression or traction of a nerve over time may also result in neuropathy; overhead athletes and throwers may be particularly susceptible to this mechanism of nerve injury. Regardless of etiology, young athletes typically present with activity-related pain, paresthesias, and dysfunction of the affected upper extremity. In addition to physical examination, diagnostic studies such as radiographs and magnetic resonance imaging (MRI) are commonly performed as part of an initial evaluation and electrodiagnostic studies may be used to confirm the diagnosis of peripheral neuropathy. Electrodiagnostic studies may consist of electromyography, which evaluates the electrical activity produced by skeletal muscles, and/or a nerve conduction study, which evaluates a nerve's ability to transmit an electrical signal. Although data are not robust, clinical outcomes for young patients with activity-related peripheral neuropathies of the shoulder are generally good, with most young athletes reporting both symptomatic and functional improvement after treatment.

Morphological measurements and classification of the spinoglenoid notch: A three-dimensional reconstruction of computed tomography in the Chinese population

BACKGROUND

The spinoglenoid notch (SGN) is the second most common location for suprascapular nerve (SN) entrapment; however, there are few relative morphological reports on this condition. Hence, the present morphological study mainly explored the anatomical structure and classification of the SGN and the relationship with entrapment of SN.

MATERIALS AND METHODS

Four hundred seventy-eight scapulae were analysed thoroughly and systematically in this study. Anatomical structure and classification of the SGN were observed and measured by a three-dimensional (3D) reconstruction of computed tomography (CT). The measurement results were then analysed and recorded.

RESULTS

Chinese scapulae were classified into three types at the SGN, and it was found that left scapulae had deeper SGN than right ones. Then, significant differences were also noted between sexes. Men had thicker, wider and deeper SGN than women. Type II (small U, 46.04%) was the most common. Type I (large U) was the widest (15.67±1.43mm) and deepest (13.71±2.39mm) compared with other types. Lastly, no significant differences in the above criteria were found in other measurements.

CONCLUSIONS

These morphological measurements of the SGN may help to improve the diagnosis and successful treatment rate of the surgery for the SN entrapment, but the relative clinical trial is necessary to support it.

A circular depression at the spinoglenoid notch of a prehistoric Andean scapula: Plausible evidence of suprascapular nerve entrapment by a paralabral cyst

While intraosseous cysts have been described in the paleopathological literature, it is rare to find reports concerning effects of soft tissue cysts, although they are relatively common in clinical contexts. Here we present plausible evidence of an extraosseous paralabral cyst, seen in an adult scapula from a Late Intermediate period commingled tomb (ca. AD 1200) at the northern highland site of Marcajirca, Ancash, Peru. The scapula demonstrated a smooth-sided concave depression at the spinoglenoid notch. The depression was notable for its regular appearance, with no bone deposition or destruction. Rather than reflect an intraosseous pathology, the defect likely resulted from pressure erosion from a space-occupying mass. A narrow strip of flattened bone connected the depression to the posterior-superior aspect of the glenoid. The location and morphology of the depression and its connection with the glenoid are consistent with the effects of a paralabral cyst that arose secondary to a tear of the posterior-superior glenoid labrum. A labral tear may act as a one-way valve permitting fluid to flow along a path of least resistance, often to the spinoglenoid notch. A cyst at the spinoglenoid notch would compress the suprascapular nerve, causing weakened function of infraspinatus and its eventual atrophy.

Transcapsular Decompression of Shoulder Ganglion Cysts

Paralabral cysts are an increasingly recognized cause of suprascapular nerve (SSN) impingement, often causing insidious weakness in the rotator cuff. Compression at the suprascapular notch is often due to the presence of a SLAP tear and leads to pain, weakness, and atrophy of both the supraspinatus and infraspinatus muscles. Compression of the SSN at the spinoglenoid notch leads to weakness and atrophy of the infraspinatus only. Arthroscopic decompression of cysts with repair of labral pathology is typically performed in a sublabral fashion, which may make visualization of the extent of the cyst difficult and places the SSN at increased risk. With any approach, an intimate knowledge of the anatomy of the SSN is vital to safe decompression. We present a surgical technique for decompression of paralabral cysts using an intra-articular transcapsular approach. This approach maximizes visualization and efficiency and reduces possible damage to the SSN.

