Working Diagnosis:
Supraclavicular nerve impingement

Treatment:
Performed hydrodissection of the anterior shoulder using 5% dextrose (D5) solution under ultrasound guidance using a GE Logiq e linear probe. There was one needlestick used for this intervention.

First, the intermediate branch of the supraclavicular nerve was targeted over the clavicle, AC joint, and deltoid using a total of 15ml D5. Next, 10ml D5 was injected into the anterior deltoid central tendon Case Photo #1 and pinnations of the deltoid. Several trigger point reactions were visualized.

Outcome:
On 1 week follow up, the patient's pain had resolved. On 4 week follow up, his pain remains resolved, and he has returned to playing volleyball 1-2 days per week without symptoms.

Author's Comments:
Anterior shoulder pain in the overhead athlete is a common issue seen in sports medicine clinics. A less commonly considered source of this pain is supraclavicular nerve impingement. The intermediate branch of the supraclavicular nerve originates from anterior rami of C3-4, and provides sensory innervation over the pectoralis major and deltoid muscles Case Photo #2 (highlighted in pink). The course of this nerve is of particular interest in this case, as it travels superolaterally over the clavicle and anterolaterally over the deltoid. The patient had a largely reassuring workup, and after noting his tenderness to sonopalpation over the deltoid branches, impingement of this nerve was felt to be the likely etiology. The decision was made to perform hydrodissection of this nerve, which resulted in significant and lasting improvement in pain.

Editor's Comments:
The supraclavicular nerve branches off the cervical plexus and courses along bony
canals, fibrous bands, and muscular structures to provide sensory innervation to the
shoulder, upper chest, and neck. Although rare, supraclavicular nerve impingement can
lead to pain, paresthesia, and weakness. Common causes of impingement involve
physiological or traumatic anatomical variations of the clavicle, resulting in thoracic
outlet syndrome, degenerative changes, or direct neural injury. In an athlete, repetitive
overhead activities can cause altered scapular kinematics and rotator cuff pathology,
which can contribute to impingement by altering the mechanics of the shoulder joint.
Thus, diagnosis of this condition often requires advanced imaging studies such as CT or
MRI scans to help identify anatomical variants or pathologies that may be present.
Conservative treatment options include medications for neuropathic pain and local
glucocorticoid injections for its anti-inflammatory effects. Hydrodilation, or
hydrodissection, involves the injection of fluid to mechanically separate the nerve from
surrounding tissues and relieve compression. Favorable outcomes with various
injectates have been observed, including normal saline, 5% dextrose in water (D5W),
corticosteroids, and local anesthetics. Ultrasound guidance has played a key role in
ensuring accurate anatomical visualization, thus increasing effectiveness and safety. If
conservative management fails, surgical interventions such as nerve decompression
may be necessary to relieve symptoms.

References:
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effectiveness and safety of commonly used injectates for ultrasound-guided
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