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Rotator Cuff Denervation Syndromes
Michael J. Tuite, MD; Soterios Gyftopoulos, MD, MSc
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          TERMINOLOGY

          • Synonyms

            • Parsonage-Turner syndrome, acute brachial neuritis, neuralgic amyotrophy, acute brachial radiculitis, quadrilateral space syndrome, idiopathic teres minor edema, neurogenic edema, denervation edema
          • Definitions

            • Edema within rotator cuff muscle(s) from motor nerve abnormality
              • May also involve deltoid muscle
            • Parsonage-Turner syndrome (viral neuritis)
              • Usually involves suprascapular nerve
              • ~ 90% have denervation edema in supraspinatus and infraspinatus muscles
              • 2/3 have ≥ 3 muscles involved
                • Deltoid is 3rd most commonly involved muscle
                • Can have deltoid edema without teres minor edema if neuritis only involves 6th cervical nerve portion of axillary nerve
            • Quadrilateral space syndrome
              • Axillary nerve compression/injury, most commonly due to fibrous band or paralabral cyst
              • Teres minor and deltoid muscle denervation edema or atrophy, depending on chronicity
              • Compression of posterior humeral circumflex artery
            • Other
              • Idiopathic teres minor atrophy
                • Older patients with cuff tears or degenerative joint disease (DJD) and chronic irritation of axillary nerve branch
                • Younger patients with inflexible fascial compartment
              • Spinoglenoid or suprascapular notch paralabral ganglion cyst
              • Brachial plexus injury or mass

          IMAGING

          • General Features

            • MR Findings

              • Ultrasonographic Findings

                • Imaging Recommendations

                  DIFFERENTIAL DIAGNOSIS

                    PATHOLOGY

                    • General Features

                      • Staging, Grading, & Classification

                        • Gross Pathologic & Surgical Features

                          CLINICAL ISSUES

                          • Presentation

                            • Demographics

                              • Natural History & Prognosis

                                • Treatment

                                  DIAGNOSTIC CHECKLIST

                                  • Consider

                                    • Image Interpretation Pearls

                                      Selected References

                                      1. Hong CC et al: Quadrilateral space syndrome: the forgotten differential. J Orthop Surg (Hong Kong). 27(2):2309499019847145, 2019
                                      2. Ahlawat S et al: Spectrum of suprascapular nerve lesions: normal and abnormal neuromuscular imaging appearances on 3-T MR neurography. AJR Am J Roentgenol. 204(3):589-601, 2015
                                      3. Brown SA et al: Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series. Mayo Clin Proc. 90(3):382-94, 2015
                                      4. Gregory T et al: Spontaneous resolution of quadrilateral space syndrome: a case report. Am J Phys Med Rehabil. 94(1):e1-5, 2015
                                      5. Kruse LM et al: Clinical outcomes after decompression of the nerve to the teres minor in patients with idiopathic isolated teres minor fatty atrophy. J Shoulder Elbow Surg. 24(4):628-33, 2015
                                      6. Gupta A et al: Neuralgic amyotrophy (Parsonage Turner syndrome). Orthopedics. 37(2):75, 130-33, 2014
                                      7. Zurkiya O et al: Quadrilateral space syndrome. J Vasc Interv Radiol. 25(2):229, 2014
                                      8. Apaydin N et al: Review of the surgical anatomy of the axillary nerve and the anatomic basis of its iatrogenic and traumatic injury. Surg Radiol Anat. 32(3):193-201, 2010
                                      9. Friend J et al: Teres minor innervation in the context of isolated muscle atrophy. Surg Radiol Anat. 32(3):243-9, 2010
                                      10. Cummins CA et al: Peripheral nerve injuries in baseball players. Phys Med Rehabil Clin N Am. 20(1):175-93, x, 2009
                                      11. Ligh CA et al: Case reports: unusual cause of shoulder pain in a collegiate baseball player. Clin Orthop Relat Res. 467(10):2744-8, 2009
                                      12. Scalf RE et al: MRI findings of 26 patients with Parsonage-Turner syndrome. AJR Am J Roentgenol. 189(1):W39-44, 2007
                                      13. Amin MF et al: An unusual cause of the quadrilateral space impingement syndrome by a bone spike. Skeletal Radiol. 35(12):956-8, 2006
                                      14. Bencardino JT et al: Entrapment neuropathies of the shoulder and elbow in the athlete. Clin Sports Med. 25(3):465-87, vi-vii, 2006
                                      15. Brestas PS et al: Ultrasound findings of teres minor denervation in suspected quadrilateral space syndrome. J Clin Ultrasound. 34(7):343-7, 2006
                                      16. Gaskin CM et al: Parsonage-Turner syndrome: MR imaging findings and clinical information of 27 patients. Radiology. 240(2):501-7, 2006
                                      17. Wilson L et al: Isolated teres minor atrophy: manifestation of quadrilateral space syndrome or traction injury to the axillary nerve? Orthopedics. 29(5):447-50, 2006
                                      18. Cothran RL Jr et al: Quadrilateral space syndrome: incidence of imaging findings in a population referred for MRI of the shoulder. AJR Am J Roentgenol. 184(3):989-92, 2005
                                      19. Elsayes KM et al: Value of magnetic resonance imaging for muscle denervation syndromes of the shoulder girdle. J Comput Assist Tomogr. 29(3):326-9, 2005
                                      20. Ryan M et al: Whole body magnetic resonance imaging in the diagnosis of Parsonage Turner syndrome. Acta Radiol. 45(5):534-9, 2004
                                      21. Sofka CM et al: Teres minor denervation on routine magnetic resonance imaging of the shoulder. Skeletal Radiol. 33(9):514-8, 2004
                                      22. Robinson P et al: Quadrilateral space syndrome caused by glenoid labral cyst. AJR Am J Roentgenol. 175(4):1103-5, 2000
                                      23. Bredella MA et al: Denervation syndromes of the shoulder girdle: MR imaging with electrophysiologic correlation. Skeletal Radiol. 28(10):567-72, 1999
                                      24. Sanders TG et al: Paralabral cyst: an unusual cause of quadrilateral space syndrome. Arthroscopy. 15(6):632-7, 1999
                                      25. Helms CA et al: Acute brachial neuritis (Parsonage-Turner syndrome): MR imaging appearance--report of three cases. Radiology. 207(1):255-9, 1998
                                      26. Yu JS et al: Denervation atrophy caused by suprascapular nerve injury: MR findings. J Comput Assist Tomogr. 21(2):302-3, 1997
                                      27. Linker CS et al: Quadrilateral space syndrome: findings at MR imaging. Radiology. 188(3):675-6, 1993
                                      28. Cormier PJ et al: Quadrilateral space syndrome: a rare cause of shoulder pain. Radiology. 167(3):797-8, 1988
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Imaging

                                          • Top Differential Diagnoses

                                            • Pathology

                                              TERMINOLOGY

                                              • Synonyms

                                                • Parsonage-Turner syndrome, acute brachial neuritis, neuralgic amyotrophy, acute brachial radiculitis, quadrilateral space syndrome, idiopathic teres minor edema, neurogenic edema, denervation edema
                                              • Definitions

                                                • Edema within rotator cuff muscle(s) from motor nerve abnormality
                                                  • May also involve deltoid muscle
                                                • Parsonage-Turner syndrome (viral neuritis)
                                                  • Usually involves suprascapular nerve
                                                  • ~ 90% have denervation edema in supraspinatus and infraspinatus muscles
                                                  • 2/3 have ≥ 3 muscles involved
                                                    • Deltoid is 3rd most commonly involved muscle
                                                    • Can have deltoid edema without teres minor edema if neuritis only involves 6th cervical nerve portion of axillary nerve
                                                • Quadrilateral space syndrome
                                                  • Axillary nerve compression/injury, most commonly due to fibrous band or paralabral cyst
                                                  • Teres minor and deltoid muscle denervation edema or atrophy, depending on chronicity
                                                  • Compression of posterior humeral circumflex artery
                                                • Other
                                                  • Idiopathic teres minor atrophy
                                                    • Older patients with cuff tears or degenerative joint disease (DJD) and chronic irritation of axillary nerve branch
                                                    • Younger patients with inflexible fascial compartment
                                                  • Spinoglenoid or suprascapular notch paralabral ganglion cyst
                                                  • Brachial plexus injury or mass

