Quadrilateral Space Syndrome

SPORTS PT DPT 10th SEMESTER

“QSS” MUJEEB UR RAHMAN ASSISTANT PROFESSOR IPM&R KMU.

Quadrilateral space syndrome Epidemiology 1% of shoulders on MRI- often misdiagnosed Most commonly dominant arm  Onset majority … 20-40 years Risk factors  overhead movts, throwers, contact

sports

Anatomy:

The QS location? Three of the sides muscles and one bone. Top border  ? Bottom border ? Inside border ? Outer border? Contents the axillary nerve (C5,C6) and the PCHA Strength, teres minor and deltoid and shoulder

sensation QLS smetimes mistaken as rc injury

Etiology and Pathology NV compression synd of the PHCA and/or the axillary

nerve or one of its major branches in the QS. QSS most commonly occurs when the NV bundle is compressed by Fibrotic bands and/or hypertrophy of the muscle. Trauma Fibrotic bands, scarring and adhesions. Throwing athletes, tennis players and dominant arm of volleyball players. Anterior shoulder dislocation (10-60% chance) Variation in axillary nerve division and a genetically smaller QS have been hypothesised to predispose to QSS.

Carrying heavy bags Crutches Children specialized

sports at early age Faulty techniques

Other reported cases of QSS include: Acute trauma, e.g. crush or traction injury Paralabral cyst arising from a detached inferior

glenoid labral tear– Ganglion cyst Aneurysms and traumatic pseudoaneurysms of posterior circumflex artery Tumours, e.g. Humeral osteochondroma

Examination: Clinical presentation Complain of vague pain posterior

shoulder/shoulder/around shoulder ? forearm Numbness and tingling in the lat arm  extending forearm non dermatomically Experienced before, during, and after physical exertion Isolated tenderness in response to palpation over the QS Pain in the QS and a positive lidocaine block test (McAdams and Dillinghampain) AROM for ER - full painful at the end-range/ overhead Manual pressure applied to end-range IR may elicit symptoms.

Worsening of dull shoulder pain with repeated

overhead movts, flexion &/or abd & ER Weakness and instability Subluxation Neurologically usually normal/ mild sensory changes in axillary N distribution. Atrophy of the deltoid may be present. In chronic cases, the lesion must be distal to the quadrilateral space when the posterior deltoid and teres minor are not affected.

Thickened band been seen along the border between

the teres minor and infraspinatus muscle tendons (baseball pitchers).  hypertrophic connective tissue Hypertrophic band  potential cause of compression  QSS  the differential diagnosis of posterior shoulder pain.

Definitive diagnosis  angiogram

Four cardinal features: (a) poorly localized shoulder pain, (b) nondermatomal distribution of paresthesia, (c) discrete point tenderness in the QS, (d) a positive arteriogram finding with the affected

shoulder in a position of abd and ER. (Cahil)

Imaging Xrays – ruling out pathologies? MRI Investigation of choice (atrophy +/- fatty infiltration in

the teres minor and/or deltoid muscle),cyst,tumours Angiography Before the advent of MR conventional angiography was the primary diagnostic modality. EMG – Axillary N involvement Nerve block

Differential diagnosis On imaging consider Disuse atrophy Turner syndrome – more than one muscles and

more than one nerve distribution

Treatment and prognosis

Treatment is initially conservative if no cause is

found. 6 months The identification of MRI findings of QSS and the

exclusion of other treatable abnormalities in the shoulder

Conservative: 1ST GOAL – Pain control NSAIDS, activity modification & restriction Therapeutic exercises:  - RC scapular muscles strengthening  - GH joint mobilization  - Posterior capsular stretching  - STW … Cross friction massage

Key rehab goal: Prevention of contractures (max ROM) Deltoid and teres minor weakness  secondary

condition… SAI RC & scap muscles  isometrics  concentric Post & inf joint mob & stretching Fibrous bands and adhesions can form along the posterior band of the inferior glenohumeral ligament, Friction massage and STM to the area of the axillary N

1. Hoskins WT, Pollard HP, Mcdonald AJ. Quadrilateral space syndrome: a case study and review of the

literature. Br J Sports Med. 2005;39 (2): e9. doi:10.1136/bjsm.2004.013367 - Free text at pubmed Pubmed citation 2. Robinson P, White LM, Lax M et-al. Quadrilateral space syndrome caused by glenoid labral cyst. AJR Am J Roentgenol. 2000;175 (4): 1103-5. AJR Am J Roentgenol (full text) - Pubmed citation 3. Cothran RL, Helms C. Quadrilateral space syndrome: incidence of imaging findings in a population referred for MRI of the shoulder. AJR Am J Roentgenol. 2005;184 (3): 989-92. AJR Am J Roentgenol (full text) - Pubmed citation 4. Vlychou M, Spanomichos G, Chatziioannou A et-al. Embolisation of a traumatic aneurysm of the posterior circumflex humeral artery in a volleyball player. Br J Sports Med. 2001;35 (2): 136-7. doi:10.1136/bjsm.35.2.136 - Free text at pubmed - Pubmed citation 5. Quadrilateral Space Syndrome Caused by a Humeral Osteochondroma: A Case Report and Review of Literature Meric Cirpar, MD,1,3 Eftal Gudemez, MD,2 Ozgur Cetik, MD,1 Murad Uslu, MD,1 and Fatih Eksioglu, MD1 6. Embolisation of a traumatic aneurysm of the posterior circumflex humeral artery in a volleyball player M Vlychou, G Spanomichos, A Chatziioannou, M Georganas, G M Zavras Quadrilateral Space Syndrome Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS, Afton Sumler, ATC, and Jodi Runge, ATC • Wichita State University

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