- Treatment:Most patients do very well with an inten-
sive physical therapy program including biomechani-
cal retraining, shoulder and ribcage elevation
exercises that enlarge the entrapped space. Pain
should be addressed adequately with specific agents
for neuropathic pain (e.g., tricyclics, anticonvulsants).
Surgical options include first rib removal, which may
be indicated in cases of vascular etiology or the pres-
ence of a cervical rib and classic electrodiagnostic
findings. Post surgical complications are of concern.
LONG THORACIC NERVE
- Anatomy and origin:The C5/C6 and occasionally also
C7 anterior primary rami join to form the long tho-
racic nerve. It crosses the first rib, lies behind the
brachial plexus and then runs down the lateral chest
wall, giving off branches to the eight digitations of the
serratus anterior. - Risk factors: Compression/entrapment injuries are
not common, but can occur after weightlifting exer-
cises, in climbers, carrying heavy backpacks, in back-
stroke swimmers (Bateman, 1967), wrestlers,
gymnasts, bowlers, golfers, soccer, volleyball, hockey,
and football players (Gregg et al, 1979), motor vehicle
accidents, and chiropractic manipulation. Depression
of the shoulder girdle by a blow to the shoulder or
downward traction of the arm may cause compression
of the long thoracic nerve against the 2nd rib (Gozna
and Harris, 1979). Differential diagnosis must include
neuralgic amyotrophy. Scapular winging is not an
unusual presentation for this disease (Suarez et al,
1996). - Symptoms and signs:Scapular winging may be seen
in the subject while standing with arms at the side; the
inferior angle of the scapula is translocated medially.
Pushing the hands/arms in forward flexion against a
wall exaggerates the winging. No sensory changes are
noted. - Prognosis for spontaneous recovery is good, except in
the case of root avulsion. Physical therapy includes
resistive exercises and general shoulder muscle
strengthening (in absence of denervation). A tempo-
rary shoulder sling support may avoid discomfort.
AXILLARY NERVE
- Anatomy and origin:Fifth and 6th nerve roots.
Fibers travel through the upper trunk of the brachial
plexus, then the posterior divisions and posterior cord.
The first terminal branch is the axillary nerve. The
nerve passes through the quadrilateral space (risk area
for compression). It then divides into a posterior trunk
that supplies the teres minor muscle and the posterior
deltoid, and terminates as the superior lateral brachial
cutaneous nerve. The anterior trunk supplies the ante-
rior and middle deltoid. Bounderies of the quadrilat-
eral space are teres minor superior, teres major
inferior, long head of the triceps medial, and the sur-
gical neck of the humerus lateral. The axillary nerve
and the posterior humeral circumflex artery traverse
this space. The axillary nerve is the most common
nerve effected in shoulder lesions.- Compression injuries are observed as quadrilateral
space syndrome(Cahill and Palmer, 1983). At risk are
throwing athletes. Other sports placing participants at
risk are football, crew, swimming, and backpacking.
Lesions may also be due to a direct blow to the deltoid
(percussion/contusion), after glenohumeral joint dis-
location 12.3% (Toolanan et al, 1993) or humerus
fracture or surgical procedures. - Symptoms and signs:Isolated axillary nerve injury
in contact sports may be unnoticed at first. In quadri-
lateral space syndrome there is posterior shoulder
pain, and paresthesias over the lateral arm and weak-
ness of the deltoid. Forward flexion and/or abduction
and external rotation of the humerus aggravate the
symptoms. Muscle hypertrophy and possibly fibrous
bands are believed to be the cause (Cahill and Palmer,
1983). Subclavian arteriography may show compres-
sion of the posterior humeral circumflex artery with
abduction and external rotation of the arm (Cahill and
Palmer, 1983). - Many, especially young subjects, recover full shoul-
der abduction even with continued denervation of the
deltoid muscle by substituting the supraspinatus
muscle for the deltoid. Throwing athletes experience
difficulty. The deltoid provides 50% of the torque
about the shoulder. With a direct blow to the deltoid
prognosis is poorer than with lesions from other
causes. Functional outcome, however, can still be ade-
quate (Perlmutter, Leffert, and Zarins, 1997). - Treatment:Rest in the acute phase and treatment of
bony or other injuries as indicated. ROM, passive
exercises to rotator cuff muscles, deltoid, and
periscapular muscles, progressing to resistive exer-
cises, after cessation of denervation. Shoulder con-
tracture must be avoided. If there is no sign of
reinnervation noted within 3–6 months after injury,
surgical exploration of the axillary nerve may have to
be considered. Neurolysis or nerve grafting (sural,
neurotization with thoracodorsal, spinal accessory or
intercostal nerves have been tried) can restore axillary
nerve function (Perlmutter, Leffert, and Zarins, 1997).- Surgery for quadrilateral space syndrome:
Decompression by the release of fascia and fibrous
- Surgery for quadrilateral space syndrome:
324 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE