What is Quadrilateral Space Syndrome (QSS)?

Quadrilateral Space Syndrome (QSS) is a rare condition that occurs when the axillary nerve and/or the posterior circumflex humeral artery get squeezed or compressed as they pass through a small area in the back of your shoulder called the 'quadrilateral space.' This compression can lead to pain, numbness, tingling, and weakness in your arm.

QSS is often caused by repetitive overhead activities, common in athletes like throwers, swimmers, and tennis players. It can also result from repeated motions that narrow the space (overuse), extra bands of tissue that can form and compress the nerve or artery (fibrous bands), trauma or injury such as a shoulder dislocation or a direct blow to the shoulder which can cause swelling or scar tissue, or muscle enlargement if muscles in the area grow significantly (e.g., in bodybuilders), they can crowd the space.

What are the common symptoms of QSS?

Symptoms typically include vague pain or a dull ache in the back of the shoulder, sometimes radiating down the arm; numbness, tingling, or a 'pins and needles' sensation in the shoulder and upper arm; pain that worsens with overhead movements or when your arm is in a 'throwing' position; tenderness when pressure is applied over the back of the shoulder in the quadrilateral space; weakness or fatigue in the arm, especially when lifting or rotating it; and sometimes, shrinking (atrophy) of certain shoulder muscles like the teres minor or deltoid.

How is QSS diagnosed?

Diagnosing QSS can be challenging because its symptoms can be similar to other shoulder problems. Your doctor will ask about your symptoms, activities, and any past injuries; perform a physical examination to check your shoulder's range of motion, strength, sensation, and tenderness; may order imaging tests like MRI or ultrasound to look at the quadrilateral space, assess muscle size, and check for any abnormalities or scarring. In some cases, nerve conduction studies (NCS) or electromyography (EMG) might be performed to evaluate how well the axillary nerve is working. An injection of local anesthetic into the quadrilateral space that temporarily relieves your symptoms can also help confirm the diagnosis.

When is surgery considered for QSS?

Surgery is usually considered if non-surgical treatments haven't significantly improved your symptoms after about six weeks or more; symptoms are severe or progressively worsening; or there's clear evidence of nerve damage or significant compression.

What do I need to do before surgery?

Your healthcare team will provide specific instructions, but generally, you may need to undergo a pre-operative physical examination and blood tests; stop certain medications (e.g., blood thinners, some anti-inflammatory drugs) a week or two before surgery; arrange for someone to drive you home after surgery and help you during the first few days of recovery; and avoid eating or drinking for a certain period before the surgery.

What can I expect immediately after surgery?

You will likely have your arm in a sling to help it rest and heal. You may experience some pain, which will be managed with medication. Your surgical site will be covered with a dressing. Your surgeon will give you instructions on wound care and activity restrictions.

How long is the typical recovery period?

Recovery times vary for each person, depending on the severity of the condition and how long the nerve was compressed. First few weeks (0-2 weeks): Focus on rest, pain management, and protecting the surgical site. Gentle elbow and wrist movements will be encouraged. Weeks 2-6: You will start physical therapy, focusing on gentle range-of-motion exercises for your shoulder. After 6 weeks: As healing progresses, your physical therapist will introduce strengthening exercises to rebuild muscle strength. Overall, it can take several weeks to months to feel significant improvement, as nerve healing is a slow process.

What does rehabilitation/physical therapy involve?

Physical therapy is crucial for a successful recovery. Your therapist will design a personalized program that may include pain and swelling management (using ice, gentle massage, or other techniques); range of motion exercises (to restore full movement in your shoulder); strengthening exercises (targeting the muscles around your shoulder, including the deltoid and teres minor, which may have been weakened); postural correction (to improve overall shoulder mechanics); and activity-specific training (gradually reintroducing movements related to your work, sports, or daily activities).

When can I expect to return to daily activities, work, driving, and sports?

This timeline varies greatly based on your recovery progress and the demands of your activities. Daily activities: Light daily activities can usually be resumed within a few days to weeks. Driving: You can typically drive once you are no longer taking strong pain medications and have sufficient control and range of motion in your shoulder to safely operate a vehicle (often a few weeks after surgery). Work: Return to work depends on the nature of your job. Light, desk-based work might be possible within a few weeks, while jobs requiring heavy lifting or repetitive overhead movements will take longer, potentially several months. Sports: A gradual return to sports, especially overhead activities, will be guided by your physical therapist and surgeon, often not for several months after surgery. Full return to competitive sports may take 3-6 months or longer.

