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What is Quadrilateral Space ...
Quadrilateral Space Syndrome
13 February, 2023
What is Quadrilateral Space Syndrome ?
It is characterized by axillary nerve and posterior humeral circumflex artery (PHCA) compression within the quadrilateral space.
The etiology of QSS is unclear, but impingement is most frequently due to
• fibrous bands,
• hypertrophy of a muscular border.
• In rare cases, QSS has also been caused by
∆hematoma resulting from fracture, ∆osteochondroma,
• 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
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,
• neural entrapment
•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.
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,
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
✓water skiing and
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.
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.
• revealed local tenderness
• loss of contour of the pectoralis major muscle
• Significant weakness of adduction and internal rotation of the arm.
(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
• 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
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.
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.
• 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
• other football codes,
• dance, and gymnastics
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