Axillary Neuropathy in Volleyball Players: Report of Two Cases and Literature Review

Home , Axillary nerve

Journal ofNeurology, Neurosurgery, and Psychiatry 1996;60:345-347 345 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.3.345 on 1 March 1996. Downloaded from SHORT REPORT

Axillary neuropathy in volleyball players: report of two cases and literature review

Dante Paladini, Renzo Dellantonio, Antonio Cinti, Franco Angeleri

Abstract pattern. Supramaximal stimulation of the right circumflex nerve at the axilla evoked a weak Two cases of isolated neuropathy, not polyphasic response at the posterior portion of consequent to acute trauma, of the axil- the right deltoid muscle with a 3-2 ms latency lary nerve of young volleyball players are and 8-6 mV amplitude; from the middle por- described. Interest in the pathology tion of the muscle, the compound muscle derives from the rarity of such case action potential (CMAP) showed reduced reports and the fact that the pathogenesis amplitude (6 mV) and a latency of 3-5 ms. No may be linked to a specific sporting activ- evoked response was obtained from the ante- ity. The lesion site is thought to be in the rior portion. The motor conduction velocity quadrilateral space. (MCV), from Erb's point to the axilla, was about 68 m/s. These data suggested discrete involvement, mainly axonal, of the right circumflex nerve in its distal part. (J Neurol Neurosurg Psychiatry 1996;60:345-347) The patient abstained from competitive sport for a prolonged period. After about six months she was seen again. Her sensory dis- Keywords: axillary nerve; entrapment neuropathy; turbance had resolved and there was improve- quadrilateral space; volleyball ment in muscular strength.

Isolated lesions of the axillary or circumflex nerve are, in most cases, due to acute trauma Case 2 and generally occur in cases of dislocation of An 18 year old left handed woman-a major the scapular-humeral articulation or fracture league professional volleyball player-pre- of the surgical collar of the humerus.' sented with progressive wasting of the left del- http://jnnp.bmj.com/ Descriptions of an isolated neuropathy of this toid muscle and a slight reduction in the nerve not consequent to acute trauma are rare. strength of shoulder abduction associated with We describe two cases of axillary nerve dysaesthesia, at times painful. Finger pressure neuropathy in professional volleyball players. over the left quadrilateral space provoked tenderness. The symptoms had appeared insidiously some months before, and worsened

Case 1 during a period of intense training. Radi- on September 25, 2021 by guest. Protected copyright. A young 24 year old right handed female semi- ography and MRI studies of the left shoulder professional volleyball player came to our and cervical spine and repeated visits to an attention complaining of hypoaesthesia in the orthopedist excluded any osteoarticular shoulder area innervated by the right axillary pathology. nerve associated with limited abduction of the An initial EMG-ENG examination showed arm and a slight wasting of the deltoid muscle. a distal circumflex nerve neuropathy with signs Institute of Neurology, University ofAncona, The symptoms could not be linked to any his- of denervation in the anterior and middle por- Ancona, Italy tory of trauma. The patient reported that the tions of the left deltoid muscle and a pro- D Paladini deficit appeared in a progressive way after a nounced reduction of the interference pattern. A Cinti F Angeleri period of intense sporting competition. Supramaximal stimulation at the axilla evoked a Neurologic Division, An EMG and electroneurography (ENG) a CMAP of reduced amplitude with signifi- Hospital of Senigallia examination showed the presence of fibrilla- cant increase in latency (7-5 ms and 5 mV in (AN), Italy tions and slow positive potentials at the level the posterior part, 18 ms and 3 mV in the mid- R Dellantonio of the anterior and middle portions of the right dle, and 15 ms and 3-8 mV in the anterior por- Correspondence to: Dr Dante Paladini, Clinica deltoid muscle. Study of voluntary muscle tion of the muscle). The MCV, from Erb's Neurologica, Universita di activation disclosed a pronounced reduction of point to axilla, was 59 m/s. The patient was Ancona, Ospedale Generale Regionale, 60020 Torrette di the interference pattern at the middle level of advised to reduce all sporting activity. Ancona, Italy. the right deltoid muscle, no motor unit poten- A follow up EMG-ENG was carried out Received 31 March 1995 tials were registered at the anterior portion of after about a year; it showed a disappearance and in revised form 30 August 1995 this muscle; its posterior portion presented, of denervation activity and a consistent reduc- Accepted 7 September 1995 however, a slight reduction of the interference tion in latency (4-9 ms posterior, 7-0 ms ante- 346 Paladini, Dellantonio, Cinti, Angeleri J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.3.345 on 1 March 1996. Downloaded from Posterior view ofthe quadrilateral space: finally, secondary to fibrous bands in the anterior (1) andposterior quadrilateral space.3 11 (2) branches ofthe The two cases of axillary neuropathy that circumflex nerve and we describe had an involvement of the termi- circumflex artery (3). nal anterior and the posterior branches of the nerve, although the second seemed less damaged. It is therefore logical to assume that the lesion was not situated beyond the bifurcation of these two branches, in proximity of the quadrilateral space. In the second case EMG- ENG examination also showed a prolonged latency distally to the probable site of compression. This fact may well be explained by axonal distal atrophy secondary to more per- sistent trauma.12 In both cases, the patients were young professional volleyball players who had general muscular hypertrophy, especially in the muscles of the shoulder girdle and arm. The circumflex nerve involved was that of the dominant arm-that is, the arm used in serv- ing and smashing, typical volleyball movements that involve significant abduction and extrarotation with flexion or extension of the arm. These types of movements can cause a reduction in the size of the quadrilateral space, rior and middle) and increase in CMAP possibly resulting in repeated compressions of amplitude (6-3 mV in the anterior portion, 7-2 the circumflex nerve between the surrounding in the middle, and 10O5 in the posterior part). hypertrophic muscles and the humerus. There remains slight wasting of the left deltoid A contributing factor in such a compression muscle; there is very little weakness noted by mechanism could be muscle strengthening the patient in raising her arm, probably due to exercises of the shoulder girdle; however, such compensation by synergic muscles. exercises are commonly done in many sports. Therefore, it is reasonable to hypothesise that muscle hypertrophy is only one factor that Discussion favours the problem. The typical movements The axillary, or circumflex, nerve originates of volleyball are the more fundamental factors from the posterior cord of the brachial plexus. that determine the neuropathy. Together with the posterior circumflex artery From the pathophysiological point of view, of the humerus, it passes through the quadri- various hypotheses have been proposed in an lateral space (figure). effort to explain the mechanism of this neu- The quadrilateral space is the anatomical ropathy. Fibrous bands have been seen in http://jnnp.bmj.com/ compartment bounded by the teres major many of the cases operated on for this syn- muscle inferiorly, by the long head of the tri- drome; necropsy data from those not having a ceps medially, and by the surgical neck of the case history of quadrilateral space syndrome humerus laterally; superiorly, it is limited ante- did not show such bands.'3 It is reasonable to riorly by the subscapular muscle and posteri- think, therefore, that the adherence bands are orly by the teres minor. The axillary nerve has secondary to microtrauma that favours the