What is the expected long-term outcome?

For many patients, surgical decompression of QSS provides significant relief from pain, numbness, and weakness, allowing them to return to their normal activities, including sports. Nerve healing can be slow, so improvement may continue for several months. While some mild symptoms may occasionally linger, the goal is to significantly improve your quality of life and shoulder function.

Shoulder Conditions

Calcific Tendonitis of the Shoulder

Get Clear, Concise Answers to Your Top Questions About Calcific Tendonitis of the Shoulder

Navigating a shoulder condition can be overwhelming. On this page, we've compiled the 15 most frequently asked questions about Calcific Tendonitis of the Shoulder to give you straightforward, expert-backed answers. Understand your symptoms, diagnosis, and what comes next with insights from Dr. Christian Veillette's practice. Plus, explore trusted external resources for even more information.

Calcific tendonitis of the shoulder is a common and often painful condition that occurs when calcium deposits build up in the tendons of your rotator cuff. While the exact cause isn't fully understood, it's not related to injury, diet, or osteoporosis. These deposits can lead to inflammation and pain, sometimes quite severe. This brochure aims to answer your most important questions about this condition, helping you understand it better and participate actively in your recovery.‍

Q1: What is Calcific Tendonitis of the Shoulder?

Calcific tendonitis is a condition where calcium crystals form within the tendons of your rotator cuff in the shoulder. The rotator cuff is a group of muscles and tendons that help you lift and rotate your arm. These calcium deposits can cause significant pain and stiffness.

Q2: What causes Calcific Tendonitis?

The exact cause is unknown, but it's believed to be related to changes in the tendon cells that lead to calcium forming. It tends to affect people between 30 and 60 years old, with women being slightly more affected than men. It's not typically caused by a single injury, but rather by a process within the tendon.

Q3: What are the common symptoms?

Symptoms can vary greatly. Some people have no symptoms at all, while others experience severe pain. Common symptoms include:

Sudden or gradual shoulder pain.
Pain that radiates down the arm.
Pain that worsens with arm movement, especially lifting the arm overhead.
Stiffness and reduced range of motion in the shoulder.
Pain that interferes with sleep.

Q4: How is Calcific Tendonitis diagnosed?

Your doctor will review your symptoms and medical history and perform a physical examination of your shoulder. Imaging tests are crucial for diagnosis:

X-rays: These are usually the first step and can clearly show the calcium deposits.
Ultrasound: Can identify smaller deposits and assess the surrounding tissues.
MRI: May be used to rule out other conditions or assess the extent of tendon damage.

Q5: What are the non-surgical treatment options?

Most cases of calcific tendonitis improve with non-surgical treatments. These include:

Rest and activity modification: Avoiding movements that worsen your pain.
Pain relievers: Over-the-counter medications like ibuprofen or naproxen can help manage pain and inflammation.
Physical Therapy: Exercises to improve your shoulder's range of motion, strength, and overall function.
Cortisone injections: A powerful anti-inflammatory medication injected directly into the affected area to reduce pain and swelling. The effects are temporary.
Needle Lavage (Barbotage): An ultrasound-guided procedure where needles are used to break up and remove the calcium deposits by flushing them with saline.
Shockwave Therapy (ESWT): Uses high-energy sound waves to break down the calcium deposits, allowing your body to reabsorb them. This can also stimulate healing.

Q6: When is surgery considered for Calcific Tendonitis?

Surgery is usually considered only if non-surgical treatments haven't relieved your pain and symptoms, and if the condition significantly impacts your daily activities or sleep.

Q7: What does the surgical procedure involve?

The most common surgical procedure for calcific tendonitis is arthroscopic removal of calcium deposits. This is a minimally invasive "keyhole" surgery.

Small incisions (about 5mm) are made around your shoulder.
A small camera (arthroscope) is inserted to visualize the calcium deposit and the surrounding area.
Small surgical instruments are used to carefully remove the calcium deposit.
Sometimes, an additional procedure called an "acromioplasty" (shaving a small part of the bone above the rotator cuff) may be performed to create more space for the tendons and prevent future impingement.

