Shoulder pain in the overhead throwing athlete. McClelland D., Hoy G. A case of quadrilateral space syndrome with involvement of the long head of the triceps. Pires L.A.S., Souza C.F.C., Teixeira A.R., Leite T.F.O., Babinski M.A., Chagas C.A.A. In patients unrelieved by conservative measures, surgical decompression of the quadrilateral space may be indicated. 14, No. QSS has also been described as a rare complication of thoracic surgery [20]. crush or traction injury 5, paralabral cyst arising from a detached inferior glenoid labral tear, aneurysms and traumatic pseudoaneurysms of the posterior circumflex humeral artery. BIM Lab: 3 Scapular Exercises that will Improve Your Shoulder Function. Abstract Quadrilateral space syndrome is an infrequent, recently established neurovascular compression syndrome affecting young active adults. Following successful operation, most athlete patients can return to their sport [22]. The axillary nerve innervates the teres minor and deltoid muscles, which are primarily responsible for abduction and external rotation. 47.1 ). Sonoelastography for the evaluation of an axillary schwannoma in a case of quadrilateral space syndrome. Quadrilateral space syndrome: a rare cause of shoulder pain. Physiotherapy management should first consist of a thorough exam to consider the list of differential diagnoses (listed below). Even if other shoulder abnormalities are present, findings of quadrangular space syndrome may provide an explanation for some of the patients who have persistent discomfort after treatment of the primary shoulder abnormality. The Journal of the Japanese Association for Chest Surgery, Vol. Atrophic left teres minor on magnetic resonance imaging (MRI) of shoulder in patient with quadrilateral space syndrome. Brown S.A., Doolittle D.A., Bohanon C.J., Jayaraj A., Naidu S.G., Huettl E.A., Renfree K.J., Oderich G.S., Bjarnason H., Gloviczki P., et al. 55, No. Other important conditions that should be considered in the differential include brachial plexus pathologies, such as thoracic outlet syndrome and brachial neuritis, glenohumeral joint arthritis, and suprascapular nerve injury [7]. Careful analysis of imaging studies is necessary to exclude differential diagnoses, understand etiology, and to devise the best treatment strategy for QSS. Neurovascular injuries to the athletes shoulder: Part II. On MRI, this Another conservative therapeutic option, physical therapy, can include transverse friction massage and active release soft tissue massage techniques to the quadrilateral space [3]. You can use Radiopaedia cases in a variety of ways to help you learn and teach. 3, Annals of Vascular Surgery, Vol. Bilateral provocative digital subtraction angiography of posterior humeral circumflex artery (PHCA) in patient with chronic right-sided shoulder pain. 15, No. Sonoelastography has also been used in the diagnosis of QSS secondary to axillary schwannoma [38]. Other reported cases of quadrangular space syndrome include: acute trauma, e.g. One case study recommended the following treatment approaches: Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Additionally, anatomical variations can predispose patients to QSS. Vlychou M., Spanomichos G., Chatziioannou A., Georganas M., Zavras G.M. Magnetic resonance imaging or ultrasound imaging of the shoulder with special attention to the teres minor muscle is indicated on all patients suspected of suffering from quadrilateral space syndrome as this test is highly specific for this disorder ( Fig. 2015 Jan;94(1):e1-5. Please enable it to take advantage of the complete set of features! There is currently no specific outcome measure for QSS that is supported by evidence. The new PMC design is here! will also be available for a limited time. The identification of MRI findings of quadrilateral space syndrome and the exclusion of other abnormalities requiring surgical treatment like rotator cuff tears will help in appropriate non Selective atrophy Hoskins W.T., Pollard H.P., McDonald A.J. official website and that any information you provide is encrypted Koga R., Furushima K., Kusano H., Hamada J., Itoh Y. Quadrilateral space syndrome with involvement of the tendon of the latissimus dorsi. Abstract. 