Arthroscopic Decompression of Spinoglenoid Notch Cyst and SLAP Repair Through a Single Working Portal

A SLAP lesion can be found with a concomitant spinoglenoid notch cyst. The cyst can cause suprascapular nerve compression, resulting in shoulder pain and weakness of external rotation. Their management varies from conservative treatment to operative treatment. Cyst decompression through the labral tear is our preferred treatment. Previous studies demonstrated a good result after arthroscopic decompression of the cyst through the labral tear combined with SLAP repair. Many surgeons usually use 3 portals to perform this procedure. However, we prefer to use only 2 portals, 1 anterior viewing portal and 1 posterior working portal. This strategy is more time and cost efficient. The patient is positioned in lateral decubitus. The SLAP lesion is demonstrated by using a probe. Tissue elevator is inserted into the labral lesion to penetrate into the cyst wall. A soft anchor is placed. A birdbeak suture passer penetrates the posterior labrum. Then knot tying is done. The advantages of this single working portal technique are short operative time, a decreased risk of iatrogenic rotator cuff injury from accessory anterolateral portal or posterior labral injury from posterolateral portal, and avoiding unnecessary superior capsule incision for cyst exposure.

Biceps Tenodesis and Intra-articular Decompression for Treatment of Superior Labral Tear from Anterior to Posterior and Associated Paralabral Cyst in Active Duty Military

Background

To examine the outcomes of combined biceps tenodesis and indirect, intra-articular arthroscopic paralabral cyst decompression for the treatment of active duty military patients with superior labral from anterior to posterior tears and associated paralabral cysts.

Methods

Retrospective chart review of all active duty patients at our institution from 2011 to 2014 with superior labral from anterior to posterior tears and associated paralabral cysts at the spinoglenoid notch treated with biceps tenodesis and indirect arthroscopic cyst decompression. Patient charts were examined for pre- and post-operative parameters including strength, range of motion, visual analog scale pain score, American Shoulder and Elbow Surgeon Score, and Single Assessment Numeric Evaluation Score.

Results

Seven patients met study criteria. All patients presented with chronic shoulder pain and decreased external rotation strength, and three patients had clinically apparent muscular atrophy. Pre- and post-operative assessment showed external rotation strength increased from a median of 4 (range 4-4) to 5 (range 4-5; p-value = 0.014), Single Assessment Numeric Evaluation increased from a median of 50 (range 0-70) to 75 (range 30-95; p-value = 0.031), American Shoulder and Elbow Surgeon increased from a median of 46.0 (range 32.0-58.0) to 66.5 (range 58.0-98.0; p-value = 0.068), and visual analog scale pain score decreased from a median of 3 (range 1-8) to 0 (range 0-5; p-value = 0.017). Median follow-up was 66 wk (range 36-138 wk). The change was statistically significant (p <0.05) for external rotation strength, Single Assessment Numeric Evaluation, and VAS reduction. Post-operatively, all patients returned to full duty at a median of 20 wk (range 12-36 wk).

Conclusion

The use of biceps tenodesis in conjunction with indirect, intra-articular arthroscopic paralabral cyst decompression is an effective technique in an active patient population with superior labral from anterior to posterior tear with associated paralabral cyst.

Arthroscopic management of suprascapular neuropathy of the shoulder improves pain and functional outcomes with minimal complication rates

PURPOSE

The purpose of this study was to systematically assess the arthroscopic management of suprascapular neuropathy, including the aetiology, surgical decision-making, clinical outcomes, and complications associated with the procedure.

METHODS

Three databases [PubMed, Ovid (Medline), and Embase] were searched. Systematic literature screening and data abstraction was performed in duplicate to present a review of studies reporting on arthroscopic management of suprascapular neuropathy. The quality of the included studies was assessed using level of evidence and the MINORS (Methodological Index for Nonrandomized Studies) checklist.