Q8: What are the potential risks of surgery?

As with any surgery, there are risks, though they are generally low for arthroscopic procedures. Potential risks include:

Infection
Bleeding
Stiffness (frozen shoulder) if rehabilitation is not followed diligently
Nerve or blood vessel damage (rare)
Continued pain or incomplete removal of calcium
Re-accumulation of calcium (rare)

Q9: What do I need to do before treatment/surgery?

Your doctor will provide specific instructions. Generally, before treatment or surgery, you may need to:

Discuss all your medications with your doctor, including over-the-counter drugs and supplements.
Follow any fasting instructions if you are having a procedure or surgery.
Arrange for someone to drive you home after your procedure.
Complete any pre-operative tests as requested by your surgeon.

Q10: What can I expect immediately after treatment/surgery, and how long is the recovery?

After non-surgical treatments (e.g., injection, shockwave): You might experience some temporary soreness or bruising. Your doctor will advise on activity restrictions.
After surgery: You will likely wear a sling for a few days to a couple of weeks for comfort and protection. Pain will be managed with medication. Physical therapy usually starts soon after surgery.
Recovery time: This varies greatly. For non-surgical treatments, improvement can be seen over weeks to months. After surgery, initial recovery (reduced pain, basic movement) might take a few weeks. Full recovery, including regaining strength and full range of motion, can take 3 to 6 months or more, depending on the individual and the extent of the condition.

Q11: How will pain be managed?

Pain management is a key part of your treatment. Your doctor may recommend:

Over-the-counter pain relievers: NSAIDs (like ibuprofen) to reduce pain and inflammation.
Prescription pain medication: For more severe pain, especially after a procedure.
Ice or heat: Applying ice packs (especially in the acute phase) or heat can help reduce pain and stiffness.
Physical therapy techniques: Your therapist may use modalities like ultrasound or electrical stimulation to help with pain.

Q12: What can I do at home to help my recovery?

Active participation in your recovery is essential!

Follow your doctor's instructions: Take medications as prescribed.
Perform home exercises: Consistent and correct performance of exercises given by your physical therapist is crucial.
Ice and/or heat: Use as recommended to manage pain and swelling.
Activity modification: Avoid activities that worsen your pain or put strain on your shoulder during recovery.
Good posture: Maintain good posture to support your shoulder.
Listen to your body: Don't push through sharp pain.

Q13: When can I expect to return to daily activities, work, and sports?

This depends on the severity of your condition, the treatment you receive, and your individual healing.

Daily activities: Light daily activities may resume within days to a few weeks after most treatments.
Work: Return to work depends on the physical demands of your job. Sedentary jobs might resume within a few days to weeks. More physically demanding jobs may require several weeks to months.
Driving: Generally, you can drive when you are off strong pain medication and can safely control the steering wheel without pain or difficulty (this may take a few weeks).
Sports: Return to sports, especially those involving overhead arm movements, will be gradual and guided by your physical therapist and doctor, typically taking several months.

Q14: What signs or symptoms should I watch out for and report to my doctor immediately?

While complications are rare, it's important to be aware of potential warning signs:

Severe or worsening pain not relieved by medication.
Fever or chills.
Redness, swelling, or warmth around the shoulder or incisions (if applicable).
Pus or discharge from surgical incisions.
Numbness or tingling in your arm or hand.
Significant weakness or inability to move your arm.
Any unexpected or concerning symptoms.

Q15: What is the expected long-term outlook for Calcific Tendonitis?

The long-term outlook for calcific tendonitis is generally very good. Most people experience significant improvement or complete resolution of their symptoms. The calcium deposits often disappear on their own over time, even without aggressive treatment. While some individuals may experience recurring pain or lingering mild symptoms, with proper management and adherence to your treatment plan, you can expect to regain good shoulder function and pain relief.

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We encourage you to write down any specific questions you have and discuss them thoroughly with your surgeon, doctor, or physical therapist. They are your best resource for personalized advice and care.

Disclaimer: This brochure provides general information and is not a substitute for professional medical advice. Always consult your doctor or qualified healthcare provider with any questions you may have regarding your specific medical condition and treatment plan.

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