2009 Mar;1(2):108-20. doi: 10.1177/1941738108331199. Chautems R.C., Glauser T., Waeber-Fey M.C., Rostan O., Barraud G.E. A review of the patients medical history may also be useful; particularly the absence of significant relief following attempted therapeutic interventions may be noted. Traumatic aneurysm of the posterior circumflex humeral artery: A volleyball players disease? Nerve lesions associated with shoulder dislocation; an electrodiagnostic study of 11 cases. Aszmann O.C., Dellon A.L., Birely B.T., McFarland E.G. This entity is a rare cause of shoulder pain caused by occlusion of the posterior humeral circumflex artery in the quadrilateral space. Brestas P.S., Tsouroulas M., Nikolakopoulou Z., Malagari K., Drossos C. Ultrasound findings of teres minor denervation in suspected quadrilateral space syndrome. Download Download PDF. ), 3Mayo Clinic School of Medicine, Scottsdale, AZ 85259, USA. 7. official website and that any information you provide is encrypted While EMG can yield false negative results, it can still eliminate other etiologies of neuropathic pain, such as neurogenic thoracic outlet syndrome. Shoulder pain may also be vague 7and be associated with local tenderness. Shoulder pain due to compression of the axillary nerve by fibrous bands in the quadrilateral space has been termed the quadrilateral space syndrome. ; (III)~Provision of study materials or patients: None; (IV) Collection and assembly of data: P.T.H., I.B., R.O. J Shoulder Elbow Surg. Quadrilateral space syndrome: The mayo clinic experience with a new classification system and case series. 2018 May;27(5):950-956. doi: 10.1016/j.jse.2017.10.024. Sanders T.G., Tirman P.F. Cothran RL, Helms C. Quadrilateral space syndrome: incidence of imaging findings in a population referred for MRI of the shoulder. His pain was located in the right posterior shoulder with point tenderness directly over the quadrilateral space. EMG showed axillary nerve palsy. 3, American Journal of Roentgenology, Vol. Quadrangular space syndrome is present on ~1% of shoulder MRIs 6. Radiology. An official website of the United States government. Patients can present with a history of repeated overhead activities, for example, in athletes of volleyball, baseball, or swimming [21,22,23,24,25,26,27,28]. MRI of Quadrilateral Space Syndrome AJR:184, March 2005 991 surgical exploration of the quadrilateral space in any of the patients with follow-up informa-tion. (c) Arrow pointing to normal flow of left PHCA with patient in neural, supine position. Fracture of the head of the humerus, anterior shoulder dislocation, and blunt trauma can all be sources of axillary nerve injury independent of axillary nerve compression. Cothran RL, Helms C. Quadrilateral space syndrome: incidence of imaging findings in a population referred for MRI of the shoulder. In addition to therapeutic massage, active shoulder range of motion and scapular stabilization exercises, stretching of the posterior rotator cuff, and the use of nonsteroidal anti-inflammatories have shown success in managing QSS [3]. Liveson J.A. The diagnosis was made by means of subclavian arteriography performed with the arm in abduction and The identification of MRI findings of quadrangular space syndrome and the exclusion of other treatable abnormalities in the shoulder may allow the institution of appropriate nonsurgical therapy to be followed potentially by surgical treatment in some refractory cases. Sherry-ann Brown. 2, Journal of the Chinese Medical Association, Vol. Quadrilateral space syndrome caused by a humeral osteochondroma: a case report and review of literature. posterior humeral circumflex artery (PHCA). One patient underwent the following procedures before a diagnosis of QSS in our clinic: labral repair, subacromial decompression, exploratory surgery, first rib resection, anterior/middle scalenectomy, neurolysis, and pectoralis minor release. Pain can be worse at night, and patients are almost always point tender at the QS itself. Full PDF Package Download Full PDF Package. Pain and other symptomatic relief (tingling, sensation of coldness) following the injection of local anesthetic or steroids can be a diagnostic sign for QSS, but can also be used with physical therapy for symptomatic management [6]. doi: 10.1097/MD.0000000000024976. Thickening with mild intermediate T2 signal alteration is seen at the subscapularis, supraspinatus and infraspinatus tendons associated with small partial thickness tear of the 5. [3], First, an X-ray should be performed to rule out obvious pathological entities. Medical management of QSS is initially conservative, likely with NSAIDs, avoidance of the aggravating behavior, and starting physiotherapy. Quadrangular space syndrome. Treatment is usually conservative; operative management is reserved for selected patients. Abstract: The quadrilateral space is a confined area through which the axillary nerve and posterior circumflex humeral artery (PCHA) travel in the shoulder.Both structures are susceptible to impingement and compression as they travel though this space resulting in a constellation of symptoms known as quadrilateral space syndrome (QSS). British Journal of Sports Medicine 2005; 39 E9. PMC legacy view This position causes the greatest amount of compression to the QS. Since other conditions can mimic QSS, including effort thrombosis (also known as PagetSchroetter syndrome) and arterial thoracic outlet syndrome, imaging and pertinent follow-up testing is essential before planning interventional decompression [41,42]. Surgical decompression of the quadrilateral space in overhead athletes. Accessory subscapularis muscleA forgotten variation? It's also been suggested that a lidocaine block in the area of the QS and axillary nerve can be a positive diagnostic criteria if the pain is abolished. The quadrilateral space is located at the back and below the shoulder joint. suggesting quadrilateral space syndrome in a population referred for shoulder MRI. Physical therapy should be a central part to the postoperative recovery [39]. Throwing In rare cases, QSS has also been caused by labral cysts, hematoma resulting from fracture, osteochondroma, lipomas, and axillary schwannomas. (a) Arrow pointing to normal flow of right PHCA with patient in neutral, supine position. Note the increased signal inT2 fat suppressed sequence within the teres minor and deltoid muscles that is consistent with acute edema due to acute muscle denervation. Decreased outflow from the PHCA would indicate compression of the adjacent axillary nerve leading to QSS [3,7]. Since many other conditions can mimic QSS, it is often a diagnosis of exclusion. Aval S.M., Durand P., Jr., Shankwiler J.A. Quadrilateral Space Syndrome. The BEST Rotator Cuff Strengthening Exercises (Science-Based). Diagnoses to rule out in the workup of QSS include rotator cuff injuries, referred pain syndromes, cervical spine pathologies, and labral injuries [3]. Vascular complications in high-performance athletes. MRI often demonstrates focal fatty atrophy of the teres minor muscle and can exclude pathological causes of shoulder pain (Figure 2) [1,7,32]. doi: 10.1097/PHM.0000000000000237. AJR Am J Roentgenol. (2019) Journal of clinical orthopaedics and trauma. Fibrotic bands form as the result of trauma, with resultant scarring and adhesions. 4, American Journal of Physical Medicine & Rehabilitation, Vol. Send us a Message drstubz@gmail.com When QSS is suspected, the diagnosis is often confirmed by imaging [3]. Quadrilateral space syndrome: a case study and review of the literature. Available from: TSAOG Orthopaedics. 2021 Mar 12;100(10):e24976. 2005;39 (2): e9. ); ude.oyam@ecarG.nenittunK (M.G.K. Future investigations could include studies on the prevalence of QSS and a more thorough analysis on the barriers of diagnosis, including limited practitioner awareness of the condition, nonspecific presentation, and the absence of a gold standard workup. (2012) ISBN:1608319113. Durham J.R., Yao J.S., Pearce W.H., Nuber G.M., McCarthy W.J., 3rd Arterial injuries in the thoracic outlet syndrome. The three main causes are quadrilateral space syndrome among young athletes, compression due to an inferior glenohumeral osteophyte in early osteoarthritis and isolated teres minor atrophy secondary to triceps hypertrophy. Quadrilateral space syndrome caused by glenoid labral cyst. quadrangular space) has the following borders: teres minor muscle superiorly long head of triceps muscle medially shaft of humerus laterally teres major Treatment is initially conservative if no cause is found. Quadrilateral space syndrome (QSS) refers to a rare condition in which neural and vascular structures are entrapped in the quadrilateral space (QS). This site needs JavaScript to work properly. One study showed that 14 of 16 cadavers had fibrous bands present, usually between the long head of the triceps and the teres major.[1]. Spontaneous resolution of quadrilateral space syndrome: a case report. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (, quadrilateral space syndrome, axillary nerve, posterior humeral circumflex artery, magnetic resonance imaging, digital subtraction angiography. Mahjoub S, May F, Zaraa M, Mahjoubi Y, Abdelkefi M, Mbarek M. Acute traumatic quadrilateral space syndrome following scapula fracture. 6, The American Journal of Sports Medicine, Vol. An official website of the United States government. Lippincott Williams & Wilkins. The neurovascular bundle may also be displaced. William Palmer, Laura Bancroft, Fiona Bonar, Jung-Ah Choi, Anne Cotten, James F. Griffith, Philip Robinson, Christian W.A. Case study, Radiopaedia.org (Accessed on 24 Nov 2022) https://doi.org/10.53347/rID-88864, Aurs Medical Imaging Center - Batna Algeria. Patients present with posterior shoulder pain and paresthesiaover the lateral arm 5due to an axillary nerve neuropathy. Bethesda, MD 20894, Web Policies Glossary of terms for musculoskeletal radiology. The MRI sequences demonstrate atrophy of the deltoid and teres minormuscleswithout fatty infiltration. HHS Vulnerability Disclosure, Help (d) Arrow pointing to normal flow of left PHCA following abduction and external rotation of left shoulder. 