RESULTS

In total, 40 studies (17 case reports, 20 case series, 2 retrospective comparative studies, and 1 prospective comparative study) were identified, including 259 patients (261 shoulders) treated arthroscopically for suprascapular neuropathy. The most common aetiology of suprascapular neuropathy was suprascapular nerve compression by a cyst at the spinoglenoid notch (42%), and the decision to pursue arthroscopic surgery was most commonly based on the results of clinical findings and investigations (47%). Overall, 97% of patients reported significant improvement in or complete resolution of their pre-operative symptoms (including pain, strength, and subjective function of the shoulder) over a mean follow-up period of 23.7 months. Further, there was a low overall complication rate (4%) associated with the arthroscopic procedures.

CONCLUSION

While most studies evaluating arthroscopic management of suprascapular neuropathy are uncontrolled studies with lower levels of evidence, results indicate that such management provides patients with significant improvements in pain, strength, and subjective function of the shoulder, and has a low incidence of complications. Patients managed arthroscopically for suprascapular neuropathy may expect significant improvements in pain, strength, and subjective function of the shoulder.

LEVEL OF EVIDENCE

Level IV, systematic review of level II to IV studies.

Arthroscopic Intra-articular Spinoglenoid Cyst Resection Following SLAP Repair

Spinoglenoid cyst (SGC) is a ganglion arising in the spinoglenoid notch and is thought to be related to SLAP lesion. This cyst often compresses the suprascapular nerve in the spinoglenoid notch. Symptomatic cysts require surgical treatment when conservative treatment fails. In particular, arthroscopic decompression through the torn labral tissue when the cyst is extending into the joint cavity is easy and convenient. However, if the cyst is confined to the spinoglenoid notch, arthroscopic approach through the torn labral tissue is challenging. Thus, we present our preferred technique of addressing the SGC through an additional superior capsular window after completing SLAP repair. We believe that our technique is easy, reproducible, and reasonable.

Suprascapular Nerve Pathology: A Review of the Literature

Background:

Suprascapular nerve pathology is a rare diagnosis that is increasingly gaining popularity among the conditions that cause shoulder pain and dysfunction. The suprascapular nerve passes through several osseoligamentous structures and can be compressed in several locations.

Methods:

A thorough literature search was performed using online available databases in order to carefully define the pathophysiology and to guide diagnosis and treatment.

Results:

Suprascapular neuropathy diagnosis is based on a careful history and a thorough clinical and radiological examination. Although the incidence and prevalence of the condition remain unknown, it is highly diagnosed in specific groups (overhead athletes, patients with a massive rotator cuff tear) probably due to higher interest. The location and the etiology of the compression are those that define the treatment modality.

Conclusion:

Suprascapular neuropathy diagnosis is based on a careful history and a thorough clinical and radiological examination. The purpose of this article is to describe the anatomy of the suprascapular nerve, to define the pathophysiology of suprascapular neuropathy and to present methodically the current diagnostic and treatment strategies.

Pediatric musculoskeletal injuries: role of ultrasound and magnetic resonance imaging

Pediatric musculoskeletal system is particularly prone to traumatic and sports-related injuries, both acute and chronic, i.e., overuse injuries, because of inherent conditions of weakness, such as the open physis, representing the weakest aspect within the bone, the ligamentous supports and changing biomechanics. Being aware that a quick diagnosis is essential to preserve the good functionality of the limb involved, it is mandatory for the radiologist to recognize the most common patterns of these injuries, identifying those requiring a prompt surgery, as well as be confident with the technique performed, and be supported by an important background experience and knowledge skills.

