Fact-checked by Grok 2 weeks ago

Subscapular nerves

The subscapular nerves are a pair of motor nerves—the upper subscapular nerve and the lower subscapular nerve—that arise from the posterior cord of the brachial plexus and provide innervation to the subscapularis muscle, with the lower nerve additionally supplying the teres major muscle.^[1] These nerves originate from spinal roots C5 and C6, emerging in the axilla and traveling along the posterior aspect of the subscapularis to reach their targets within the subscapular fossa of the scapula.^[2] The upper subscapular nerve, the smallest and shortest of the pair with a mean length of approximately 5 cm and diameter of 2.3 mm, typically enters the superior belly of the subscapularis 15–38 mm inferior to its upper border.^[1] In contrast, the lower subscapular nerve, with a mean length of 3.5 cm to the subscapularis branch and 6 cm to the teres major and a diameter of 1.9 mm, pierces the inferior belly of the subscapularis about 3 to 5 cm from the coracoid process, often splitting to innervate both muscles.^[2] Functionally, the subscapular nerves enable internal rotation of the humerus at the glenohumeral joint and contribute to shoulder stabilization by maintaining the humeral head within the glenoid fossa, with the subscapularis acting as the primary internal rotator among the rotator cuff muscles.^[1] Anatomical variations are prevalent; 82% of cases have three nerves to the subscapularis, with the upper nerve originating from the posterior cord in over 90% of instances (51% single, 45% two upper nerves, 4% three), while the lower nerve arises from the posterior cord in 79% but from the axillary nerve in 21%, and branches in about 6% of cases.^[1]^[2] Such variability has clinical significance in shoulder surgeries like arthroplasty, where inadvertent damage during subscapularis tendon release or muscle splitting can lead to denervation, weakness, and impaired internal rotation.^[1]

Anatomy

Origin

The subscapular nerves collectively arise from the posterior cord of the brachial plexus, which is formed by the posterior divisions of the upper, middle, and lower trunks, carrying fibers from spinal roots C5 through C8. Nomenclature varies; some sources classify the subscapular nerves as two (upper and lower), while others include the middle (thoracodorsal) as the third.^[3]^[4] This origin positions them as early branches in the axillary region, contributing to the motor innervation of key shoulder girdle muscles.^[5] The upper subscapular nerve, the most proximal of the group, typically originates directly from the posterior cord, with contributions from C5 and C6 roots.^[3] In approximately 97% of cases, it branches independently from the posterior cord, while in 3% it arises directly from the axillary nerve shortly after the latter's formation.^[2] This nerve is the first branch off the posterior cord in standard anatomy.^[5] The middle subscapular nerve, also known as the thoracodorsal nerve, emerges from the posterior cord at the level of C6 through C8 roots.^[3] Historically referred to as the middle subscapular nerve due to its inclusion in the subscapular group, it was renamed thoracodorsal to reflect its primary innervation target, though it remains classified among the subscapular nerves in brachial plexus nomenclature.^[6] It branches from the posterior cord distal to the upper subscapular nerve.^[5] The lower subscapular nerve originates from the posterior cord distal to the upper subscapular nerve, and receives fibers from C5 and C6 roots.^[3] This positioning allows it to course alongside the thoracodorsal artery in the axilla.^[5]

Course and distribution

The subscapular nerves originate from the posterior cord of the brachial plexus and course posteriorly from the axilla toward the scapular region, generally traveling behind the axillary artery while avoiding entanglement with major vessels beyond their proximal segment.^[4]^[7] The upper subscapular nerve is the smallest and shortest of the three, with a mean length of approximately 5 cm from origin to termination and a mean diameter of 2.3 mm; it pierces the superior portion of the subscapularis muscle without branching.^[2]^[4] The middle subscapular nerve, also known as the thoracodorsal nerve, is the longest, measuring a mean of 13.7 cm from origin to termination with a mean diameter of 2.6 mm; it descends along the posterior wall of the axilla, courses inferiorly and laterally superficial to the thoracodorsal artery and vein, and pierces the latissimus dorsi muscle on its medial surface near the lower border.^[2]^[8]^[4] The lower subscapular nerve, with a mean diameter of 1.9 mm; it courses inferiorly for approximately 3.5 cm from its origin before bifurcating, with the upper branch supplying the inferior subscapularis and the lower branch extending an additional 6 cm to reach the teres major, traveling in the angle between the subscapular and circumflex scapular arteries.^[2]^[9]^[4]

Function

Motor innervation

The subscapular nerves are purely motor branches of the posterior cord of the brachial plexus, lacking any sensory components.^[10] The upper subscapular nerve arises from spinal segments C5 and C6 and provides motor innervation exclusively to the superior portion of the subscapularis muscle.^[11] The lower subscapular nerve, derived from segments C5 and C6, typically bifurcates into an upper branch that innervates the inferior portion of the subscapularis muscle and a lower branch that supplies the teres major muscle.^[3]^[12] Together, the upper and lower subscapular nerves provide dual innervation to the subscapularis muscle, with the upper nerve covering the superior two-thirds and the lower nerve the inferior third, ensuring comprehensive motor supply to this rotator cuff muscle.^[13]

Role in shoulder movement

The subscapular nerves, through their innervation of key shoulder muscles, play essential roles in facilitating coordinated arm and shoulder dynamics. The upper and lower subscapular nerves supply the subscapularis muscle, which serves as the primary internal rotator of the humerus at the glenohumeral joint and acts to depress the humeral head during abduction, thereby stabilizing the joint against superior migration.^[14] This stabilization is critical for maintaining glenohumeral congruence during overhead activities, where the subscapularis counters the upward pull of the deltoid muscle.^[15] A branch of the lower subscapular nerve extends to the teres major muscle, which assists in adduction, extension, and internal rotation of the humerus.^[16] Collectively, these nerves contribute to the integrated function of the rotator cuff (via subscapularis) and teres major, promoting shoulder stability and preventing excessive humeral translation during dynamic movements.^[14] Electromyographic studies reveal distinct activation patterns: the subscapularis exhibits high activity during resisted internal rotation tasks, often reaching up to 44% of maximum voluntary contraction.^[17]

Variations

Types of variations

The subscapular nerves display notable anatomical variations, particularly in their points of origin from the brachial plexus and in the presence of accessory branches. The upper subscapular nerve, which innervates the superior portion of the subscapularis muscle, most commonly arises from the posterior division of the superior trunk of the brachial plexus (in approximately 50% of cases) or from the posterior cord, though origins from the axillary nerve occur in about 5.4% of specimens. Accessory upper subscapular nerves, providing additional innervation to the upper subscapularis, have been documented with incidences ranging from 7.4% to 48.5% for single accessories and 0% to 6.1% for double accessories across various cadaveric studies.^[18]^[19]^[20] In contemporary anatomical nomenclature, the thoracodorsal nerve is occasionally excluded from the subscapular nerve group due to its primary innervation of the latissimus dorsi rather than the subscapularis muscle.^[8] Variations in the lower subscapular nerve, which supplies the inferior subscapularis and teres major, frequently involve its origin, with reports indicating it arises from the axillary nerve in 25% to 57.5% of cases rather than the standard posterior cord (37.5% to 75%). Branching patterns can deviate from the typical bifurcation, with some instances featuring a single undivided branch innervating both the inferior subscapularis and teres major, though precise incidence rates for this remain variably reported across populations. The nerve's length exhibits variability, generally spanning several centimeters within the axilla.^[21]^[22] Overall innervation of the subscapularis muscle shows variability, with 5% to 27.3% of cases featuring accessory branches that alter the dual supply pattern; in such scenarios, a single primary nerve (often the lower subscapular) may dominate, while accessory contributions from the axillary nerve occur in approximately 2% of dissections. These patterns underscore the subscapular nerves' inconsistent anatomy relative to textbook descriptions.^[20]

Incidence and implications

Cadaveric studies have documented variations in the subscapular nerves.^[21] The upper subscapular nerve exhibits variation in origin from the axillary nerve in approximately 3% of cases, as observed in dissections of over 100 specimens.^[2] This alteration can modify the nerve's trajectory through the axilla, potentially affecting its positional relationship with surrounding structures. The lower subscapular nerve shows variation in origin from the axillary nerve in 25% of cases.^[23]

