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Best Quadrilateral Treatment in Delhi

Quadrilateral Space Syndrome treatment and cure
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What is Quadrilateral ?

Quadrilateral Space Syndrome (QSS) is a relatively rare condition characterized by the compression of the axillary nerve and/or the posterior circumflex humeral artery (PCHA) as they pass through a confined anatomical area in the shoulder called the “quadrilateral space.” This space is bordered by:-

  • Superiorly: Teres minor muscle
  • Inferiorly: Teres major muscle
  • Medially: Long head of the triceps brachii muscle
  • Laterally: Surgical neck of the humerus
Causes of Quadrilateral Space Syndrome

The compression in the quadrilateral space can be caused by various factors, often leading to a reduction in the space available for the nerve and artery. Common causes include:-

  • Repetitive Overhead Activity/Overuse: This is a primary cause, particularly in athletes involved in sports that require frequent arm abduction (lifting away from the body) and external rotation (outward rotation), such as:
    • Baseball pitchers (especially during the late cocking phase of throwing
    • Swimmers
    • Volleyball players
    • Tennis players
    • Others who engage in occupations requiring repetitive overhead arm movements.
  • Fibrous Bands: The presence of tight, abnormal fibrous bands within the quadrilateral space can compress the neurovascular structures. These bands may form as a result of trauma or simply be anatomical variations.
  • Muscle Hypertrophy: Enlargement or overuse of the surrounding muscles (teres major, teres minor, triceps) can reduce the space. This is often seen in athletes or bodybuilders.
  • Trauma/Injury:
    • Shoulder Dislocation: Especially anterior dislocations, can directly injure or cause swelling/scarring that compresses the structures.
    • Scapular Fractures: Can alter the anatomy of the space.
    • Blunt force injury to the posterior shoulder.
  • Cysts and Masses:
    • Paralabral Cysts: Often associated with labral tears (e.g., inferior labral tears), these cysts can extend into the quadrilateral space and compress its contents.
    • Ganglion Cysts
    • Lipomas (benign fatty tumors)
    • Hematomas (collections of blood)
    • Tumors (rarely)
    • Aneurysms or Pseudoaneurysms of the posterior circumflex humeral artery.

Anatomical Variations: Some individuals may have a naturally smaller quadrilateral space or variations in nerve/vessel branching that predispose them to compression.

Symptoms of Quadrilateral Space Syndrome

The symptoms of QSS arise from the compression of the axillary nerve and/or the posterior circumflex humeral artery. They can be vague and often mimic other shoulder conditions, making diagnosis challenging.

  • Neurological Symptoms (due to axillary nerve compression):
    • Pain: Often a dull, aching pain localized to the posterior and lateral aspect of the shoulder. This pain may radiate down the arm. It typically worsens with activities involving shoulder abduction and external rotation.
    • Paresthesia: Numbness, tingling, or “pins and needles” sensation in the distribution of the axillary nerve, which includes the lateral aspect of the deltoid muscle (over the “regimental badge” area of the shoulder) and upper posterior arm.
    • Weakness: Weakness in shoulder abduction (lifting the arm out to the side) and external rotation, primarily affecting the deltoid and teres minor muscles. This weakness may be subtle initially as other muscles compensate.
    • Muscle Atrophy: In chronic cases, there may be noticeable atrophy (wasting) of the teres minor and/or deltoid muscles.
  • Vascular Symptoms (due to PCHA compression/occlusion):
    • Intermittent Ischemia: Symptoms related to reduced blood flow to the arm or hand, which may include.
    • Pain with activity (claudication-like symptoms)
    • Feeling of fatigue or heaviness in the arm
    • Coldness or pallor (paleness) of the affected arm/hand (less common but possible in severe cases).
    • Rarely, distal emboli can occur from arterial thrombosis or aneurysm formation.
    • Tenderness: Point tenderness may be present when palpating the quadrilateral space.
Advanced Physiotherapy for Quadrilateral Space Syndrome
  • Pain and Inflammation Management:
    • Rest and Activity Modification: Identifying and temporarily avoiding activities that aggravate symptoms, especially repetitive overhead movements.
    • Modalities: Therapeutic modalities like ice/heat, ultrasound, or electrical stimulation (e.g., TENS) to manage pain and inflammation.
  • Manual Therapy:
    • Soft Tissue Mobilization: Specific techniques to release tension and adhesions in the muscles surrounding the quadrilateral space (teres major, teres minor, triceps). This may include deep tissue massage, myofascial release, and active release techniques.
    • Nerve Gliding/Neurodynamics: Gentle exercises and manual techniques to promote the smooth gliding of the axillary nerve through the quadrilateral space, reducing impingement.
    • Joint Mobilization: Addressing any hypomobility or stiffness in the glenohumeral (shoulder) joint, thoracic spine, and cervical spine that might contribute to altered shoulder mechanics.
  • Restoration of Range of Motion and Flexibility:
    • Gentle Stretching: Focusing on stretching tight muscles that may be contributing to compression, such as the pectoralis major/minor, latissimus dorsi, and internal rotators.
    • Posterior Capsule Stretching: Addressing any tightness in the posterior shoulder capsule, which can alter glenohumeral kinematics.
  • Strengthening and Motor Control:
    • Scapular Stabilization Exercises: Strengthening the muscles that stabilize the scapula (shoulder blade), such as the serratus anterior, rhomboids, and lower trapezius. Proper scapular control is crucial for optimal shoulder mechanics and reducing stress on the quadrilateral space.
    • Rotator Cuff Strengthening: Strengthening the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, teres minor) to improve shoulder stability and dynamic control. Emphasis on external rotators and scapular retractors.
    • Deltoid and Teres Minor Re-education: Specific exercises to re-activate and strengthen the deltoid and teres minor, especially if atrophy or weakness is present due to axillary nerve involvement. This may involve isometric, concentric, and eccentric exercises, gradually progressing in resistance and range.
    • Proprioceptive and Neuromuscular Control Exercises: Exercises to improve the body’s awareness of joint position and coordinated muscle activity, such as balance exercises, unstable surface training, and plyometrics (for athletes).
  • Biomechanics and Movement Retraining:
    • Postural Correction: Addressing poor posture, especially rounded shoulders or forward head posture, which can alter shoulder girdle mechanics.

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