Arthroscopic decompression with indigo carmine for treating paralabral cysts in the shoulder

Paralabral cysts in the shoulder are a relatively rare pathology. It is sometimes difficult to detect the location of a paralabral cyst in the shoulder using arthroscopy, and it can be difficult to confirm sufficient decompression by arthroscopy. We describe the case of a 64-year-old woman who underwent arthroscopic decompression for a paralabral cyst in the shoulder. Indigo carmine was injected into the cyst under ultrasonography guidance just before the operation. The leakage point of indigo carmine was detected using arthroscopy. Arthroscopic decompression was performed until the indigo carmine was completely discharged. Her shoulder pain, limited range of motion, and muscle weakness during abduction and external rotation improved postoperatively. Magnetic resonance imaging confirmed the disappearance of the cyst. Arthroscopic decompression using an ultrasonography-guided injection of indigo carmine is a useful treatment for a paralabral cyst in the shoulder.

The successful arthroscopic treatment of suprascapular intraneural ganglion cysts

OBJECT High-resolution magnetic resonance imaging (MRI) can distinguish between intraneural ganglion cysts and paralabral (extraneural) cysts at the glenohumeral joint. Suprascapular intraneural ganglion cysts share the same pathomechanism as their paralabral counterparts, emanating from a tear in the glenoid labrum. The authors present 2 cases to demonstrate that the identification and arthroscopic repair of labral tears form the cornerstone of treatment for intraneural ganglion cysts of the suprascapular nerve. METHODS Two patients with suprascapular intraneural ganglion cysts were identified: 1 was recognized and treated prospectively, and the other, previously reported as a paralabral cyst, was identified retrospectively through the reinter-pretation of high-resolution MR images. RESULTS Both patients achieved full functional recovery and had complete radiological involution of the intraneural ganglion cysts at the 3-month and 12-month follow-ups, respectively. CONCLUSIONS Previous reports of suprascapular intraneural ganglion cysts described treatment by an open approach to decompress the cysts and resect the articular nerve branch to the glenohumeral joint. The 2 cases in this report demonstrate that intraneural ganglion cysts, similar to paralabral cysts, can be treated with arthroscopic repair of the glenoid labrum without resection of the articular branch. This approach minimizes surgical morbidity and directly addresses the primary etiology of intraneural and extraneural ganglion cysts.

SLAP repair with arthroscopic decompression of spinoglenoid cyst

Introduction: A spinoglenoid cyst with suprascapular nerve disorders is highly associated with superior labrum anterior posterior (SLAP) lesion. Conservative or surgical treatment is applied to relieve pain and neurological symptoms. The purpose of this study was to evaluate clinical outcomes of patients treated by arthroscopic surgery for SLAP lesion with a spinoglenoid cyst.

Methods: The subjects of this study were six patients with SLAP lesion with a spinoglenoid cyst who underwent arthroscopic surgery. There was one female and five males with a mean age of 48.5 years. SLAP lesion was found in all the patients at arthroscopy. A small tear of the rotator cuff was found in the two patients. The SLAP lesion was repaired using suture anchors, and the rotator cuff tears were repaired by suture-bridge fixation. The spinoglenoid cyst was decompressed through the torn labrum in three patients, and through the released superior to posterior portion of the capsule in the other three patients.

Results: All patients showed excellent improvement in pain and muscle strength at the final follow-up examination. The mean Constant score was improved from 60.5 points preoperatively to 97.2 points postoperatively. The mean visual analog scale (VAS) score decreased from 4.5 on the day of the surgery to 2.5 within one week postoperatively. Postoperative MRI showed disappearance or reduction of the spinoglenoid cyst in four and two patients, respectively. There were no complications from the surgical intervention and in the postoperative period.

Discussion: The patients treated by decompression through the released capsule obtained pain relief at an early period after the surgery. Arthroscopic treatment for a spinoglenoid cyst can provide a satisfactory clinical outcome. Arthroscopic decompression of a spinoglenoid cyst through the released capsule is recommended for a safe and reliable procedure for patients with suprascapular nerve disorders.

Arthroscopic release and labral repair for bifocal compression of the suprascapular nerve

We present a rare case of combined proximal and distal compression of the suprascapular nerve causing supra- and infraspinatus weakness and wasting in a 17-year-old rower. Clinical findings, magnetic resonance imaging and electromyeographic studies confirm this. The case was managed with an arthroscopic approach, consisting of arthroscopic labral repair and decompression of a paralabral cyst, combined with arthroscopic release of the transverse scapular ligament. An excellent result was achieved, with the patient returning to full competitive rowing prior to the 6-month clinical review. This case highlights the interesting nature of bifocal compression of the suprascapular nerve, as well as the successful use of arthroscopic techniques to manage the problem.

