Proximal vs Distal Approach of Ultrasound-guided Suprascapular Nerve Block for Patients With Adhesive Capsulitis of the Shoulder: Prospective Randomized Controlled Trial

Published:December 01, 2020DOI:



      To evaluate the early clinical outcomes of ultrasound (US)-guided suprascapular nerve block (SSNB) using a proximal approach compared with a distal approach for outpatient treatment of adhesive capsulitis.


      Randomized controlled trial.


      Outpatient clinic


      Participants (N=47) with symptomatic adhesive capsulitis.


      Participants were randomly assigned to either US-guided SSNB using a proximal approach (n=23, proximal group) or a distal approach (n=24, distal group).

      Main Outcome Measures

      The primary outcome measure was the visual analog scale (VAS) for pain at week 12. Secondary outcomes included the American Shoulder Elbow Surgeon’s (ASES) score, University California Los Angeles score, Short Form-36 mental and physical component summaries, and range of motion. All patients completed clinical follow-up at 2, 6, and 12 weeks after treatment. On US images, depth and insertion angle of needle during injection were measured.


      The VAS significantly improved in both groups at week 12. After treatment, no significant differences were found in early clinical outcomes (weeks 2, 6, and 12) between groups (all P>.05), except that ASES at 2 weeks showed a significantly higher score in the distal group than in the proximal group (87.1±4.8 and 83.0±6.3, respectively; P=.014). The mean depth and insertion angle of needle was significantly lower (depth: 13.4±3.9 and 30.6±4.3 mm, respectively; P<.001; insertion angle: 19.6°±6.4° and 38.7°±5.8°; P<.001) in the proximal group than in the distal group.


      This study demonstrated that proximal approach of US-guided SSNB provided favorable short-term outcomes of pain and functional improvement and that outcomes were comparable to those of the distal approach in adhesive capsulitis. The suprascapular nerve was located more superficially and easily identified in the proximal approach, suggesting that this method might improve the accuracy of injection.


      List of abbreviations:

      ASES (American Shoulder Elbow Surgeon’s score), MCID (minimal clinically important difference), SF36-MCS (Short Form-36 mental component summary), SF36- PCS (Short Form-36 physical component summary), SSN (suprascapular nerve), SSNB (suprascapular nerve block), UCLA (University of California Los Angeles score), US (ultrasound), VAS (visual analog scale)
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        • Dahan T.H.
        • Fortin L.
        • Pelletier M.
        • Petit M.
        • Vadeboncoeur R.
        • Suissa S.
        Double blind randomized clinical trial examining the efficacy of bupivacaine suprascapular nerve blocks in frozen shoulder.
        J Rheumatol. 2000; 27: 1464-1469
        • Jones D.S.
        • Chattopadhyay C.
        Suprascapular nerve block for the treatment of frozen shoulder in primary care: a randomized trial.
        Br J Gen Pract. 1999; 49: 39-41
        • Chang K.V.
        • Hung C.Y.
        • Wang T.G.
        • Yang R.S.
        • Sun W.Z.
        • Lin C.P.
        Ultrasound-guided proximal suprascapular nerve block with radiofrequency lesioning for patients with malignancy-associated recalcitrant shoulder pain.
        J Ultrasound Med. 2015; 34: 2099-2105
        • Park J.Y.
        • Bang J.Y.
        • Oh K.S.
        Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3877-3883
        • Ritchie E.D.
        • Tong D.
        • Chung F.
        • Norris A.M.
        • Miniaci A.
        • Vairavanathan S.D.
        Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?.
        Anesth Analg. 1997; 84: 1306-1312
        • Vorster W.
        • Lange C.P.
        • Briet R.J.
        • et al.
        The sensory branch distribution of the suprascapular nerve: an anatomic study.
        J Shoulder Elbow Surg. 2008; 17: 500-502
        • Harmon D.
        • Hearty C.
        Ultrasound-guided suprascapular nerve block technique.
        Pain Physician. 2007; 10: 743-746
        • Peng P.W.
        • Wiley M.J.
        • Liang J.
        • Bellingham G.A.
        Ultrasound-guided suprascapular nerve block: a correlation with fluoroscopic and cadaveric findings.
        Can J Anaesth. 2010; 57: 143-148
        • Podgorski M.
        • Rusinek M.
        • Cichosz M.
        • Olewnik L.
        • Polguj M.
        • Grzelak P.
        "Pseudo-suprascapular notch": is it a sonographic trap in suprascapular nerve block?.
        Reg Anesth Pain Med. 2019; 44: 77-80
        • Siegenthaler A.
        • Moriggl B.
        • Mlekusch S.
        • et al.
        Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach.
        Reg Anesth Pain Med. 2012; 37: 325-328
        • Taskaynatan M.A.
        • Ozgul A.
        • Aydemir K.
        • Koroglu O.O.
        • Tan A.K.
        Accuracy of ultrasound-guided suprascapular nerve block measured with neurostimulation.
        Rheumatol Int. 2012; 32: 2125-2128
        • Rothe C.
        • Steen-Hansen C.
        • Lund J.
        • Jenstrup M.T.
        • Lange K.H.
        Ultrasound-guided block of the suprascapular nerve - a volunteer study of a new proximal approach.
        Acta Anaesthesiol Scand. 2014; 58: 1228-1232
        • Laumonerie P.
        • Ferre F.
        • Cances J.
        • et al.
        Ultrasound-guided proximal suprascapular nerve block: a cadaveric study.
        Clin Anat. 2018; 31: 824-829
        • Bae K.H.
        • Kim H.H.
        • Lim T.K.
        Proximal approach of ultrasound-guided suprascapular nerve block: comparison with subacromial steroid injection.
        Clin Should Elbow. 2019; 22: 210-215
        • Ko K.-P.
        • Kang D.-H.
        • Shin B.-K.
        [The proximal approach in an ultrasound-guided suprascapular nerve block] [Korean].
        J Korean Orthop Assoc. 2017; 52: 521-528
        • Zuckerman J.D.
        • Rokito A.
        Frozen shoulder: a consensus definition.
        J Shoulder Elbow Surg. 2011; 20: 322-325
        • Laucis N.C.
        • Hays R.D.
        • Bhattacharyya T.
        Scoring the SF-36 in orthopaedics: a brief guide.
        J Bone Joint Surg Am. 2015; 97: 1628-1634
        • Brazier J.E.
        • Harper R.
        • Jones N.M.
        • et al.
        Validating the SF-36 health survey questionnaire: new outcome measure for primary care.
        BMJ. 1992; 305: 160-164
        • Han S.H.
        • Oh K.S.
        • Han K.J.
        • Jo J.
        • Lee D.H.
        Accuracy of measuring tape and vertebral-level methods to determine shoulder internal rotation.
        Clin Orthop Relat Res. 2012; 470: 562-566
        • Coory J.A.
        • Parr A.F.
        • Wilkinson M.P.
        • Gupta A.
        Efficacy of suprascapular nerve block compared with subacromial injection: a randomized controlled trial in patients with rotator cuff tears.
        J Shoulder Elbow Surg. 2019; 28: 430-436
        • Jerosch J.
        • Saad M.
        • Greig M.
        • Filler T.
        Suprascapular nerve block as a method of preemptive pain control in shoulder surgery.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 602-607
        • Dorn C.
        • Rumpold-Seitlinger G.
        • Farzi S.
        • Auer J.
        • Bornemann-Cimenti H.
        The effect of the modified lateral suprascapular block on shoulder function in patients with chronic shoulder pain.
        Anesth Pain Med. 2015; 5e31640
        • Chan C.W.
        • Peng P.W.
        Suprascapular nerve block: a narrative review.
        Reg Anesth Pain Med. 2011; 36: 358-373
        • Jung T.W.
        • Lee S.Y.
        • Min S.K.
        • Lee S.M.
        • Yoo J.C.
        Does combining a suprascapular nerve block with an intra-articular corticosteroid injection have an additive effect in the treatment of adhesive capsulitis? A comparison of functional outcomes after short-term and minimum 1-year follow-up.
        Orthop J Sports Med. 2019; 7 (2325967119859277)
        • Blasco L.
        • Laumonerie P.
        • Tibbo M.
        • et al.
        Ultrasound-guided proximal and distal suprascapular nerve blocks: a comparative cadaveric study.
        Pain Med. 2020; 21: 1240-1247
        • Price D.
        Novel ultrasound-guided suprascapular nerve block.
        Reg Anesth Pain Med. 2012; 37: 676-677
        • Ferre F.
        • Cugnin N.
        • Martin C.
        • et al.
        Regional anesthesia with noninvasive ventilation for shoulder surgery in a patient with severe chronic obstructive pulmonary disease: a case report.
        A A Case Rep. 2017; 8: 261-264
        • Lee J.H.
        • Cho S.H.
        • Kim S.H.
        • et al.
        Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL.
        Can J Anaesth. 2011; 58: 1001-1006
        • Zhang H.
        • Miao Y.
        • Qu Z.
        Ultrasound-guided subomohyoid suprascapular nerve block and phrenic nerve involvement: a cadaveric dye study: a promising nerve block for shoulder surgery.
        Reg Anesth Pain Med. 2019 Jun 7; ([Epub ahead of print])
        • Tashjian R.Z.
        • Deloach J.
        • Green A.
        • Porucznik C.A.
        • Powell A.P.
        Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease.
        J Bone Joint Surg Am. 2010; 92: 296-303
        • Farrar J.T.
        • Young Jr., J.P.
        • LaMoreaux L.
        • Werth J.L.
        • Poole R.M.
        Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale.
        Pain. 2001; 94: 149-158