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 does the surgical procedure involve?

The goal of surgery, called decompression, is to relieve pressure on the axillary nerve and posterior circumflex humeral artery. This typically involves making a small incision at the back of your shoulder; identifying the compressed nerve and artery; carefully removing or cutting any fibrous bands, scar tissue, or other abnormal structures that are causing the compression. The procedure is designed to free up the nerve and artery, allowing them to function normally.

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.

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).

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

Frozen Shoulder (Adhesive Capsulitis)

Get Clear, Concise Answers to Your Top Questions About Frozen Shoulder (Adhesive Capsulitis)

Navigating a shoulder condition can be overwhelming. On this page, we've compiled the 15 most frequently asked questions about Frozen Shoulder (Adhesive Capsulitis) 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.

Frozen shoulder, also known as adhesive capsulitis, is a condition that causes pain and stiffness in your shoulder joint, gradually making it very difficult to move. It happens when the strong tissue surrounding your shoulder joint, called the joint capsule, becomes inflamed, thickens, and tightens, limiting your shoulder's movement.

Q1: What is Frozen Shoulder (Adhesive Capsulitis)?

Frozen shoulder is a condition where the shoulder joint capsule becomes inflamed, stiff, and constricted, leading to a significant loss of both active and passive motion. It's like the shoulder is "stuck" in place.

Q2: What causes Frozen Shoulder?

Often, the exact cause isn't known (this is called "idiopathic"). However, it's thought to be due to inflammation and scarring within the shoulder joint capsule. Certain factors can increase your risk, including:

Diabetes
Thyroid disorders
Shoulder injury or surgery
Prolonged immobilization (e.g., after a stroke or arm fracture)
Being between 40 and 70 years old (more common in women)

Q3: What are the common symptoms?

Symptoms usually develop gradually and progress through stages:

Painful (Freezing) Stage: Increasing shoulder pain with any movement, often worse at night. Movement starts to become limited. This stage can last 3 to 9 months.
Frozen Stage: Pain may lessen, but stiffness becomes more severe, making daily activities very difficult. This stage can last 4 to 12 months.
Thawing Stage: Your shoulder motion slowly starts to improve as the capsule loosens. This can take 5 months to 2 years.

Q4: How is Frozen Shoulder diagnosed?

Diagnosis is primarily made by your doctor based on your symptoms and a physical exam. Your doctor will assess your active range of motion (how far you can move your arm yourself) and passive range of motion (how far they can move your arm for you). X-rays or MRI scans may be used to rule out other problems like arthritis or rotator cuff tears.

Q5: What are the non-surgical treatment options?

Most cases of frozen shoulder improve with non-surgical treatment. Options include:

Pain relievers: Over-the-counter medications like ibuprofen or naproxen to reduce pain and inflammation. Stronger prescription pain relievers may be used for severe pain.
Corticosteroid injections: Injections of anti-inflammatory medication into the shoulder joint can help reduce pain and inflammation, especially in the early stages.
Physical therapy: This is crucial and involves specific stretching and range-of-motion exercises to gradually regain movement and flexibility.
Heat and cold therapy: Applying mild heat can help relax muscles and improve circulation, while ice can reduce pain and inflammation.

Q6: What does physical therapy involve?

Physical therapy is a cornerstone of frozen shoulder treatment. A physical therapist will guide you through gentle, progressive stretching exercises to improve your shoulder's flexibility and range of motion. Examples include:

Pendulum swings
Finger walks up a wall
Towel stretches
Cross-body stretches
External and internal rotation exercises

Q7: When is surgery considered for Frozen Shoulder?

Surgery is usually considered only if non-surgical treatments haven't significantly improved symptoms after a long period (typically 6-12 months).

Q8: What does surgical treatment involve (briefly)?

The most common surgical procedure is arthroscopic capsular release. This involves using small incisions and a camera to visualize the inside of the shoulder joint. The surgeon then carefully cuts and releases the tight, scarred parts of the joint capsule, allowing for improved motion. Another less common option is manipulation under anesthesia, where the surgeon gently forces the shoulder to move while you are asleep to break up scar tissue.

Q9: What are the potential risks of surgery?

While rare, potential risks of surgery include:

Infection
Nerve or blood vessel damage
Fracture (with manipulation under anesthesia)
Recurrence of stiffness
Continued pain

Q10: What do I need to do to prepare for treatment/surgery?

Your doctor will provide specific instructions. Generally, this might include:

Discussing all your medications, allergies, and health conditions with your doctor.
Stopping certain medications (like blood thinners) before surgery, if applicable.
Arranging for someone to drive you home after an injection or surgery.
Preparing your home for recovery, such as having easily accessible items.

Q11: What can I expect immediately after treatment/surgery?

After an injection, you might experience temporary soreness at the injection site. After surgery, you'll likely have some pain and swelling. You will typically begin physical therapy almost immediately to maintain the motion gained during the procedure. You may wear a sling for comfort initially.

Q12: How long is the typical recovery period?

Recovery from frozen shoulder is a long process, whether treated non-surgically or surgically.

Non-surgical recovery: Can take anywhere from 6 months to 2 years, or sometimes even longer, to fully resolve.
Surgical recovery: While immediate motion can improve, full recovery and return to activities can still take several months (typically 3-6 months for significant improvement, longer for full recovery) with dedicated physical therapy.

Q13: How will pain be managed?

Pain will be managed with a combination of approaches, including:

Over-the-counter pain relievers (NSAIDs like ibuprofen)
Prescription pain medications (if needed)
Ice and heat application
Corticosteroid injections (in earlier stages)
Physical therapy exercises designed to reduce pain and improve motion.

Q14: What can I do at home to help my recovery?

Adhere to your physical therapy exercises: This is critical for regaining motion. Do them consistently as prescribed.
Manage pain: Use pain medication as directed and apply ice or heat as advised.
Stay active within limits: Avoid activities that cause sharp pain, but gentle movement throughout the day is important to prevent further stiffness.
Maintain good posture: This can help reduce strain on your shoulder.
Eat a healthy diet and get enough rest: These support your body's healing process.

Q15: When can I expect to return to daily activities, work, driving, and sports?

This varies greatly depending on the severity of your frozen shoulder, your individual progress, and whether you had surgery.

Daily activities: You'll gradually be able to perform more daily tasks as your pain decreases and motion improves.
Work: Light, desk-based work might be possible relatively soon, while jobs requiring heavy lifting or repetitive arm movements will take longer.
Driving: You should only drive when you can comfortably and safely control the steering wheel and perform necessary movements.
Sports: Return to sports will be a gradual process, typically after significant pain reduction and regaining most of your shoulder's strength and range of motion. This can take several months to a year or more.

It is important to remember that every individual's recovery journey is unique. Your healthcare team will guide you on appropriate timelines.

‍

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.

‍

Browse all articles