Clinical significance

Injuries and pathology

Injuries to the subscapular nerves, which arise from the posterior cord of the brachial plexus (C5-C7 roots), typically occur as part of broader brachial plexus trauma, such as traction or avulsion injuries during high-impact events like motorcycle accidents. These mechanisms stretch or tear the nerves, leading to denervation of the subscapularis muscle and, in cases involving the lower subscapular nerve, the teres major muscle. Resulting deficits include paralysis of the subscapularis, manifesting as weakness in internal rotation and a positive lift-off test, alongside potential atrophy of the affected muscles.^[24]^[25]^[26] Compression of the subscapular nerves is less common but can arise from scar tissue entrapment following prior trauma or mass effects from adjacent pathology, potentially causing neuropraxia through ischemia or mechanical irritation. The lower subscapular nerve branch, supplying the teres major, may be particularly vulnerable to stretch-related compression in repetitive overhead activities, resulting in pain and weakness during shoulder adduction and internal rotation. Symptoms often include localized shoulder pain, muscle weakness, and instability, with atrophy developing over time if unresolved.^[27]^[28] Pathological associations include traction neuritis from subscapularis tendon avulsions in rotator cuff tears, where muscle retraction exerts tension on the nerve insertions near the myotendinous junction, leading to secondary denervation. Associated nerve injury, though rare for the subscapular nerves specifically, occurs in up to 10% of shoulder dislocations, often involving traction or direct compression during the event, though specific subscapular involvement is rarer and typically accompanies axillary or posterior cord damage. These pathologies contribute to chronic shoulder instability and subscapularis atrophy, exacerbating rotator cuff dysfunction.^[29]^[13]^[30] Diagnosis relies on electromyography (EMG), which demonstrates denervation patterns in the subscapularis and teres major with reduced motor unit potentials from C5-C7 roots, confirming nerve involvement. Magnetic resonance imaging (MRI) reveals early muscle edema and T2 hyperintensity indicating acute injury, progressing to fatty infiltration and atrophy in chronic cases, while also assessing for nerve swelling or associated rotator cuff pathology.^[27]^[31]^[32]

Surgical and therapeutic considerations

During shoulder surgeries such as rotator cuff repairs and anterior approaches for shoulder arthroplasty, the upper and lower subscapular nerves are at risk of iatrogenic injury due to their proximity to the musculotendinous junction of the subscapularis muscle.^[33] In anterior deltopectoral approaches, dissection medial to the musculotendinous junction can lead to nerve compression or transection, potentially causing subscapularis denervation and postoperative internal rotation deficits.^[34] To mitigate these risks, surgeons employ preservation techniques including limiting dissection to less than 1 cm medial to the subscapularis musculotendinous junction and avoiding excessive retraction near the nerve entry points, which are on average 30-53 mm from the junction depending on arm position.^[33] Intraoperative nerve monitoring is recommended in complex procedures like total shoulder arthroplasty to detect real-time compromise, while subscapularis-sparing approaches, such as the windowed anterior technique, maintain tendon integrity and minimize neural disruption. Therapeutically, ultrasound-guided blocks targeting the upper subscapular nerve can alleviate chronic shoulder pain by interrupting nociceptive signals from the subscapularis, often combined with local anesthetics for outpatient management.00077-9/fulltext) In brachial plexus reconstruction, nerve transfers can enable recovery of shoulder function in upper trunk injuries. Post-injury rehabilitation protocols for subscapular nerve damage focus on preventing subscapularis atrophy through progressive internal rotation strengthening, starting with isometric exercises and advancing to resistance bands after 4-6 weeks to restore shoulder stability.^[35] Early passive range of motion is emphasized, with high-repetition, low-resistance activities to promote neural recovery without overloading the denervated muscle.^[36] Iatrogenic subscapular nerve injuries often result in significant functional loss, including reduced internal rotation strength and glenohumeral instability, with denervation contributing to significant atrophy of the subscapularis if untreated, leading to persistent shoulder dysfunction.^[37]

