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Quadrilateral Space Syndrome

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Quadrilateral Space Syndrome FUNCTIONAL REHABILITATION R. Barry Dale, PhD, PT, ATC, CSCS, Report Editor Quadrilateral Space Syndrome Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS, Afton Sumler, ATC, and Jodi Runge, ATC • Wichita State University QUADRILATERAL space syndrome (QSS) is a History uncommon condition that has been reported to affect athletes who perform overhead QSS has been reported to have a spontaneous movement patterns, such as baseball play- onset during sport participation or as a result 1,2,7-15 ers,1-4 tennis players,5 and volleyball players.6 of acute trauma. Misdiagnosis may Cahill and Palmer7 described it as a rare be responsible for an underestimate of the 16 7 condition that involves compression of the prevalence of QSS. Cahill described four posterior humeral cir- cardinal features of QSS: (a) poorly localized cumflex artery (PHCA) shoulder pain, (b) nondermatomal distribu- Key PointsPoints and the axillary nerve tion of paresthesia, (c) discrete point ten- within the quadrilat- derness in the quadrilateral space, and (d) a Qaudrilateral space syndrome is an uncom- eral space, which pro- positive arteriogram finding with the affected mon condition. duces pain over the shoulder in a position of abduction and exter- posterior aspect of nal rotation. A high index of suspicion should Symptoms are caused by entrapment of the shoulder that may be maintained for this unusual diagnosis the axillary nerve within the quadrilateral in the overhead athlete who presents with space. radiate into the arm and forearm with a recalcitrant posterior shoulder pain. Conservative treatment should be non-dermatomal dis- attempted prior to surgical intervention. tribution. Symptoms Examination typically occur with the arm in an over- The athlete who has QSS will typically head position, e.g., the late cocking or early complain of vague pain in the shoulder and acceleration phase of the throwing motion. around the shoulder that can radiate as far The quadrilateral space is formed by the distally as the forearm in a nondermatomal teres major inferiorly, the long head of the pattern.3,16 This may be experienced before, triceps medially, the teres minor posteriorly, during, and after physical exertion. There the subscapularis anteriorly, and the surgical is often isolated tenderness in response neck of the humerus laterally (Figure 1).7 This to palpation over the quadrilateral space, space is located in close proximity to the pos- which is very close to the posterior rotator terior band of the inferior joint capsule of the cuff muscles, teres minor, and infraspina- glenohumeral joint. It is not uncommon for tus (Figure 2). McAdams and Dillingham17 athletes who perform overhead movement recently reported the opinion that the most patterns to be positioned in abduction and important findings in patients with QSS are extreme external rotation. pain in the quadrilateral space and a positive © 2009 Human Kinetics - ATT 14(2), pp. 45-47 ATHLETIC THERAPY TODAY MARCH 2009 45 Subscapular nerve Anastomosis between suprascapular and circumflex scapular arteries Infraspinatus Fibrous capsule of shoulder joint Upper lateral brachial cutaneous nerve Triangular space transmitting branch of circumflex scapular artery Quadrangular space transmitting Posterior circumflex humeral artery Axillary nerve Radial nerve and profunda brachii artery Figure 1 View of quadrilateral space. Reprinted with permission from Agur ARM. Grant’s Atlas of Anatomy, 9th ed. Baltimore: Williams and Wilkins; 1991, pg 386. space when the posterior deltoid and teres minor are not affected.18 We have commonly seen a thickened band along the border between the teres minor and infraspina- tus muscle tendons in baseball pitchers. Typically, this thickening is attributed to hypertrophic connec- tive tissue of the involved musculature. A number of authors have identified such a hypertrophic band of connective tissue as a potential cause of compression in the quadrilateral space.7,10,17,19-20 Athletic trainers should consider QSS in the differential diagnosis of pos- terior shoulder pain. Definitive diagnosis may require an angiogram to identify an occlusion of the circumflex scapular artery, which accompanies the axillary nerve through the quadrilateral space. Conservative Management At least six months of conservative management is Figure 2 View of area of point tenderness in posterior shoulder. recommended before surgical intervention is per- lidocaine block test. Active range of motion for external formed.3,12,14,16,17,21,23 During this six-month period, rotation of the shoulder is typically full, but is painful at treatment should include NSAIDs, therapeutic exer- the end-range. Manual pressure applied to end-range cise, manual therapy, and restriction of activities that internal rotation may elicit symptoms. produce symptoms. Glenohumeral joint mobilization, Neurologic examination is normal in most cases, rotator cuff and scapular strengthening, cross-friction but atrophy of the deltoid may be present.16 In chronic massage, and posterior capsule stretching have been cases, the lesion must be distal to the quadrilateral found to provide beneficial effects. 46 MARCH 2009 ATHLETIC THERAPY TODAY.
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