                                              IMAGING

                                              • General Features

                                                • MR Findings

                                                  • Ultrasonographic Findings

                                                    • Imaging Recommendations

                                                      DIFFERENTIAL DIAGNOSIS

                                                        PATHOLOGY

                                                        • General Features

                                                          • Staging, Grading, & Classification

                                                            • Gross Pathologic & Surgical Features

                                                              CLINICAL ISSUES

                                                              • Presentation

                                                                • Demographics

                                                                  • Natural History & Prognosis

                                                                    • Treatment

                                                                      DIAGNOSTIC CHECKLIST

                                                                      • Consider

                                                                        • Image Interpretation Pearls

                                                                          Selected References

                                                                          1. Hong CC et al: Quadrilateral space syndrome: the forgotten differential. J Orthop Surg (Hong Kong). 27(2):2309499019847145, 2019
                                                                          2. Ahlawat S et al: Spectrum of suprascapular nerve lesions: normal and abnormal neuromuscular imaging appearances on 3-T MR neurography. AJR Am J Roentgenol. 204(3):589-601, 2015
                                                                          3. Brown SA et al: Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series. Mayo Clin Proc. 90(3):382-94, 2015
                                                                          4. Gregory T et al: Spontaneous resolution of quadrilateral space syndrome: a case report. Am J Phys Med Rehabil. 94(1):e1-5, 2015
                                                                          5. Kruse LM et al: Clinical outcomes after decompression of the nerve to the teres minor in patients with idiopathic isolated teres minor fatty atrophy. J Shoulder Elbow Surg. 24(4):628-33, 2015
                                                                          6. Gupta A et al: Neuralgic amyotrophy (Parsonage Turner syndrome). Orthopedics. 37(2):75, 130-33, 2014
                                                                          7. Zurkiya O et al: Quadrilateral space syndrome. J Vasc Interv Radiol. 25(2):229, 2014
                                                                          8. Apaydin N et al: Review of the surgical anatomy of the axillary nerve and the anatomic basis of its iatrogenic and traumatic injury. Surg Radiol Anat. 32(3):193-201, 2010
                                                                          9. Friend J et al: Teres minor innervation in the context of isolated muscle atrophy. Surg Radiol Anat. 32(3):243-9, 2010
                                                                          10. Cummins CA et al: Peripheral nerve injuries in baseball players. Phys Med Rehabil Clin N Am. 20(1):175-93, x, 2009
                                                                          11. Ligh CA et al: Case reports: unusual cause of shoulder pain in a collegiate baseball player. Clin Orthop Relat Res. 467(10):2744-8, 2009
                                                                          12. Scalf RE et al: MRI findings of 26 patients with Parsonage-Turner syndrome. AJR Am J Roentgenol. 189(1):W39-44, 2007
                                                                          13. Amin MF et al: An unusual cause of the quadrilateral space impingement syndrome by a bone spike. Skeletal Radiol. 35(12):956-8, 2006
                                                                          14. Bencardino JT et al: Entrapment neuropathies of the shoulder and elbow in the athlete. Clin Sports Med. 25(3):465-87, vi-vii, 2006
                                                                          15. Brestas PS et al: Ultrasound findings of teres minor denervation in suspected quadrilateral space syndrome. J Clin Ultrasound. 34(7):343-7, 2006
                                                                          16. Gaskin CM et al: Parsonage-Turner syndrome: MR imaging findings and clinical information of 27 patients. Radiology. 240(2):501-7, 2006
                                                                          17. Wilson L et al: Isolated teres minor atrophy: manifestation of quadrilateral space syndrome or traction injury to the axillary nerve? Orthopedics. 29(5):447-50, 2006
                                                                          18. Cothran RL Jr et al: Quadrilateral space syndrome: incidence of imaging findings in a population referred for MRI of the shoulder. AJR Am J Roentgenol. 184(3):989-92, 2005
                                                                          19. Elsayes KM et al: Value of magnetic resonance imaging for muscle denervation syndromes of the shoulder girdle. J Comput Assist Tomogr. 29(3):326-9, 2005
                                                                          20. Ryan M et al: Whole body magnetic resonance imaging in the diagnosis of Parsonage Turner syndrome. Acta Radiol. 45(5):534-9, 2004
                                                                          21. Sofka CM et al: Teres minor denervation on routine magnetic resonance imaging of the shoulder. Skeletal Radiol. 33(9):514-8, 2004
                                                                          22. Robinson P et al: Quadrilateral space syndrome caused by glenoid labral cyst. AJR Am J Roentgenol. 175(4):1103-5, 2000
                                                                          23. Bredella MA et al: Denervation syndromes of the shoulder girdle: MR imaging with electrophysiologic correlation. Skeletal Radiol. 28(10):567-72, 1999
                                                                          24. Sanders TG et al: Paralabral cyst: an unusual cause of quadrilateral space syndrome. Arthroscopy. 15(6):632-7, 1999
                                                                          25. Helms CA et al: Acute brachial neuritis (Parsonage-Turner syndrome): MR imaging appearance--report of three cases. Radiology. 207(1):255-9, 1998
                                                                          26. Yu JS et al: Denervation atrophy caused by suprascapular nerve injury: MR findings. J Comput Assist Tomogr. 21(2):302-3, 1997
                                                                          27. Linker CS et al: Quadrilateral space syndrome: findings at MR imaging. Radiology. 188(3):675-6, 1993
                                                                          28. Cormier PJ et al: Quadrilateral space syndrome: a rare cause of shoulder pain. Radiology. 167(3):797-8, 1988