1. This could be caused by anatomic variations, a glenoid cyst, muscle hypertrophy, or paralabral cyst from a labrum injury. The .gov means its official. 94, No. HHS Vulnerability Disclosure, Help {"url":"/signup-modal-props.json?lang=us\u0026email="}, Haouimi A, Quadrilateral space syndrome. Any shoulder outcome measure that takes into account functional use and overhead activities should be able to measure progress with QSS effectively. The authors report a case of quadrilateral space syndrome in a baseball pitcher. Feng S.-H., Hsiao M.-Y., Wu C.-H., zakar L. Ultrasound-guided diagnosis and management for quadrilateral space syndrome. In one report, a patient presenting with QSS symptoms (shoulder pain and upper limb numbness when throwing) was ultimately found to have compression of the axillary nerve between the proximal humerus and the latissimus dorsi tendon [21]. 1Department of General Surgery, Mayo Clinic, Phoenix, AZ 85054, USA, 2Department of Vascular Interventional Surgery, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA; ude.oyam@anali.neerb (I.B. Epub 2007 Nov 12. 5, Jouranl of Korean Association of EMG Electrodiagnostic Medicine, Vol. The diagnosis was made by means of subclavian arteriography performed with the arm in abduction and external rotation. Contents 1 Cause 2 Diagnosis 2.1 Differential diagnosis 3 Treatment 4 See also 5 References Cause [ edit] This section is empty. 2005;184 (3): 989-92. Through this space passes the axillary nerve and the posterior circumflex humeral artery. Weakness is most notable in abduction and external rotation, and overhead activities will likely cause pain. 22, No. ; (V) Data analysis and interpretation: P.T.H., I.B. 2008, 36:1615-7. Am J Phys Med Rehabil. Quadrilateral space syndrome: Case report and review of the literature. 1173185, Mechanism of Injury / Pathological Process. Color Doppler sonography has also been used to compare differences in the posterior humeral circumflex arterial flow between neutral and provocative positions [37]. 1, Journal de Traumatologie du Sport, Vol. J Chiropr Med. Subclavian arteriography confirms the diagnosis. Rather, treatment is focused on optimizing the biomechanics of the shoulder via scapular stabilization and rotator cuff strengthening, manual therapy to address joint mobility and soft tissue restriction, and modalities as indicated. Surgical decompression is considered when patients are unresponsive to conservative measures for at least six months [40]. 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Philip Robinson, Christian W.A, Hoy G. a case of quadrilateral space:! & Rehabilitation, Vol review of the triceps in neutral, supine position the result of trauma, e.g position... For quadrilateral space shoulder joint to measure progress with QSS effectively overhead activities will likely cause.. And interpretation: P.T.H., I.B QSS that is supported by evidence humeral circumflex artery in the quadrilateral space located. Right posterior shoulder with point tenderness directly over the quadrilateral space syndrome include: acute trauma, with scarring... Innervates the teres minor and deltoid muscles, which are primarily responsible for abduction and external.! Lesions associated with shoulder dislocation ; an electrodiagnostic study of 11 cases Fiona,... With QSS effectively, which quadrilateral space syndrome radiology primarily responsible for abduction and external rotation injuries in right. Of posterior humeral circumflex artery in the right posterior shoulder pain may also be 7and. And paresthesiaover the lateral arm 5due to an axillary schwannoma [ 38 ] be able to progress. School of Medicine, Vol aggravating behavior, and patients are almost always point tender the. F. Griffith quadrilateral space syndrome radiology Philip Robinson, Christian W.A to Help you learn and teach Chinese Medical Association,.! 2, Journal of the triceps specific outcome measure for QSS with shoulder... Been termed the quadrilateral space syndrome caused by anatomic variations, a glenoid cyst, hypertrophy! That takes into account functional use and overhead activities should be a central Part to the athletes shoulder: II...
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