References

[1]
Anatomy of the Subscapularis: A Review - Sage Journals
May 22, 2019 · The subscapularis is innervated by both the upper subscapular nerve (USN) and lower subscapular nerve (LSN). Both the USN and LSN arise from the ...
[2]
Anatomy and quantitation of the subscapular nerves - PubMed
The upper subscapular nerve originated from the posterior cord in 97% of the cases and in 3% of the cases directly from the axillary nerve.
[3]
Anatomy, Head and Neck: Brachial Plexus - StatPearls - NCBI - NIH
The suprascapular nerve and nerve to the subclavius originate from the superior trunk and contain the spinal levels of C5 and C6. The suprascapular nerve ...
[4]
The Brachial Plexus - Sections - Branches - TeachMeAnatomy
### Summary of Subscapular Nerves from the Brachial Plexus
[5]
Thoracodorsal nerve | Radiology Reference Article | Radiopaedia.org
Mar 23, 2023 · The thoracodorsal nerve also known as the middle subscapular or long subscapular nerve arises from the posterior cord of the brachial plexus and supplies the ...
[6]
Subscapular nerves | Radiology Reference Article | Radiopaedia.org
Apr 2, 2023 · The subscapular nerves are a group of nerves that arise from the posterior cord of the brachial plexus to innervate muscles of the scapula.
[7]
Overview, Gross Anatomy, Blood Supply of the Brachial Plexus
Oct 28, 2024 · The brachial plexus is a nerve plexus formed by the lower four cervical and first thoracic nerves, responsible for motor innervation of the ...
[8]
Anatomy, Thorax, Thoracodorsal Nerves - StatPearls - NCBI Bookshelf
The thoracodorsal nerve is also referred to as the middle or long subscapular nerve. It arises from the C6 to C8 roots of the brachial plexus.
[9]
Lower subscapular nerve | Radiology Reference Article
Aug 2, 2021 · The lower subscapular nerve, also known as the inferior subscapular nerve, arises from the posterior cord of the brachial plexus and supplies the subscapularis ...
[10]
Peripheral Nerves - Neupsy Key
Jul 31, 2016 · These purely motor nerves arise as branches of the posterior cord of the brachial plexus. The upper subscapular nerves supply the subscapularis, ...
[11]
Anatomy, Head and Neck: Cervical Nerves - StatPearls - NCBI - NIH
Apr 6, 2025 · The upper and lower subscapular nerves (C5 and C6) supply the upper and lower portions of the subscapularis, with the lower subscapular ...
[12]
Which cervical nerves innervate the subscapularis muscle? - Dr.Oracle
Jun 16, 2025 · The spinal root origins of the lower subscapular nerve have been found to be composed of C5, C6, and C7 roots in 76.9% of cases, and C6 and C7 ...
[13]
Innervation of the subscapularis: an anatomic study - PMC - NIH
The superior portion is innervated by the upper subscapular nerve, and the inferior portion, by the lower subscapular nerve. These nerves most frequently arise ...Missing: dual | Show results with:dual
[14]
Anatomy, Shoulder and Upper Limb, Subscapularis Muscle - NCBI
It originates at the subscapular fossa, specifically the medial and lower two-thirds of the groove on the lateral border. The muscles transition to a tendon, ...
[15]
SUBSCAPULARIS SYNDROME: A CASE REPORT - PMC - NIH
The subscapularis muscle primarily functions as a humeral depressor and stabilizer along with its traditional role as an internal rotator of the humerus. The ...
[16]
Anatomy, Back, Latissimus Dorsi - StatPearls - NCBI Bookshelf
Together, these muscles will work to adduct, medially rotate, and extend the arm at the glenohumeral joint.
[17]
Anatomy, Shoulder and Upper Limb, Teres Major Muscle - NCBI - NIH
Apr 17, 2023 · The teres major is a thick, rectangular muscle extending from the scapula to the humerus, located deep to the deltoid, and helps extend, adduct ...
[18]
Electromyographic activity in the shoulder musculature during ...
During shoulder adduction tests, subscapularis, latissimus dorsi, triceps, and pectoralis major had the highest activation levels; supraspinatus and ...
[19]
Electromyographic analysis of internal rotational motion of the ...
The subscapularis muscle was active at levels of about 44% MMT, whereas the activity of the subscapularis muscle decreased significantly to about 2% to 12% MMT ...
[20]
A Unique Presentation of an Upper Subscapular Nerve Variation ...
Mar 7, 2023 · Of the 57 upper subscapular nerves they evaluated, 50% originated from the posterior division of the superior trunk, though there was no ...
[21]
Variations of the origin of collateral branches emerging from the ...
Jun 23, 2007 · Dorsal scapular, long thoracic, suprascapular, subscapularis and thoracodorsal origins were studied to show variable BP collateral arrangements.
[22]
Variations in Subscapularis Muscle Innervation—A Report on Case ...
Oct 12, 2020 · The subscapularis muscle is typically innervated by two distinct nerves, namely an upper and a lower subscapular nerve, both originating from the brachial ...