INDIRECT ARTHROSCOPIC DECOMPRESSION OF SPINOGLENOID CYST WITH SUPRASCAPULAR NEUROPATHY: REPORT OF TWO CASES AND LITERATURE REVIEW

Suprascapular nerve compression is rare and should be considered in the differential diagnosis of patients with shoulder pain and external rotation deficit. Spinoglenoidal cysts may cause compression, and posterosuperior glenoid labrum lesions are the most likely hypothesis to explain their appearance. Magnetic resonance imaging and electromyography define the diagnosis. Indirect arthroscopic decompression of the cyst and repair of the glenoid labrum enable complete neurological recovery. The authors report two cases of isolated paralysis of the infraspinatus muscle caused by compression due to spinoglenoidal cysts that were treated by means of arthroscopy, and present the pre and postoperative assessments.

Outcome After Arthroscopic Decompression of Inferior Labral Cysts Combined With Labral Repair

PURPOSE

To analyze the clinical and radiologic outcomes of arthroscopic cyst decompression and labral repair in patients with inferior paralabral cysts with chronic shoulder pain.

METHODS

Between March 2006 and September 2012, 16 patients who were identified as having inferior paralabral cysts presented with chronic shoulder pain. All patients underwent a thorough physical examination and preoperative magnetic resonance arthrographic evaluation. The mean age was 30 years (range, 17 to 50 years). The mean follow-up period was 38 months (range, 16 to 60 months). Clinical outcome scores (American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test) and passive shoulder range of motion were evaluated at last follow-up. Follow-up magnetic resonance imaging was performed at a mean of 8 months to determine the labral healing status and assess for cyst recurrence.

RESULTS

The incidence of isolated inferior paralabral cysts was 0.6% (16 of 2,656 cases). Of the patients, 8 had multiple cysts and 8 had a single cyst. The mean length and width of the cysts were 1.0 cm and 0.4 cm, respectively. Eight cases had a history of trauma, and 13 patients were involved in sports activities. Seventy-five percent of cases showed a positive relocation test. The mean American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test scores improved from 64, 22, and 8.7, respectively, preoperatively to 83, 31, and 10, respectively (P < .001), at final follow-up. Shoulder range of motion did not show any significant improvement. The location of the labral tear was as follows: anteroinferior tear in 5 cases, posteroinferior tear in 8 cases, and combined anteroinferior and posteroinferior tear in 3 cases. All cysts were found to be in association with a labral tear. A mean of 2.7 anchors were used for inferior labral repair. These cysts were found only in male patients. None of the patients showed any evidence of cyst recurrence on follow-up magnetic resonance imaging.

CONCLUSIONS

Inferior labral tears treated with cyst decompression and labral repair showed satisfactory clinical results without any recurrence. Inferior paralabral cysts should be considered in the differential diagnosis in patients presenting with chronic shoulder pain, particularly active male patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Spectrum of suprascapular nerve lesions: normal and abnormal neuromuscular imaging appearances on 3-T MR neurography

OBJECTIVE. In this article, we will review the normal anatomy and imaging features of various neuromuscular abnormalities related to suprascapular neuropathy. CONCLUSION. Suprascapular neuropathy can be difficult to distinguish from rotator cuff pathology, plexopathy, and radiculopathy. Electrodiagnostic studies are considered the reference standard for diagnosis; however, high-resolution 3-T MR neurography (MRN) can play an important role. MRN enables direct visualization of the nerve and simultaneous assessment of the cervical spine, brachial plexus, and rotator cuff.

