Suprascapular Nerve Block Disrupts The Normal Pattern Of Scapular Kinematics Sean McCully David...
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Suprascapular Nerve Block Disrupts The Normal Pattern Of Scapular Kinematics
Sean McCullyDavid SuprakPeter Kosek
Andrew Karduna
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Rotator Cuff Tears
• Incidence as high as 40% for people 40 years and older
• Disruption of motion between the scapula and humerus, may result in alterations in:
- muscle moment arms- compression of cuff tendons- joint stability
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Pathology of Cuff Tears
• Majority start with supraspinatus tendon
• Next most commonly involved is the infraspinatus tendon
supraspinatus
infraspinatus
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Models of Cuff Tear or Dysfunction
• Animal modelsinjection of collagenase (Soslowsky et al, 2002) injection of carrageenan (Tillander et al, 2001)
• Cadaver modelssurgical simulation of tears (Parsons et al., 2002)simulated paralysis (Sharkey et al., 1994)
• In-vivo modelsmuscle fatigue (Ebaugh et al., 2005)
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Suprascapular Nerve
superior trunk of brachial plexus
passes through suprascapular notch
innervates supraspinatus and infraspinatus
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Suprascapular Nerve Block
• Performed clinically for pain relief due to arthritis, frozen shoulder and operations
• Used in biomechanical studies of:
Strength
Colachis and Strohm, 1971; Howell et al, 1986; Kuhlman et al, 1992
Glenohumeral Kinematics
Howell et al, 1991
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Purpose
Investigate the use a suprascapular nerve block as an model of dysfunction of the supraspinatus and infraspinatus.
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Protocol
• 15 healthy subjects (mean age 26 years)
Baseline kinematics and force
Suprascapular nerve block
Repeat kinematics and force
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KINEMATICS
• ISB recommendation (Wu et al, 2005)
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Polhemus 3Space Fastrak
electronics unit
digitizer
sensors
transmitter
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Scapular Tracker
sensor
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Method Validation
bone sensor
skin sensor
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Sensor Placement
humerus
scapula
thorax
transmitter
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Scapular Rotations
Retraction/Protraction
Anterior/Posterior Tilting
Lateral/Medial Rotation
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Clavicular Rotations
Retraction/ProtractionElevation/Depression
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ISOMETRIC FORCE
• External rotation with arm at the side
• Data recorded with a load cell
• At this position, 75% of external rotation torque comes from infraspinatus and supraspinatus (Kuechle et al, 2000)
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NERVE BLOCK
• 100 mg of lidocaine
• Injected into the suprascapular notch
• Nerve stimulator to confirm needle placement
• Data collection 10 minutes after injection
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scapulartracker
needle
stimulationwire
lidocaineinjection
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Subject Inclusion
• Threshold of 50% reduction in external rotation force (Colachis and Strohm, 1971)
4 subjects did not meet criterion
• Additional subject excluded due to inability to lift arm
• n=10 for statistical analysis
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Results
• No effect on clavicular rotation
• No effect on scapular posterior tilting
• Significant effect for scapular internal rotation and upward rotation
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Internal Rotation
10
15
20
25
30
35
40
0 20 40 60 80 100 120
Sca
pu
lar
Rot
atio
n [
deg
]
Humeral Elevation [deg]
External
Internal
**
* ** *pre-block
post-block
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0
5
10
15
20
25
30
35
0 20 40 60 80 100 120
Sca
pu
lar
Rot
atio
n [
deg
]
Humeral Elevation [deg]
Downward
Upward
*
**
*
*
*
**
pre-block
post-block
Upward Rotation
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0
1
2
3
4
5
6
7
0 20 40 60 80 100 120
Sca
pu
lar
Rot
atio
n [
deg
]
Humeral Elevation [deg]
Downward
Upward
*
**
**
*
*
*
increase in upward rotation
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0
1
2
3
4
5
6
7
0 20 40 60 80 100 120S
cap
ula
r R
otat
ion
[d
eg]
Humeral Elevation [deg]
Downward
Upward
*
**
**
*
*
*
increase in upward rotation
Nerve Block
0
5
10
15
20
0 30 60 90 120 150
Incr
ease
in U
R [
deg
]
Arm Elevation [deg]
averaged from: Paletta, 1997 Yamaguchi, 2000 Mell, 2005
Cuff Tears0
3
6
9
20 40 60 80 100 120 140 160
Sca
pu
lar
Rot
atio
n [
deg
]
Humeral Elevation [deg]
Downward
Upward*
*
*
*
Fatigue
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Discussion
• Results support use of model
• Although the supraspinatus and infraspinatus do not directly control the movement of the scapula, they appear to indirectly affect the scapulothoracic rhythm.
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Limitations
• Assessment of successful block
• Proprioception
• Young subjects
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What does this mean?
A) Results similar to cuff tears
Scapular changes due to tears are compensatory and represent an alternative method for arm elevation
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What does this mean?
B) Results similar to fatigue
Scapular changes during to repetitive motion are due to fatigue of the rotator cuff muscles and may lead to cuff tears
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What does this mean?
C) What is going on in the subacromial space?
increaseupward rotation
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