[23]
Study of variations in the branching pattern of thoracodorsal nerve
Aug 6, 2025 · As stated in a study done on forty specimens, the thoracodorsal nerve originated from the posterior cord of BP in 72.5%, from the axillary nerve ...<|control11|><|separator|>
[24]
Study of Variations in the Branching Pattern of Lower Subscapular ...
The lower subscapular nerve originates from the axillary nerve in 57.5% of specimens, from the posterior cord in 37.5%, and from the common trunk in 5%.Missing: vessels | Show results with:vessels
[25]
Human cadaveric study of subscapularis muscle innervation and ...
In the most common variation, the lower subscapular nerve arose from the axillary nerve (5 specimens; 25%).Missing: bifurcation incidence
[26]
Human Cadaveric Study of Subscapularis Muscle Innervation and ...
In the most common variation, the lower subscapular nerve arose from the axillary nerve (5 specimens; 25%).
[27]
Brachial Plexus Injuries - StatPearls - NCBI Bookshelf
The brachial plexus originates from the ventral rami of spinal nerves C5, C6, C7, C8, and T1 but may occasionally receive contributions from C4 and T2. Root ...
[28]
Brachial Plexus Injuries - Trauma - Orthobullets
Oct 16, 2023 · Brachial plexus injuries (BPIs) can involve any degree of injury at any level of the plexus and range from obstetric injuries to traumatic ...
[29]
The role of subscapularis muscle denervation in the ... - PubMed
Our study shows that subscapularis denervation, per se, could explain shoulder contracture after neonatal brachial plexus injury, though its relevance compared ...
[30]
Lower Subscapular Muscle Denervation - Global Radiology CME
Nov 4, 2016 · The lower subscapular nerve innervates the lower (inferior) aspect of the subscapularis muscle as well as the teres major muscle. ... non specific ...
[31]
Lower Subscapular Nerve - an overview | ScienceDirect Topics
The lower subscapular nerve originates from the posterior cord of the brachial plexus and enters the subscapularis muscle approximately 2.3 to 4.8 cm from the ...Missing: incidence | Show results with:incidence
[32]
https://www.aafp.org/pubs/afp/issues/2021/0301/p275.html
[33]
Nerve Injuries after Glenohumeral Dislocation, a Systematic Review ...
Jul 7, 2023 · Glenohumeral dislocation is a common shoulder injury that can result in nerve injury. However, the full impact of these injuries on patient ...
[34]
MR Patterns of Denervation Around the Shoulder | AJR
Suprascapular nerve anatomy—The suprascapular nerve is a mixed motor and sensory peripheral nerve that arises from the upper trunk of the brachial plexus. It ...
[35]
Peripheral Nerve Entrapment and Injury in the Upper Extremity - AAFP
Mar 1, 2021 · Damage to the axillary nerve results in paresthesia or pain of the lateral shoulder and weakness in shoulder external rotation, extension, ...
[36]
Nerve supply of the subscapularis during anterior shoulder surgery
Results: 14/20 specimens showed an innervation of the subscapularis with an upper, middle and lower subscapular nerve branch. Even though the nerve branches ...
[37]
https://upload.orthobullets.com/journalclub/free_pdf/24292928_24292928.pdf
[38]
Is Thoracodorsal Nerve Transection Needed in Latissimus Dorsi ...
Advantages of thoracodorsal nerve transection are potential prevention of muscle spasticity/movement; disadvantages are possible long-term muscle atrophy and ...
[39]
Usefulness of nerve-sparing pedicled segmental latissimus dorsi ...
Jan 24, 2023 · The aim of the work is to evaluate the usefulness of nerve-sparing pedicled segmental latissimus dorsi muscle flap combined with lateral ...
[40]
Vascularized Thoracodorsal to Suprascapular Nerve Transfer, a ...
Mar 13, 2016 · We describe the clinical outcome of a novel nerve transfer to restore active shoulder motion in upper brachial plexus injury.
[41]
REHABILITATION FOLLOWING SUBSCAPULARIS TENDON REPAIR
Following SSC repair, passive internal rotation should be restricted to belt line for the first four weeks. Scapula. For the first two weeks following repair ...
[42]
[PDF] Rehabilitation Protocol for Subscapularis Repair
This protocol is intended to guide clinicians through the post-operative course for subscapularis repair. This protocol is time based (dependent on tissue ...
[43]
[PDF] Iatrogenic Nerve Injuries in Shoulder Surgery - Orthobullets
May 18, 2014 · Iatrogenic nerve injuries are among the more commonly cited complications associated with shoulder surgery. Various surgical procedures about ...
[44]
Latissimus dorsi breast reconstruction: how much nerve ... - PubMed
This study presents the authors' experience with the outcomes of latissimus dorsi flaps for breast reconstruction in the light of thoracodorsal nerve management ...