A 48-year-old male recreational football player presents with a three-month history of right shoulder pain. The pain is felt in the deltoid region and has been aggravated by overhead activity. He cannot identify a clear precipitant. On examination he was found to have a painful arc and positive rotator cuff impingement signs. The most marked finding however was of significant, isolated weakness of shoulder external rotation.
An x-ray series of the shoulder was normal. MRI images show a multi-septated paralabral cyst arising from the posterosuperior glenoid margin and extending into the spinoglenoid notch and the infraspinatus fossa. This is causing compression of the suprascapular neurovascular bundle against the scapula and is associated with neuropathic signal change within infraspinatus. There was subtle irregular intermediate signal change within the superior labrum but no obvious tear or other abnormality in this structure.
This patient elected to undergo a guided aspiration of the cyst (with infiltration of steroid). This was done without complication. Within three months there was a definite improvement in his pain and weakness. He had returned to all normal activities and was satisfied with his shoulder function at nine-month follow-up.
It is likely that this cyst was caused by an abnormality to the posterior labrum (allowing normal joint fluid to accumulate). While this patient was successfully managed with aspiration this is not always the case. Many patients do not respond to this treatment, or only transiently respond. In this situation, surgical decompression and labral repair are generally needed. One case series estimates the success of aspiration alone at only 50%.
A paralabral cyst (at the level of the scapular spine) should be suspected whenever there is isolated painless weakness of infraspinous. The cyst compresses the suprascapular nerve and impairs its function. The nerve can also be affected more proximally at the suprascapular notch. This often happens after repeated overhead activity (classically in volleyball players). When compression happens at this level both supraspinatus and infraspinatus are generally affected.
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