Quadrilateral Space Syndrome

13 February, 2023 | Quadrilateral Space

What is Quadrilateral Space Syndrome ?

 It is characterized by axillary nerve and posterior humeral circumflex artery (PHCA) compression within the quadrilateral space.

 • ETIOLOGY

The etiology of QSS is unclear, but impingement is most frequently due to 

 • trauma,

 • fibrous bands, 

 • hypertrophy of a muscular border. 

 • In rare cases, QSS has also been caused by 

∆labral cysts,

∆hematoma resulting from fracture, ∆osteochondroma,

∆lipomas, and 

∆axillary schwannomas.

 •  It is most frequently due to trauma, fibrous bands, or hypertrophy of one of the muscular borders.

 • first described by Cahill and Palmer in 1983 . Cahill originally described four distinct features of QSS: 

(1) diffuse pain around the shoulder

(2) paresthesia in a nondermatomal distribution

(3) point tenderness above the quadrilateral space

(4) positive angiogram finding in provocative positioning

SYMPTOMS

caused by repeated overhead activity (such as baseball or volleyball athletes), but other pathologies including 

lipomas, hematomas, and labral cysts may cause compression in the quadrilateral space .

acute findings in QSS including pain, •paraesthesia, 

•atrophy

• neural entrapment 

•vascular compression

•QSS should be considered for all patients with a chief complaint of neck pain, s sehoulder pain, lateral arm paraesthesia, and/or quadrilateral space tenderness.

 

TREATMENT

physical therapy, can include

 •  transverse friction massage 

 •  active release technique (ART)

 •  soft tissue massage techniques to the quadrilateral space (MFR).

 •  In addition to therapeutic massage, active shoulder range of motion (ROM)and

 •  scapular stabilization exercises,

 •  stretching of the posterior rotator cuff, 

 • NSAID's

 

II. RAPTURE OF PACTORALIS MAJOR

The injury results from violent, eccentric contraction of the muscle and tends to present in athletes as an uncommon sports injury.

Most common sport associated with this injury is

 •  weight lifting :- particularly during the ‘bench press’. 

 • Other sports include 

✓wrestling

✓water skiing and

✓ rugby.

Mode of injury

 • pectoralis major rupture is either due to direct injury or indirect trauma due to extreme muscle tension or a combination of both. 

 • the arm is abducted and externally rotated and during which the pectoralis major tendon is under maximum tension.

 • MECHANISM OF INJURY

 • Most injuries occur as the weight is lowered down to the chest

                                       

The muscle normally helps to ‘brake’ the motion.

 

 preventing the weight from falling on the chest.

                                     

                       eccentric contraction 

                                     

                            uncoordinated 

                                     

               as a result of muscle fatigue or weakness

                                     

                    tries to favour that side 

                                     

               allows the weight to slip to one side. 

                                     

                              This results in 

                                      

                    sudden eccentric contraction 

                                      

                     of the pectoralis major 

                                       

                           leading to rupture.

                                       

 • Direct trauma causes :- tears of the muscle belly, 

 • Excessive tension or indirect trauma causes:-

 avulsion of the humeral insertion or

 disruption at the musculo-tendinous junction.

EXAMINATION

 •  revealed local tenderness

 •  bruising

 •  loss of contour of the pectoralis major muscle 

 •  Significant weakness of adduction and internal rotation of the arm.

REHABILITATION

(1) elbow exercises from day 1 post surgery.

(2) Isometric rotator cuff 

 •   pectoralis major strengthening 

 •   shoulder in neutral rotation (at 2 weeks along) 

 •   passive external rotation 

(3) Progressive physiotherapy included

 •  range of motion, 

 •  strengthening and 

 •  endurance exercises.

 

Functional results were analysed using:

 

 • Visual analogue scores for pain.

 

 • Functional shoulder evaluation score.

 

 • Isokinetic strength assessment.

 

III. SCAPULAR BODY FRACTURE

result of a high-energy impact

players in sports that involve collisions 

– either accidental or intentional 

– such as rugby and soccer are at increased risk of scapular fracture. 

Athletes participating in 

 •  football, 

 • wrestling, and 

 • water skiing 

 • tended to suffer injury as a result of forceful rotation movements. 

 • In contrast, ice hockey, boxing, and badminton injuries happen due      to forceful swinging movements.

 • Fatigue fractures are rare.

 •  for repetitive stress fractures include pitching in baseball players

 • an extended season of batting in cricket players, 

 •  jogging with hand weights in runners

CLASSIFICATION

is based on the mechanism and site of injury

 • Type A: Extra-articular fracture involving the scapula neck and body.

 • Type B: Intra-articular glenoid fracture involving more than 25% of the articular surface.

 • Type C: Intra-articular glenoid fracture extending into the base of the coracoids.

DIAGNOSIS

some typical characteristics are:-

 • A sudden onset of pain, usually localized across the shoulder blade     or at the top of the shoulder 

– a fatigue fracture of the scapula likely presents with a much more      gradual onset of pain.

 • Pain that worsens with arm movement or deep inhalation.

 • Pain that is severe attempts to raise the arm overhead.

 • limited abduction.

 • A grinding sensation during movement.

 • Swelling, tenderness, and bruising in the superior scapula region, or on the top of the shoulder overlying the coracoid and acromion processes.

 • When viewed from the side, a slightly flattened or deformed appearance compared to the unaffected side.

REHABILITATION

 • The typical rehab protocol for conservative treatment is as follows (2-6 WEEKS)

 

 • Immobilize using a sling and swathe for comfort (6 weeks)

 • Begin a progressive ROM exercises as soon as the pain subsides.

 • Start progressive loading against resistance once pain free, concentrating on developing the maximum range of motion – for example, using Therabands.

 • Introduce heavier and more sports-specific loading when movements are pain-free, and follow up imaging confirms union is taking place.

 

IV. PROXIMAL HAMSTRING RAPTURE

 

Although an uncommon form of hamstring damage only eight to 12% of all hamstring injuries.

The most likely mechanism for a proximal hamstring rupture is 

 •  sudden knee extension with concurrent hip flexion, while under an eccentric load.

 •  This motion happens in a slip or fall, and in sports such as 

 •  water and snow skiing

 •  bull riding

 •  running

 •  rugby 

 •  other football codes, 

 •  dance, and gymnastics