Gas-Containing Paralabral Ganglion Cyst of the Shoulder: A Case Report

CASE

A thirty-three-year-old woman presented with right shoulder pain and moderate atrophy of the infraspinatus muscle, with grade-4 (of 5) external rotation strength. Magnetic resonance imaging showed a gas-containing ganglion cyst. Surgical excision and arthroscopic evaluation were performed. The extra-articular arthroscopic view of the ganglion showed bubbles within the mucous material. One year after surgery, she had pain-free, normal range of motion and normal strength of the affected shoulder.

CONCLUSION

We report a rare case of a gas-containing ganglion cyst that originated in the posterosuperior glenohumeral capsule and caused entrapment of the suprascapular nerve.

Arthroscopic Treatment of Suprascapular Neuropathy from a Suprascapular Notch Cyst Using a Lateral Subacromial Approach

Introduction

We describe a safe surgical technique for arthroscopic decompression of a suprascapular notch cyst in the setting of compressive suprascapular neuropathy.

Step 1: Position the Patient

Position the patient in the standard beach-chair position.

Step 2: Mark Anatomic Landmarks

Palpate and mark the subcutaneous landmarks of the shoulder in preparation for later arthroscopy.

Step 3: Diagnostic Arthroscopy

Create standard anterior and posterior portals for glenohumeral visualization.

Step 4: Perform Suprascapular Cyst Decompression Through a Lateral Subacromial Approach

Establish accessory superior and lateral portals and transition to a lateral viewing portal to perform suprascapular notch decompression.

Step 5: Release the Transverse Scapular Ligament

Establish a G Portal and release the transverse scapular ligament using arthroscopic scissors.

Step 6: Closure

Perform arthroscopic lavage of the subacromial space and glenohumeral joint and close arthroscopic portals.

Results

As suprascapular nerve entrapment is a relatively rare entity, with only a limited number of studies from which to draw conclusions regarding the outcomes of arthroscopic suprascapular nerve release, Shah et al. recently reported on their results in twenty-four patients using this surgical technique.

Indications

Contraindications

Pitfalls & Challenges

Acetabular paralabral cyst: an unusual cause of femoral vein compression

Acetabular labral tears are a known cause of hip pain in the young, active patient. Labral tears can be due to trauma, femoroacetabular impingement, capsular laxity, dysplasia, and degenerative pathology. Paralabral cysts are relatively common in association with labral tears of the hip, with cysts seen on magnetic resonance imaging studies in as many as 50% to 70% of patients with labral tears. In some cases the cysts can become sizeable and cause neurovascular compression. Nonoperative interventions for the management of paralabral cysts in the shoulder and knee have shown high recurrence rates. In the shoulder and knee, arthroscopic debridement of paralabral cysts has shown good results with lower recurrence rates and resolution of neurovascular function. In the hip there is limited literature regarding surgical management of paralabral cysts. We present a surgical technique for arthroscopic decompression of acetabular paralabral cysts combined with labral repair.

Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst in the shoulder

BACKGROUND

The purpose of this study was to report the outcomes of all-intra-articular arthroscopic decompression and labral repair in patients with symptomatic paralabral cysts.

METHODS

From 2005 to 2011, 20 consecutive cases of symptomatic paralabral cysts were included in this study. All surgical procedures were conducted with intra-articular arthroscopic decompression by use of a probe through the site of labral tear for cyst evacuation and suture anchor repair for the associated posterosuperior labrum. Clinical scores and magnetic resonance imaging (MRI) were obtained preoperatively and at follow-up. MRI was used to evaluate the size and segmentation of the cyst and the presence of the labral tear.

RESULTS

MRI revealed paralabral cysts in association with labral tears in all cases. Cysts were extended in the spinoglenoid notch with a mean size of 2.5 × 2.6 × 2.2 cm on MRI. Cysts were nonsegmented in 5 cases (25%) and had multiple segments in 15 cases (75%). Mean follow-up was 42.8 ± 21.22 months. The mean visual analog scale score for pain, the American Shoulder and Elbow Surgeons score, and the Simple Shoulder Test score significantly improved at the last follow-up (P < .001, P < .001, and P = .001, respectively). The postoperative MRI study performed at a mean of 6 months for 18 of 20 cases (90%) revealed complete cyst removal. The satisfaction level with surgery was good to excellent in 18 patients, fair in 1 patient, and poor in 1 patient. No complication was related to the surgical procedure.