its anterior and posterior terminal branches in establishment of scar tissue. On the other on September 25, 2021 by guest. Protected copyright. the quadrilateral space or just after it. Fibres hand, the compression of the nerve or artery for the teres minor depart from the posterior could be a direct consequence of entrapment branch or directly from the main trunk just between hypertrophic muscle heads and the before or after the passage of the nerve humerus. The nerve also can be damaged by through the quadrilateral space.2 microtrauma and stretching secondary to the Quadrilateral space syndrome, or more pre- large and violent articular excursions often cisely, the compression of the circumflex nerve seen during sporting activity. in this space, sometimes associated with varying In the cases reported in the medical litera- degrees of compression of the posterior cir- ture, the treatment was both conservative cumflex artery of the humerus, is a rare syn- (analgesics, physical therapy, and kinetic ther- drome first described by Cahill and Palmer in apy) and surgical, with various outcomes.414 In 1983.3 the two cases that we studied, the suspension Isolated neuropathy of the axillary nerve has or reduction of physical activity resulted in a been described as being secondary to acute clinical improvement with disappearance of trauma involving the shoulder4 or the quadri- the sensory symptoms and a discrete recovery lateral space directly,5 secondary to sport in strength. The fact that the suspension of the activity in baseball pitchers67 and tennis play- specific sporting activity was able to induce a ers,8 and after the use of prosthetic devices for favourable evolution supports the idea of gene- the upper arm using a "figure of eight" type of sis of microtrauma caused both by the type of suspension,9 secondary to hypertrophy and athletic movement and muscular hypertrophy. steady use of contiguous muscles,410 and On the other hand, the extreme rarity of similar Axillary neuropathy in volleyball players: report of two cases and literature review 347 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.3.345 on 1 March 1996. Downloaded from

case descriptions in athletes, supports the 6 Cormier PJ, Matalon TAS, Wolin PM. Quadrilateral space syndrome: a rare cause of shoulder pain. Radiology 1988; hypothesis of a predisposing genetic cause- 167:797-8. for example, a smaller than normal quadrilat- 7 Redler MR, Ruland U, McCue FC. Quadrilateral space syndrome in a throwing athlete. Am Jf Sports Med 1986; eral space caused by an anomalous insertion of 14:511-3. the muscle heads. 8 Linker CS, Helmes CA, Fritz RC. Quadrilateral space syndrome: findings at MR imaging. Radiology 1993;188: 675-6. We thank Dr Paolo Guidoni for the anatomical drawing. 9 Reddy MP. Nerve entrapment syndrome in the upper extremity controlateral to amputation. Arch Phys Med Rehabil 1984;65:24-6. 10 Kirby JF, Kraft GH. Entrapment neuropathy of anterior branch of axillary nerve: report of case. Arch Phys Med 1 Liveson JA. Nerve lesions associated with shoulder disloca- Rehabil 1972;53:338-40. tion: an electrodiagnostic study of 11 cases. Neurol 11 McKowen HC, Voorhies RM. Axillary nerve entrapment in Neurosurg Psychiatry 1984;47:742-4. the quadrilateral space. Neurosurg 1987;66: 932-4. 2 Sunderland S. Nerves and nerve injuries. Edinburgh: 12 Brown WE. The physiological and technical basis of elec- Churchill Livingstone, 1978;62:843-8. tromyography. Boston: Butterworth Publishers, 1984;2: 3 Cahill BR, Palmer RE. Quadrilateral space syndrome. 7 37-94. Hand Surg 1983;8:65-9. 13 Cahill BR. Quadrilateral space syndrome. In: Omer GE, 4 Francel TJ, Dellon AL, Campbell JN. Quadrilateral space Spinner M, eds. Management ofperipheral nerve problems. syndrome: diagnosis and operative decompression tech- Philadelphia: WB Saunders, 1980:602-6. nique. Plast Reconstr Surg 199 1;87:911-6. 14 Nambisan RN, Karakousis CP. Axillary compression syn- 5 Bateman JE. Nerve injuries about the shoulder in sports. drome with neuroapraxia due to operative positioning. Bone Joint Surg 1967;49-A(4) :785-92. Surgery 1989;105:449-53. http://jnnp.bmj.com/ on September 25, 2021 by guest. Protected copyright.