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
THANK YOU