CONCLUSION

Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst can be a simple and effective treatment, regardless of segmentation or size. It also resulted in complete removal of the cyst at a mean of 6 months postoperatively as revealed by MRI. An additional subacromial procedure might not be necessary for complete decompression.

Type 2 Superior Labral Anterior to Posterior Lesion-Related Paralabral Cyst Causing Isolated Infraspinatus Paralysis: Two Case Reports

Type 2 superior labral anterior to posterior (SLAP) lesion is a common cause of shoulder pain requiring surgical operation. SLAP tears are often associated with paralabral cysts, but they rarely cause nerve compression. However, we experienced two cases of type 2 SLAP-related paralabral cysts at the spinoglenoid notch which were confirmed as isolated nerve entrapment of the infraspinatus branch of the suprascapular nerve by electrodiagnostic assessment and magnetic resonance imaging. In these pathological conditions, comprehensive electrodiagnostic evaluation is warranted for confirmation of neuropathy, while surgical decompression of the paralabral cyst combined with SLAP repair is recommended.

SLAP Lesion with Supraglenoid Labral Cyst causing Suprascapular Nerve Compression: A case report

ABSTRACT

We present a case of left suprascapular nerve palsy in a 39- year-old female secondary to compression from a large ganglion cyst. She presented with a two month history of left posterior shoulder pain which affected her work and disturbed her sleep. Clinical examination revealed a positive O'Brien's test. Supraspinatus and infraspinatus strength was mildly weakened. A magnetic resonance imaging (MRI) scan of the left shoulder revealed a superior labral anterior to posterior (SLAP) lesion with a large supraglenoid labral cyst extending posteriorly to the spinoglenoid notch, resulting in compression of the suprascapular nerve. Arthroscopy revealed the SLAP lesion with a haemorrhagic labral cyst at the posterosuperior aspect. Arthroscopic decompression of the cyst and SLAP repair with two suture anchors was performed. At 22 months postoperative follow-up, the patient's left shoulder remained asymptomatic with full range of motion and full strength.

KEY WORDS

SLAP lesion; Supraglenoid Labral Cyst; Suprascapular Nerve Compression.

The effect of infraspinatus hypotrophy and weakness on the arthroscopic treatment of spinoglenoid notch cyst associated with superior labrum anterior-to-posterior lesions

PURPOSE

Patients with spinoglenoid notch cyst associated with superior labrum anterior-to-posterior (SLAP) lesions were evaluated. The patients were all treated by arthroscopic cyst decompression combined with SLAP repair. The hypothesis of the study was that the patients who underwent prolonged conservative treatment period prior to surgery would exhibit significant infraspinatus hypotrophy and weakness, and their postoperative clinical and functional outcomes would be less satisfactory.

METHODS

Sixteen patients exhibited positive MRI and EMG findings with clinical signs of weakness and pain. The median age was 40.5 years (range 32-52), and the study group consisted of 11 males and 5 females with a median follow-up period of 26 months (12-48). The median duration of symptoms and conservative treatment prior to the surgical intervention was 3.5 months (1-14). Seven patients in group A exhibited infraspinatus hypotrophy. Group B comprised 9 patients without infraspinatus hypotrophy.

RESULTS

The results of the pre- and postoperative Constant scores, visual analogue scale (VAS) scores, and external rotation strength test rates were compared between groups. They all improved in terms of pain, strength, and function (P < 0.05). Significant differences were observed between the pre- and postoperative external rotation strengths and Constant scores (P < 0.05). However, no significant difference was observed between the pre- and postoperative VAS scores (n.s.). A significant correlation was observed in group A between surgical timing, the preoperative external rotation strength ratio (P = 0.04) and the postoperative VAS scores (P = 0.013).

CONCLUSION

The arthroscopic treatment was satisfactory with good clinical outcomes. Infraspinatus hypotrophy occurred in cases of prolonged surgical duration and significantly affected external rotation strength and functional outcomes.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.